I "RD3d TIS Columbia SHniuemV ^\ mti)f CitpofBfttjgork College of ^bpgicians anh #)urgeong Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://w\A/w.archive.org/details/operationsofsurgOOjaco THE OPERATIONS OF SURGERY THE OPERATIONS OF SURGERY (JACOBSON) SIXTH EDITION BY R. P. ROWLANDS, M.S.Lond., F.R.C.S.Eng. Surgeon to Guy's Hospital ; Lecturer on Anatomy to the Medical School AND PHILIP TURNER, B.Sc, M.S.Lond., F.R.C.S.Eng. Surgeon to Guy's Hospital ; Teacher of Operative Surgery to the Medical School Timitb 707 illustrations (40 in Colour) VOLUME I THE UPPER EXTREMITY; THE HEAD AND NECK; THE THORAX; THE LOWER EXTREMITY; THE VERTEBRAL COLUMN NEW YORK THE MACMILLAN COMPANY 1915 ■RD3.2. V.I Printed in Ureal Britain PREFACE TO THE SIXTH EDITION This book, of which five previous editions have appeared, was the outcome of a strong belief which Mr. Jacobson held for many years, that a work on operative surgery which aimed at being more comprehen- sive in scope and fuller in detail than those already published, would be of service to many who had recently been appointed to hospital staffs, and to those who were working for the higher examinations. For these this book is specially intended, and, as the authors have pointed out here and there, some of the recommendations made apply to those who have not a well-appointed hospital staff at their back. Time and space set a limit to the operations which can be described. Therefore preference is given to those we have found most useful. In the special departments of surgery such as those of the nose, ear and throat, gynaecology and orthopaedics, only the important and well- established operations which a general surgeon can safely perform are considered here, and no attempt is made to compete with treatises on these special subjects. In this edition we have endeavoured to save space and avoid needless repetition by devoting special chapters to " the examination, preparation and after-treatment of the patient." The whole book has been carefully revised and a great deal of it has been entirely rewritten ; this applies especially to the sections on Abdominal Surgery, and the chapters on the Surgery of the Blood- vessels, and of the Brain, Ear, Nose and Throat. We are well aware that the book will, from time to time, require much alteration. This is unavoidable in a subject so progressive and changeful as modern surgery ; it is especially unavoidable when a writer desires to do full justice to the work done by the crowd of labourers engaged in the same field at the present time. Many of the methods suggested in these pages will, later on, be rejected, but it is only by submitting novelties and suggestions to the one true test, that of time, that we shall know how many are really worthy to survive. If this book aids in bringing about the application of this test, it will not have failed, altogether, in its purpose. The plan of the book, with which some judges found fault, remains unchanged. Mr. Jacobson adopted the division by regions deliberately, desiring that those for whom the book is intended should study the anatomy of each region at the same time as the account of the operations. In this edition it has been found convenient to insert the section on the Leg in the first volume, so that the increasing claims of abdominal surgery could be adequately met in the second volume. To our great regret Mr. Jacobson has been unable to continue the laborious and brilliant work which built up this book and maintained vi PREFACE its great reputation for so many years. Mr. Philip Turner has made himself entirely responsible for the sections dealing with the Surgery of the Head and Neck, Chest and Upper Extremity. Mr. G. Bellingham Smith, Senior Obstetric Physician and Gynsecologist to Guy's Hospital, has again thoroughly revised and largely rewritten the chapters dealing with the operations on the Ovary and Uterus. Many new and original illustrations have been added, and we desire to express our grateful acknowledgments to Sir Watson Cheyne, Sir A. Pearce Gould, Sir Victor Horsley, Sir Arbuthnot Lane, Sir W. Macewen, Sir Henry Morris, Sir Berkeley Moynihan, Sir St. Clair Thomson, Messrs. Barker, James Berry, Burghard, Dobson, Freyer, Hey Groves, Sampson Handley, Jonathan Hutchinson, McGavin, Miles, Paul, Rawling, Scott, Swain, Tilley, West, and to Doctors Binnie, Connell, Crile, Garre, Halstead, Kelly, Kocher, C. H. Mayo, W. J. Mayo, Willy Meyer, Quincke, Scudder, Tuttle, Young and others ; also to The Annals of Surgery, and acknowledgments are also made to some who have passed away, such as Bucknall, Edebohls, Heath, Lockwood, Greig Smith, and Wheelhouse. It remains for us to acknowledge very gratefully the encouragement given by the reviewers of previous editions, and a host of correspondents from all parts of the world. We only wish that this edition may deserve some of the kind things written of its predecessors, and that it will be found to give proof of the two main objects which we have tried to keep before us — to do justice to the work of others and to save our readers some of the difficulties and anxieties which have beset our paths. CONTENTS PART I OPERATIONS ON THE UPPER EXTREMITY CHAP. I Prelimixary Considerations. — Examination and preparation of the patient ......... 1 II. Infusion. — Transfusion. — Skin-grafting 34 III. Some Generai, Points with regard to Amputations, the Ligature of Arteries, and the Surgery of Blood-vessels and Lymphatics ........ 46 IV. Operations on the Hand. — Amputation of fingers. — Amputa- tion of the thumb.— Partial excision of the thumb. — Excision of the fingers. — Conservative surgery of the hand. — Reunion of severed digits. — Supernumerary digits. — Webbed fingers. — Contracted palmar fascia. — Congenital and other contractions of the fingers. — Needles in the hand. — Palmar haemorrhage. — Compound palmar ganglion.— Tuberculous teno-s}Tiovitis. — Palmar aneurysm. — Operations for the union of divided tendons. — Tenorraphy. — Tenoplasty. — Tendon transplantation espe- cially in relation to its employment in infantile paralysis . . 57 V. Operations on the Wrist. — Excision of the wrist-joint — Operation in mal-united Colles"s fracture and separation of the lower epiphysis of the radius. — Amputation through the -nTist- joint. — Ligature of the radial artery at the back of the wrist . Ill VI. Operations on the Forearm. — Ligature of the radial artery in the forearm. — Ligature of the ulnar artery in the forearm. — Partial excision of the radius or ulna. — Operative treatment of Volkmann's contraction. — ^Amputation through the forearm . 126 VII. Operations in the neighbourhood of the Elbow-joint. — Amputation through the elbow-joint. — Excision of the elbow- joint. — Erasion of the elbow-joint. — Operation for fracture of the olecranon. — Operations for fracture of the condyles of the humerus and for separation of the lower epiphysis of the humerus. — Venesection. — lagature of the brachial artery at the bend of the elbow ....... 142 Vin. Operations on the Arm. — Ligature of the brachial arterj-. — Amputation through the arm. — Excision in continuity of the shaft of the humerus. — Bone-grafting. — Operations on the musculo-spiral nerve ,.".,.... 171 vii viii CONTENTS CHAP. IX. Operations on the Axilla and the Shottlder. — Ligature of the axillary artery. — Amputation at the shoulder-joint. — Excision of the shoulder-joint. — Gunshot injuries of the shoulder-joint ......... 187 X. Excision of the Scapula 228 XI. Removal of the Upper Extremity, Arm, Scapula, and GREATER P.UIT OF THE Clavicle. — Interscapulo-thoracic am- putation .......... 234 XII. Operations on the Clavicle. — Renioval of the clavicle . . 240 PART II THE HEAD AND NECK XIII. Operations on the Scalp. — Fibro-cellular growths, moUusoum fil)rosum, or pachj'dermatocele of the scalp. — Aneurysm by anastomosis. — Operative interference in growth of the cranial bones and dura mater . ... . . . . 244 XIV. Trephining. — Operative interference immediate or later in fractures of the skuU. — Trejihining in fractured skull. — ^Trephin- ing for pus between the skull and dura mater, — Trephining for middle meningeal haemorrhage. — Trephining and exploration of cerebral abscess due to injury. — Trephining for epilepsy and other later results of a cranial injuri% — ^Operative interference in the case of foreign bodies in the brain . . . . . 250 XV. Cerebral Locausation in reference to Operations. — Opera- tions for tumour of the brain. — Practical value of cerebral locali- sation. — Questions arising before operation on a cerebral growth. — Operative procedures on the brain, chiefly for the removal or the palliative treatnient of growths. — Craniectomy for microcephalus, idiocy, &c. — Trephining in general paral3'sis of the insane, and in other forms of insanity. — Operative treat- ment of hydrocephalus. — Drainage of the ventricles . . 289 XVI. Operations on the Ear. — The radical mastoid operation. — Abscess in the brain. — Meningitis. — Ojjeration for otitis media 330 XVII. Operations on the Face. — Operations on the fifth nerve. — Removal of parotid growths. — Operations on the facial nerve. — Stretching the facial nerve. — Operative treatment of intractable facial paralj'sis of peripheral origin. — Restoration of Steno's duct. — Operative treatment of lupus. — Operative treatment of rodent ulcer. — Removal of parotid growths. — Practical points in the removal of parotid growths. — Operative treatment of na?vi. — Operative methods of treatment .... 363 XVIII. Excision of the Eyeball 406 XIX. Operations on the Frontal Sinuses .... 410 CONTENTS ix CHAP. l'A(Ji: XX. Operations OF THE Jaws. — Excision of tlic upijei- jaw, paitiiii and coniijlcte. — Operations on the antrum of Higliinorc. — Excision of the lower jaw, partial and complete. — Operations for fixity of the lower jaw . . . . . . . 41!) XXr. Plastic Operations for Repair of the Xosk . . . 44^ XXII. Operations on the Nasal Foss.e. — Removal of foreign bodies. — Turbinectomy.— Operations for deflected septum. — Removal of nasal polypi. — Operation for naso-pharyngeal fibroma and sarcoma. — Removal of adenoids and enlarged tonsils .......... 454 XXIII. Operations on the Lips.- -Hare-lip and other plastic opera- tions on the lips and face . . . . . . . 47i) XXIV. Operations on the Palate. — Operations for cleft palate. — Removal of growths from the palate ..... 504 XXV. Removal of the Toncjue. — Operations for epithelioma of the tongue .......... 59 XXVI. Operations for Growths of the Tonsil, FauceS; i3as:3 o:-' the ToNcaiE and Pharynx ...... 550 XXVII. Operations on the Air-pass*ages in the Xeck. — Thy- rotomy. — Laryngotomy or inter-crico-thyrotomy. — Trache- otomy. — Tracheotomy with special reference to cases of mem- branous laryngitis. — Intubation of the larynx as a substitute for tracheotomy in membranous laryngitis or stenosis of the larynx. — Technique of intubation. — Other indications for tracheotomy. — Extra-laryngeal operations for removal of growths of the larynx ; excision of the larynx, partial or complete .......... 559 XXVIII. Removal OF Foreign Bodies from the Upper Air-passages • AND FROM THE ClisOPHAGUS ...... 602 XXIX. Operations on the Thyroid Gland. — Extirpation of part of the gland. — Enucleation of encapsuled tumours. — Ijgature of the thyroid arteries . . . . . . . 610 XXX. Operations for the Removal of Large Deep-seated Growths in the Xeck, Tuberculous Glands, Lymphangeto- MATA, Thyroglossal AND BRANCHIAL Cysts. — Removal of cervical ribs ......... 638 XXXL Operations on the (Esophagus. — ffisophagotomy. — O^so- phagostomy. — Esophagectomy. — Oesophageal pouches . 649 XXXII. Operations on the Spinal Accessory, LTpper Cervical Nerves, and Sympathetic. — Partial neurectomy, or nerve- stretching. — Resection of the cervical sympathetic for exoph- thalmic goitre, &c. ...... . . 661 XXXIII. Ligature of the Arteries of the Head and Neck. — Ligature of the temporal arterJ^ — Ligature of the facial artery. — Ligature of the occipital artery. — Ligature of the lingual artery. — Ligature of the common carotid. — Ligature of the external carotid. — Ligature of the internal carotid. — Ligature of the vertebral artery. — Ligature of the subclavian in its second and third parts. — Ligature of the first part of the subclavian. — Ligature of the irmominate. — Surgical intei-ference in aneurysms of the innominate and aorta ...... 670 CONTEXTS PART III OPERATIONS ON THE THORAX CHAP. PAGE XXXIV. Removal of the Breast ...... 727 XXXV. Paracentesis and Incision of the Chest. — Empyema. — Resection of ribs. — ^Operative interference in injuries of the chest 760 XXXVI. Operations on the Lvng and the ^Iediastinum . . 778 XXXVII. Tapping or Incising the Pericardium. — Suture of wounds of the heart. — Cardiolj^sis ...... 794 PART IV OPERATIONS ON THE LOWER EXTREMITY XXX\'III. Amputation at the Hip-joint. — Excision of the hip-joint. — Operative treatment of hip-disease. — Operative treatment of sacro-iHac disease ........ 805 XXXIX. Congested Dislocation of the Hip : Coxa Vara . . 826 XL. Ligature of Arteries in the Buttock and Thigh 835 XLI. Amputation through the Thigh. — Removal of exostosis. — Fractures of the femur ....... 846 XLII. Amputation through the Kkee- joint. — Erasion, excision and arthrodesis of the joint a\ iring of fractures of the jiateUa. — Removal cf loose bodies and detached cartilages from the knee-joint .... . 862 XLIII. Ligature of Arteries in the Popliteal Space and the Leg 894 XLIV. Amputation of the Leg. — Operation for Xecrosis. — Com- jjound fracture. — Simiile fracture.— Varicose veins . . 905 XLV. Ligature of Dorsalis Pedis. — Amputations of the foot. — Excision and erasion of the anlde-jomt.— Excision of the os calcis. — Tarsectomy ....... 930 XLVI. Osteotomy for Ankylosis of the Hip-joint, Coxa Vara, Genu Valgum, and Genu Varum .... 953 XL^'II. Tenotomy and Tendon Lengthening. — Treatment of severe talipes 961 XLVIII. Operations ON Xerves. — Suture, grafting, and anastomcsis . 978 PART V OPERATIOXS OX THE VERTEBRAL COLUMX XLIX. Spina Bifida. — Laminectojuy. — Tapping the spinal theca. — Spinal anx'sthesia. — Amci-association .... 983 IXDEX . 1009 \>5 PAKT I ()Im:ijati()ns on thi: l i>im:r ex tkemij v CHAPTER I PRELIMINARY CONSIDERATIONS. EXAMINATION AND PREPARATION OF THE PATIENT Patients requiring surgical operative treatment may roughly be divided into two groups : I. Those in whom the operation is urgently required for some injury or disease w^hich seriously imperils life. II. Those in whom the condition is less urgent, so that there is no immediate necessity for the operation. In the first group, cases of acute intestinal obstruction for instance, the symptoms may be so grave that previous examination of the patient may be undesirable ; any risk must be taken in the attempt to save life. In the latter group undue haste is not only unnecessary but should be avoided ; a careful examination and preparation of the patient should always be made before the operation. The preliminary examination will frequently enable the surgeon to decide upon the most desirable treat- ment, i.e. as to w^hether, in elderly patients, a palliative or a radical operation will give the best prospect of ultimate success ; it will also aid the anaesthetist in the selection and the administration of the anaes- thetic. The preliminary preparation, too, will usually play a very important part in determining the success of the operation. In addition to an examination of the physical condition and the functional activity of the chief organs it is also necessary to take into consideration the age, sex, occupation, habits, and temperament of the patient, and to make inquiries as to the existence of any general consti- tutional or hereditary disorder. Age. It was formerly thought that operations were not well borne in childhood and in old age. Though to a certain extent still true, modern methods and precautions have considerably diminished the risk of operations at the two extremes of life. Young children are said to stand haemorrhage badly, but as Sir Frederick Treves has pointed out, if the relation of the amount of blood lost to the total amount in the body is considered, young children are probably not more seriously affected than adults. Post-operative shock is often excessive in infants and young children, and is a frequent cause of death after abdominal and other operations which necessitate the manipulation of the intestines or other important \'iscera. On the other hand, children often show" a remarkable power of recuperation and may recover from an apparently desperate condition. Both these points are illustrated by the results obtained by the modern method of treating an intussusception by laparotomy {q.v.). Difficulties with children often arise from the restless character of the patients, which may make it almost impossible to keep the affected part at rest ; displacement of dressings may also occur, which is likely to interfere with the healing of the wound. When the SURGERY I 1 I 2 OPERATIONS ON THF: UPPER EXTREMITY incision is in the region of the groin the dressings may, in spite of the most careful nursing, get soiled, and then infection of the wound and serious suppuration may ensue. A point in favour of operations in children is that they are not adversely affected by prolonged rest in bed and show no tendency as the result of this to develop such complications as chest troubles or bed-sores. In old age attention should be directed to the condition of the patient's organs and tissues rather than to the actual number of years. Some elderly people are quite good subjects for operation. Such, generally speaking, are spare, active and mry ; fat, flabby, plethoric old people are, on the other hand, usually bad subjects. Like children, old people do not stand shock well ; they also are seriously affected by loss of blood and do not show the recuperative powers of younger patients. It must be remembered, too, that in old people confinement to bed may lead to congestion of the base of the lungs and hypostatic pneumonia — a very fatal sequela in such patients. Bed-sores may appear as the result of long-continued pressure on the ill-nourished skin over the bony prominences, and will not infrequently contribute to a fatal result. ISTo operation, however, for an acute condition, seriously threatening life, and capable of cure or relief by surgical interference, is contra- indicated solely on account of old age. If a skilled ana'sthetist considers that a general ansesthetic is not desirable, either spinal anaesthesia or local anaesthesia may be employed. The results of prostatectomy show what can be done by operative treatment in old men, who apart from their urinary trouble are often very feeble and whose organs are by no means healthy. Sex. By some, women are regarded as better subjects for surgical operations than men. This, however, is the effect of temperament rather than sex, and the bearing of the former upon operative treatment will be discussed below. When operating upon women it is always necessary to bear in mind the importance of any unsightly or disfiguring scar, especially upon any exposed part of the body. In a man a scar upon the face can often be completely concealed by the moustache or beard ; in a woman such con- cealment is impossible. It is thus necessary, when planning any such operation, to take care that the scar is in as inconspicuous a position as possible. This can frequently be accomplished by making the incision in the line of some natural fold or crease in the skin. Accurate apposition of the edges of the incision, early removal of stitches, and primary union of the wound are all of the greatest importance in securing a neat scar. Unless urgently called for by some acute trouble, operations in Ihe groin, perineum, or abdomen should not be carried out during menstrua- tion. With regard to operations in other regions the wish of the patient should be considered. Many women prefer to have nothing done at this time, but should the patient make no objection no harm is likely to result. Operations are best avoided during pregnancy, especially during the later months. The danger here, of course, is that an abortion may follow. The chance of such an accident is however slight, and not infrequently it will be felt that the risk should be taken. Operations for acute abdominal troubles, and the removal of ovarian EXAMINATION OF THE PATIENT .3 cysts, have frequently been undertaken in pregnant women without anv mishap. What has })een said about pregnancy also to a great extent applies to operations during lactation. This throws considerable strain upon the system and renders it desirable to postpone any operation which is not urgently required. Temperament. Before recommending any serious operation it is always well to have some knowledge of the patient's temperament and to observe his mental attitude towards the disease and the treatment. Such information may help one considerably in the choice of treatment, operative or otherwise ; it will also frequently have a great influence upon the ultimate result. A placid and cheerful state of mind is an encouraging sign in a patient who has to face a serious operation. An apathetic fatalistic attitude, in which the patient does not care, or scarcely wishes to recover, is on the other hand of very bad omen. Considerable care must be exercised before recommending operations, unless they are very ob\'iously indicated, in neurotic subjects. A good example of this is seen in the symptoms which are associated with a movable kidney. These patients are very often neurotic, and in such, even though the kidney by the operation of nephropexy be firmly fixed in its normal position, the symptoms wdll probably continue. The same operation for similar symptoms in a patient of normal sensi- bility and placid temperament will probably result in their complete disappearance. Mental worry of any description is a serious disadvantage to any patient who requires operative treatment. Restlessness of mind will probably lead to bodily restlessness, and the two combined mav have a very ill effect. Worry in men is generally due to business matters, and in women to their household affairs and their children. On this account, as well as for convenience in nursing and treatment generally, it is usually advisable not to operate in the patient's own home but to have them removed from familiar surroundings to a hospital or nursing institution. Under these circumstances visitors can be limited or if necessary totally forbidden, and the worries, which though often trivial are very real, can thus be kept from the patient ; it is practically im- possible to secure this freedom from mental irritation if the operation takes place in the patient's own home. In restless and neurotic patients, too, the new surroundings and unaccustomed faces are often of the very greatest benefit. Habits. The success of an operation may be seriously affected by the patient's habits. Unfortunately these are often unrecognised before the operation, for the patient is naturally averse to give information, and if the suspicions of the surgeon are aroused the suggestion will probablv be denied. That the vicious habit is indulged in is thus usually revealed by disturbances, either mental or physical, after the operation. The most frequent and important of these habits to be considered is alcoholism. An alcoholic is certainly a bad subject for at any rate major operations. This is true not only in the case of drunkards but also in that more numerous class of individuals who, though they would deny ever being intoxicated, are yet continually taking small doses and are unable to do without the drug. The dangers attending operations upon alcoholics are three in number ; (a) there is the possibility of an attack of de- lirium tremens, or of some less serious mental disturbance ; (b) the normal healing of the wound is likely to be interfered with; (c) there may be serious general complications. 4 OPERATIONS OX THE UPPER EXTREMITY Delirium tremens may appear for the first time in an alcoholic subject after an operation. It may occur in a chronic alcoholic patient as well as in an occasional or habitual drunkard. The actual cause is probably alteration in diet and mode of life, and enforced abstinence, rather than the actual operation. When operating on an alcoholic subject it is thus best not to deprive him completely of the drug, but to allow small regular doses of stimulant. Post-operative delirium tremens is always a serious and not infrequently a fatal complication. The continued absorption of alcohol has undoubtedly a deleterious effect upon the tissues. The powers of repair are seriously affected, so that the healing of the wound, both superficially and in its deeper parts, may be impeded. The resistance of the tissues to bacterial infection is also diminished, and hence suppuration, cellulitis, and erysipelas occur much more readily and are overcome with greater difficulty than in a healthy patient. Alcoholics are also liable, for much the same reasons, to a number of grave \"isceral troubles, such as pneumonia, dilatation of the heart, chronic nephritis, while gastric disturbances of more or less severity are also exceedingly common. These may appear after, or if already present are likely to be accentuated by, an operation. These troubles are often accompanied by delirium tremens. All these complications are especially likely to appear in hard drinkers after severe operations for serious acute injuries and diseases. It will thus be seen that a considerable mortality is to be expected after such operations on these patients. Alcoholics, too, will probably give much trouble to the anaesthetist. They may be expected to take large quantities of ether or chloroform, the stage of excitation is much prolonged, and it is difficult, and indeed in some cases almost impossible, to secure complete muscular relaxation. What has been said of alcohol is to a great extent true of the subjects of other drug habits, such as morphia and cocaine. The sudden depriva- tion of the drug is likely to upset both the mental and physical functions of the body. On this account the patient should in all these cases be still allowed reduced cpiantities of the drug to which he is accustomed. Excessive smoking mav lead to troubles in anaesthetising of a similar though less severe character to those seen in alcoholics. Such a patient may often with advantage be allowed to smoke occasionally a few days after the operation, provided of course that the disease or injury was not in the region of the mouth, respiratory passages, or other situation where the practice would be harmful. We must now consider certain general constitutional conditions which have an important bearing upon operative treatment. Obesity. This is of the greatest importance, for such patients are bad subjects for nearly all operations. This is due to a varietv of causes. The excessive deposit of fat may be the result of continued excess in eating and drinking, which of itself is a serious matter. The excess of fat in the subcutaneous tissues may be associated with a fatty deposit in the mesentery and the omentum, while fatty liver and fatty infiltration or degeneration of the heart are also likely to be present. Such patients may be unable to breathe satisfactorily unless well propped up in bed, a position which their weight may render it difficult to maintain. The administration of the anaesthetic will, on account of the fatty ^^scera, be both difficult and dangerous. Their unwieldiness may make subse- quent nursing and after-treatment very difficult. The skin itself is EXAMINATION OF THE PATIENT 5 often unhealthy, eczema may be actually present, or readily appear in natural folds or clefts such as the ^roin, the axilla, the umbilicus, or in women, beneath the breasts. Satisfactory cleansing of the skin is under these circumstances difficult or impossible, and the wound on this account is very liable to become infected. The thick layer of adipose tissue may impede the satisfactory exposure of deep parts, and also interferes with the exact closure of the wound ; its blood-supply is poor and hence sloughing and cellulitis are likely to occur, especially if the margins of the skin incision have been much undermined. These facts help to explain the bad prognosis in cases of strangulated umbilical hernia, which nearly always occurs in excessively obese patients. The mortality after operations in these cases is very high, and is a great contrast to the results after operations for strangulated femoral and inguinal hernias, which are not usually associated with obesity. The prognosis in malignant disease, e.g. of the breast, is worse in obese than in spare patients. The growth extends widely in the fat, and its limits cannot be recognised ; the presence of the fat, too, obscures and renders difficult the recognition and complete removal of outlying nodules and of enlarged glands. Hsemophilia is a contra-indication to any but an absolutely essential and necessary operation. It is a rare condition, and as nothing abnormal is usually noticed until the hgemorrhage occurs, the surgeon often does not suspect it until after the operation. Most serious and even fatal haemorrhage may occur after the most trivial procedures, such as extraction of a tooth or incising an abscess. It must be remembered that though the tendency to excessive bleeding is usually noticed at a very early age, the child may reach the age of eight years or more before any abnormal liability to bleed is noticed. Should the patient live so long, the tendency to bleed diminishes towards middle age. Status lymphaticus is a condition about which little is known, but which is of the greatest importance both to the surgeon and the anaesthetist. It is characterised by enlargement of the thymus, and a general increase of the lymphatic tissues of the body, which may be indicated by slight enlargement of the lymphatic glands, enlargement of the tonsils, the presence of adenoids and a palpable spleen. These patients are generally pale flabby children, frecjuently rickety, who in spite of an unhealthy appearance are usually thought to be quite well. The subjects of this disease are liable to die suddenly from some apparently very trivial cause ; death may take place either during or shortly after the administration of an anaesthetic, or from shock after an opera- tion, often for some comparatively slight trouble such as adenoids. Postmortem nothing to account for the sudden death is usually found, except the excess of lymphoid tissue. The exact way in which death is caused is thus still a matter of doubt. The symptoms are so vague that status lymphaticus can scarcely be diagnosed though it may sometimes be suspected. Needless to say, under these circumstances the administration of an anaesthetic or any surgical operation must be undertaken with great caution. Other general constitutional conditions such as tuberculosis, syphilis, rheumatism, and gout are not in themselves of great importance in relation to operative treatment. Their chief importance is that they may be the cause of serious visceral troubles, which will be discussed in detail later on. Of course no operation should be performed during an acute 6 OPERATIONS OX THE UPPER EXTREMITY attack of gout or rheumatism, or during the primary or secondary stages of syphihs, unless it were most urgently called for. Apart from this, and in the absence of visceral complications, there is no reason why such patients should not do well. Tuberculous patients who require surgical treatment stand even extensive operations remarkably well. Active phthisis is. however, a strong contra-indication to the operative treatment of co-existing surgical tuberculous disease, unless for the relief of some urgent symptom. It is now necessary to consider the influence which lesions of the various viscera exercise upon the prognosis and the results of surgical operations. Very commonly when an operation is recommended the patient or his friends will ask " What is the risk ? " or '* Is the operation dangerous ? " These are frequently difficult questions to answer. Xo operation is entirely free from risk, even in a young and robust individual with, as far as one can tell, perfectly healthy organs. Indeed, when a death does occur during ansesthesia, it is surprising how often the operation is of a comparatively trivial nature, such as removal of adenoids or circumcision, in an apparently healthy patient. Death is then often due to some unsuspected or undiagnosable trouble such as the status lymphati- cus. The danger is naturally increased when the patient has some definite organic disease, for though he may survive the actual anaesthetic and operation, yet death may still occur after a longer or shorter interval from the additional strain thrown upon the diseased organ, or the vital powers may be so depressed that the patient dies from post- operative shock. It is thus of the greatest importance that some examination of the chief organs should be carried out before all except the most urgent operations. In the latter this examination may be reduced to a minimum, or even omitted altogether, for the disease or injury, a depressed fracture of the skull or a strangulated hernia for instance, may be such that unless quickly relieved death will surely and quickly occur. Under these circumstances any examination which will delay the operation must be avoided ; any risk, however serious, has to be taken. In young and healthy patients an elaborate investigation of all organs is not usually called for. The patient's general appearance is noted and he is questioned with reference to pre\aous illnesses and his general health. It should, however, be an invariable rule before any operation, even of the most trifling description, if a general anaesthetic is required, that the condition of the heart and circulation should be ascertained by actual examination, and that the urine should be carefully tested, especially for the presence of sugar and albumen. Xeglect of these precautions may result in a lamentable disaster. The influence oi \'iscerai lesions upon the prognosis of operative treatment may be considered under the following two heads, (a) As regards the immediate danger of the operation. Here it is necessary to estimate the effect of the anaesthetic and the shock of the operation upon • the diseased organ. We have already seen that even when serious visceral disease is known to exist, operation may be strongly indicated as the only possible means of saving the patient's life. The dangers of the anaesthetic may then be usually overcome with the help of a skilled anaesthetist, by the use of modern apparatus and methods, or by the employment of local or of spinal anaesthesia. These patients, however, may be unable to rally after the operation, the diseased organ may fail, or some compli- cation may develop which will lead to a fatal termination. Examination of the patient 7 (b) The (jfect of the Irsio)!, upon, the ultimate result of the operation. Even where no iniinediato (liiiij^'cr is anticipated frotn the antesthetic or the oper- ation, the probabh'ciTect of the visceral trou})h', upon the ultimate result must be carefully considered. For instance, if an elderly patient is known to suffer from chronic Bright's disease, or from a serious valvular lesion of the heart, one would not recommend an operation for the'radical cure of an uncomplicated hernia, for, apart from the immediate risks, the visceral disease is likely to prove fatal in the course of a few months or years. On the other hand, should such a patient have a strangulated hernia, one would unhesitatingly advise him to take the risk of the operation. In this case, while the immediate danger would not be excessive, the alternative to operation would be certain death from ob- struction. The existence of visceral trouble will in many serious diseases lead the surgeon to advise palliative treatment in preference to a radical operation. These points have especially to be considered before advising extensive operations for the removal of malignant growths in elderly patients. The present writer some time ago removed an extensive growth from the floor of the mouth of a patient who had a trace of albumen in his urine. Though at the time of the operation this man appeared to be strong and in good health, yet he died only four months later of cardiac dilatation and failure secondary to the chronic renal disease. Heart and Circulatory System. Preliminary examination of the heart and the circulatory system should be systematically carried out, chiefly on account of the danger of the anaesthetic and post-operative shock to a patient suffering from valvular disease or myocardial degeneration. ^ In addition to an examination of the cardiac sounds, it is of the greatest importance to ascertain whether there is any hypertrophy or dilatation of the heart, and in the event of this to look for any signs of circulatory failure such as oedema, enlargement of the liver, or an unduly rapid or irregular pulse. Advanced valvular disease is an absolute contra-indication to any but the most indispensable operations. Fibroid or fatty degeneratian of the myocardium is probably of at least as great importance as valvular disease and is far more difficult to detect. Before deciding upon an operation upon patients with these serious lesions, the risk of the operation and the ultimate benefit to be expected must be carefully considered. Such patients require careful anaesthetisation, but then usually take the anaesthetic well ; indeed, the pulse of a patient with valvular disease frequently becomes slower and more regular when he is under the influence of an anaesthetic. During the administration the greatest care must be taken to avoid any obstruction to respiration, for a diseased heart is liable to fail with the extra stress thrown upon it by even a slight degree of asphyxia. The successful termination of the anaesthetic and the operation by no means ends the danger for such a patient, for after he has been returned to bed the pulse may gradually get weaker, and death may still occur after a longer or shorter interval from cardiac failure. The existence of cardiac disease has, as a rule, no adverse influence upon the wound, which may be expected to heal in a normal manner. In advanced cases of valvular disease, however, oedema may appear around the wound, and there then is an increased liability to infection. Quite apart from any gross lesion of the heart, the circulation 1 Dr. Joseph C. Bloodgood (Annals of Surgery. 1912, vol. Iv, p. 641) in a paper on "The Estimation of the Vital Resistance of the Patient with Reference to the Possibility of Recovery after Operations," insists also on the importance of measuring the blood pressure. § OPERATIONS ON THE UPPER EXTREMITY may be seriously depressed as the result of some chronic disease such as tuberculosis of a bone or joint with many sinuses, or from some serious acute trouble such as intestinal obstruction or peritonitis. In the latter, indeed, if for any reason delay has occurred, the pulse may be so rapid and small that it can scarcely be felt or counted ; if in addition the extremities are cold, death may shortly be expected, and any operation is contra-indicated. When the circulation is less severely affected, the operation may be carried out under spinal or local anaesthesia, if a general anaesthetic is considered undesirable. Such patients often take a general anaesthetic surprisingly well, but only too frequently after the operation the pulse again fails, the heart does not respond to stimula- tion or infusion, and the patient dies. In addition to the condition of the heart, attention should also be directed to the character of the arteries. Extensive atheroma means that the tissues are degenerate, and that their nutrition is imperfectly carried out. A thickened arterial wall or a high tension pulse may direct the attention of the surgeon to arterio-sclerosis or to chronic renal disease. If there is any disease of the heart or of the circulatory system, and the operation, though desirable, is not urgently necessary, the operation may often vnth advantage be postponed for some days or weeks, during which time the cardiac lesion is treated. While the operation is in progress the surgeon should always observe the amount of bleeding and the colour of the blood. In this way important indications of depression of the circulation will often be brought to his notice. In severe cases of cardiac failure an extensive incision may be made ■v^ith practically no haemorrhage, and the few drops of blood which escape will be distinctly bluish in colour. These are indications for immediate attention to the condition of the patient. Respiratory System. A patient with any recent acute lung or pleural disease is naturally a bad subject for an anaesthetic or an operation. Occasionally, however, operation may be the only possible method of treatment of some complication, an empyema for instance. Under such circumstances the operation, or rather the anaesthetic, may be accompanied by considerable risk. Speaking of these cases. Sir Frederick Hewitt ^ says : " The most hazardous cases are those in which respiratory em- barrassment from recent pleurisy or pleuro-pneumonia co-exists with quick and hampered cardiac action. When the patient is slightly dusky, his temperature elevated, his breathing rapid and his pulse accelerated and sharp under the finger, the use of an anaesthetic is attended by considerable risk. This risk is greater in patients with previously fatty and dilated hearts than in others." Means for minimising this risk will be considered when the operation for empyema is described, but in very serious cases a local anaesthetic may be employed. Patients with slight chronic bronchitis, phthisis or emphysema may be expected to take an anaesthetic and to stand an operation well, provided that the heart is not secondarily affected. Obese patients with bronchitis are very bad subjects. They may be unable to breathe in the recumbent position ; the pulmonary trouble may be increased by the anaesthetic and lead to failure of the heart, which is probably already weakened by fatty infiltration and degeneration. A bronchitic patient presents other difficulties to the surgeon. The continual coughing will make the patient restless and, especially after abdominal operations, will throw great strain 1 Ancesthetics, 1901, p. 127. EXAMINATION OF THE PATIENT 9 upon the stitches. Bandages around the chest or the abdomen if tight produce much dyspnoea and discomfort, while if loose they are very liable to slip and the dressings to become displaced. An ansesthetic, especially ether, may sometimes apparently be the cause of an acute attack of bronchitis or pneumonia. The latter may be a broncho- pneumonia when it is probably due to imperfect expectoration of catarrhal secretion, or a lobar pneumonia when the inhalation may be the pre- disposing cause. In rare cases an anaesthetic may render active a latent tuberculous disease. In elderly patients prolonged rest in bed may lead to congestion of the bases of the lungs, a condition which is likely to develop into hypostatic pneumonia. This is a very fatal post-operative complication in such patients, and is best avoided by getting them up as soon as possible. The condition of the upper respiratory passages should always be noted, for any obstruction to the free flow of air is pretty certain, owing to venous engorgement, to be increased during anaesthesia. When the field of operation is the buccal or pharyngeal cavity, the removal of a malignant growth of the tongue, floor of the mouth, or the pharynx, for example, blood may be drawn into the larynx and seriously obstruct breathing. Even when it causes no actual obstruction, portions of clot may be inhaled and thus be the starting-point of a septic broncho-pneumonia — a serious danger after these operations. In such cases intratracheal insufilation of ether ^ is the most satisfactory method of maintaining anaesthesia, and is most efficient in preventing the entrance of blood into the respiratory passages. Plugging the pharynx with sterilised gauze after a preliminary laryngotomy, or Crile's method of inducing anaesthesia by means of nasal tubes with subsequent packing of the pharynx may also be employed. Tumours of the neck, especially an enlarged thyroid, may be a considerable source of danger during anaesthesia. This to a great extent is mechanical, and is the result of asphyxia brought about by the pressure of the tumour, which is increased in size by vascular engorgement, upon the trachea. These dangers and the means by which they may be over- come will be fully considered when the operative treatment of goitre is discussed. Urinary System. An examination of the urine should be made as a routine measure before every surgical operation. Should albumen be present every endeavour should be made to ascertain its origin and its significance. If necessary the centrifugalised deposit should be examined microscopically for the presence of casts, for if the albumen is the result of any form of nephritis it must have a most important bearing upon the prognosis and the treatment. Patients suffering from Bright's disease are certainly bad subjects for operation. They may be unable to rally from the shock of a severe operation, owing probably to the imperfect excretion of toxic products. In other cases definite symptoms of uraemia may supervene or even suppression of urine, either of which is practically certain to terminate fatally. These serious complications are especially likely to occur when the operation is for some injury or disease of the pelvic or renal organs. It must also be remembered that patients with chronic nephritis are very liable to a number of serious complications. Of these cardiac dilation and hypertrophy which may terminate in heart failure is the most important. Other complications, such as bronchitis, pleurisy, pneumonia, pericarditis, and peritonitis, 1 See p. 781. 10 OPERATIONS ON THE UPPER EXTREMITY are of a chronic inflammatory nature. Any of these may readily appear as the result of the extra strain of an operation upon the system. If already present they will certainly be made worse, and in either case the patient is very likely to succumb. Lastly, as the result of changes in the vascular system and the deficient excretion of toxic products, various cutaneous lesions, such as eczema, boils, carbuncles, and even erysipelas, may already be present or are likely to develop. These, in addition to a greatly increased liability to wound infection, may seriously and adversely affect the progress of the patient. The mere presence of albumen is, of course, in itself not a contra-indication to operation ; in women it may be the result of a vaginal discharge, while in men it may be derived from some lesion in the urethra or the bladder. An explanation of the albuminuria should, however, in all cases be sought for. Even when chronic nephritis is known to exist, operations are not necessarily contra- indicated ; such patients may do well even after severe operations. What is needed is a careful consideration and estimation of the risks to be run and the benefits to be expected. The latter will often be found to altogether outweigh the former. If possible in such a case a period of rest and treatment of the nephritis and its complications should precede the surgical treatment. Should the operation be required for some disease of the kidneys or other portion of the genito-urinary tract, it is most necessary to ascertain the source of any albuminuria, haematuria, or pyuria, and to investigate the excretory functions of the kidneys. Fortunately the modern methods of radiography, cystoscopy, and catheterisation of the ureters, with examination of the urine secreted by each kidney, are of the greatest service in enabling one to estimate the functional condition of these organs. We may here consider the question of operations upon patients who are suffering from diabetes. Such patients are very bad subjects for operative treatment, and this disease should contra-indicate any except absolutely necessary operations. The dangers may be considered in the three following groups. (a) There is a distinct danger that the patient may die of diabetic coma. This condition usually develops as the result of mental or physical shock in the subjects of this disease. An anaesthetic or an operation is thus very likely to be the exciting cause. The liability to coma is much diminished if the disease is being treated and the amount of sugar lost is under control. Especially dangerous are those cases in which the disease is unrecognised and untreated, when death may unexpectedly follow a comparatively trivial operation. For instance, the writer knows of the case of a young man aged 20 who was operated upon for a varicocele. Next day the patient became comatose, and the urine, then tested for the first time, was found to contain large quantities of sugar. (6) The tissues of a diabetic patient are unduly liable to infection by pyogenic organisms. The wound is thus liable to slough, suppurate, or to become the starting-point of a spreading cellulitis which is very difficult to treat. Gangrene, usually moist in character, may occur in diabetics, either spontaneously or after operation. In either case arterial degen- eration and peripheral neuritis, which commonly co-exist, are probably predisposing causes. The gangrene usually occurs in elderly patients, is commonly moist in character, spreads rapidly, and almost always ends fatally. EXAMINATION OF THE PATIENT 11 (c) Certain complications are likely to occur in diabetic patients which will assuredly have a serious bearing upon the prognosis. In addition to the septic troubles mentioned alDove, the skin may be the seat of various lesions such as eczema, boils, or even carbuncles. Lastly it must be remembered that a diabetic is very liable to develop tuberculous disease of the lungs. It is always desirable in diabetic patients to post- pone, if possible, any operation until treatment by dieting and by drugs has produced a considerable decrease in the excretion of sugar. The dangers of the operation will in this way be greatly diminished. Should the condition be regarded as glycosuria rather than as diabetes, that is when there is but a small amount of sugar and no polyuria, the actual operation risk is not serious. It must, however, be remembered that a persistent glycosuria is a grave condition and that such cases may eventu- ally develop into true diabetes. Alimentary System. Diseases of the digestive tract will naturally have a considerable effect upon the general health and condition of the patient. The subjects of chronic dyspepsia, and those suffering from chronic constipation, are not likely to be in a satisfactory state for a severe operation, and it must be remembered that these troubles are certain to be increased by the subsequent rest in bed. Operations should be avoided, if possible, in patients with serious organic disease of the liver such as cirrhosis, lardaceous or fatty disease. Colitis, dysentery, and other chronic intestinal disorders are also contra-indications to general operations, though in these and other similar conditions surgical treat- ment may be required, and successfully carried out, for the intestinal disease itself. The condition of the mouth and teeth should always be observed, and if septic or carious teeth are present they should, if time permits, be attended to before the operation. This is especially desirable if the operation is for some disease in the mouth or pharynx. Apart from its effect upon digestion and the general health, oral sepsis means that the patient has a septic focus from which organisms may be carried by the blood-stream to the wound, or indeed to any part of the body. Nervous System. The influence of functional disease of the nervous system has been indicated A\'hile the question of temperament was under discussion. An hysterical p;itient i-s very liable to nervous attacks either before or after the operation ; in the latter case these are likely seriously to interfere with the after-treatment. Necessary operative measures may be carried out in the insane with a good prospect of success. provided that there is no marked bodily disease and that there are no unclean or mischievous habits which would seriously imperil a satisfactory result. When, however, the patient is \'ioleut or maniacal, an operation has but a faint prospect of success. "When there is a definite organic nervous trouble, such as locomotor ataxy for instance, none but essential operations should be carried out. These diseases may, however, run a very chronic course, and the patients often do well in spite of the disease of the nervous system. When grave symptoms are caused by some lesion of the nervous system which is amenable to surgical treatment, an operation may be successful even when the condition of the patient appears to be most desperate. He may be absokitely comatose as the result of increased intra-cranial pressure after a depressed fracture, haemorrhage from the middle meningeal artery, or from a cerebral abscess, and vet recover after these conditions have been relieved. 12 OPERATIONS ON THE UPPER EXTREMITY PREPARATION OF THE PATIENT FOR THE OPERATION General Preparation. It is now necessary to consider in some detail the preliminary treatment and the general preparation. It is advisable in all cases that the patient should be mider observation in the hospital ward, imrsing home, or wherever the treatment is to be carried out. for at least twenty-four hours beforehand. Of course in grave surgical emergencies, time is of such importance that the operation must be performed as soon as possible, at the expense of or even to the total exclusion of all these precautions. In many cases a longer period than twenty-four hours is desirable, and. as has already been indicated, when there is any adverse local or constitutional trouble ample time should if possible be allowed for its satisfactory treatment. Immediately upon admission to the institution the patient should have a hot bath and thoroughly wash the whole body. Should the local or constitutional condition render this undesirable, he is at once put to bed and then thoroughly washed by a nurse. This will be repeated daily through the whole period of preliminary observation. During this time the condition of the teeth and mouth should also always receive attention, especially if the operation is for some disease of the upper respiratory passages. When tartar is present, or when there are septic or carious teeth or roots, it is desirable that these should receive attention before the operation. When these troubles are not present, the use of the tooth- brush, and the occasional use of some antiseptic mouth-wash such as chinosol 1 in 1000, are all that are required. Any other focus of infection such as tonsilUtis, nasal catarrh, boils or other cutaneous lesions, especially if in or near the field of operation, should also receive careful attention. The bowels should be emptied by a purgative administered on the preceding day, followed by a saline aperient or soap and water enema six hours before the operation. Should the operation be for some disease of the rectum or other part of the intestinal tract, it is most desirable that the bowel shall be empty. In the former case, an opera- tion for piles for example, a copious enema should be administered about eight hours before the operation. On the other hand the purging must not be overdone, for it is naturally a bad thing for the operation to take place while the patient has an attack of diarrhoea from this cause. Excessive purgation, too. is likely to have a serious effect in elderly patients, or in those suffering from an exhausting disease. It is desirable that for some days beforehand only light and easily digestible food should be taken. The stomach should always be empty during the administration of an ansesthetic. and hence the time of the meal immediately preceding vdW depend upon the hour at which the operation will take place ; it is generally agreed that the best time is the morning at an early hour. In this case a healthy adult will have had nothing after his evening meal the preceding day, with perhaps the exception of a cup of weak tea two or three hours before. If, however, the patient's general condition is weak, or in old people, such long starvation is undesirable. These may be allowed small oc- casional feeds of clear soup or chicken broth throughout the night. In some cases where there is much exhaustion a little alcohol in the form of weak brandy or whisky and water may also be allowed. If the opera- tion is to take place at any other hour of the day the last meal should, as prp:paratiox of the patient 13 a general rule, be given about five hours before the commencement of the anaesthesia. The bladder should always be emptied before the patient is brought into the operating room. Should there be any question as to this having been satisfactorily accomplished, a catheter should be passed, especially before abdominal or pelvic operations. The patient should be suitably clothed in a clean night-gown or pyjama suit ; the former is usually to be preferred, and should be made to completely unbutton at the back so that it may be readily adjusted or removed as required during the operation. In weak and exhausted patients, and especially in elderly people and children, additional warmth may be secured by loosely bandaging the limbs and any part of the body which need not be exposed, over a thin covering of cotton-wool or gamgee tissue. Any false teeth must be removed before the commencement of the ansesthetic. Asepsis. It is now necessary to consider a most important series of preparations and precautions, the object of which is to prevent infection of the wound. In other words we have to describe the means for securing Asepsis. A short sketch is all that can here be given ; for fuller details the reader is referred to some such book as Lockwood's Aseptic Surgery (1909), from which many of the facts described below are taken. The importance of asepsis is now universally admitted. If any wound suppurates, even to the slightest extent, it means that infection has somehow occurred ; in the great majority of cases this is brought about by some failure in the aseptic precautions of the surgeon or his assistants. The universal presence of pathogenic organisms which are the cause of inflammation, suppuration, and serious comphcations such as pyaemia and septicaemia, has been amply proved. Any object, be it a ligature, an instrument, the hand of the surgeon or the skin of the patient, must be regarded as septic and liable to infect a wound, unless it has been specially prepared to ensure the destruction of all organisms which may be present. Infection of a wound may be brought about in any of the following ways. (1) Air Infection. Though the air may contain large numbers of micro-organisms.^ both pathogenic and non-pathogenic, this source of infection is not of great importance provided that certain precautions are taken. When the air is dry and contains much dust, many organisms will be present ; if the air is perfectly still the dust and bacteria gravitate, with the result that the air does not infect culture-plates. Also when the air is saturated ^^^th moisture it is practically sterile. Organisms are with difficulty detached from a moist surface ; dust must therefore be both carefully and thoroughly removed from the ope- rating room. Expired air, in ordinary quiet breathing, is stated to be practically free from organisms. When, however, as happens in coughing, sneezing, or talking, small particles of saliva or nasal mucus are projected, various pathogenic organisms are certain to be present. Streptococci, for instance, are always found in saliva. Particles of dust from the hair are naturally septic and can readily infect a wound. It is thus very necessary that the surgeon and his assistants should take precautions to ^ Mr. Lockwood quotes experiments in which sterilised culture-plates were exposed for a few minutes in hospital wards and operating theatres. Among the organisms found were the Bacillus coU, Staphylococcus pyogenes aureus and albus, as well as many non-pathogenic moulds and sarcinse. Streptococcus pj'ogenes was found in the air of the erysipelas ward, while the tubercle bacillus was very commonly present in the air of wards occupied by phthisical patients. 14 OPERATIONS ON THE UPPER EXTREMITY prevent this accident, which is exceedingly hkely to happen on bending over a wound, especially if two heads should come into contact. It may here be mentioned that flies and other insects may be the means of con- veying septic organisms and so infecting a wound. (2) Skin Infection. Infection of the wound by organisms which are found either upon the surface or in the deeper layers of the skin is undoubtedly a very common cause of suppuration after operations. I'he wound may be infected from the skin of the patient or from the hands of the surgeon or of any of his assistants. The surface of the human skin swarms vnth various cocci, bacteria, and other organisms both pathogenic and non-pathogenic, even in a cleanly individual ; this is especially the case when there is any hair present to collect and retain particles of dust. When the skin is obviously dirty, or when any disease such as eczema is present, their variety and number are greatly increased. Organisms are certain, too, to be present in large numbers in any natural folds, wrinkles, or depressions, such as the axillse, the groin, or the umbilicus. Such localities always require careful attention, and even then, owing to the numerous sweat and sebaceous glands and a liability to dermatitis, are very difficult to render surgically clean. With regard to the hands of the surgeon, the grooves beneath the nails, and any loose tags of skin, are certain to contain and shelter many infective organisms. Needless to say, rough, cracked, or chapped hands, or the presence of any sej^tic lesion, mean many organisms which it will be difficult or impossible to destroy even by the most careful cleansing process. It is necessary to bear in mind that numerous cocci and bacteria always exist in the deeper layers of the skin. This is largely owing to the presence of the sebaceous and the sweat glands. If the surface of the skin is carefully cleansed, and perspiration subse- quently occurs, these septic organisms are brought to the surface in large numbers by the secretion ; their presence may also be proved if, after the skin has been prepared, material is squeezed from the sebaceous glands. The fatty nature of the secretion also to a great extent protects the organisms and thus hinders their destruction by watery antiseptic solutions which do not dissolve fatty substances. (3) Infection hy Instruments. Unless careful precautions are taken, a clean wound may be easily infected by the use of instruments which have previously been ■ employed for a septic case. Blood, pus, or other septic material may readily lodge in the serrations or joints of such instruments as forceps or scissors. Instruments are now made as far as possible entirely of metal, with only necessary grooves and ridges, in order to facilitate cleaning. After use, all blood or discharge must be removed by careful washing and brushing ; many such instruments as forceps and scissors are constructed with detachable joints which allow the two halves of the instrument to be separated during the cleansing process. If not properly cleaned, even boiling may fail to effect perfect sterilisation, for the albumen of the blood \n\\ be coagulated and will thus form an envelope which is likely to protect organisms and especially spores from the action of antiseptic lotions, or even for some time from the action of boiling water. (4) Infection hy Towels, Swabs, and Dressings. Unless all these articles are freshly and effectively sterihsed before the operation they may easily infect the wound. Towels, for instance, though fresh from the laundry and apparently quite clean, are in reahty extremely septic, PREPARATION OK THE PATIENT l.> partly owing to contamination by dust, but also by the water in whicii they were washed, probably in company with many other soiled and dirty articles. Dry gauzes and wools, even though impregnated with antiseptics, will also collect dust and thus harbour many organisms. Unless recently sterilised, gauzes should only be applied to the wound after immersion in an antiseptic lotion. Marine sponges are now practi- cally obsolete, for, owing to their porous structure, when they have once been used their subsequent sterilisation is a matter of considerable difficulty and uncertainty. Their place is taken by swabs of absorbent material such as gamgee tissue enclosed in layers of gauze. (5) Infection hy Sutures and Ligatures. All materials used for ligatures and sutures are certain to be contaminated until they have been carefully sterilised. This is especially the case with catgut, which is prepared from the intestines of sheep after the mucous membrane has been more or less thoroughly removed by scraping. Raw catgut, from its origin and mode of preparation, is thus certain to contain numerous pathogenic organisms, and unless effectively sterilised is extremely likely to infect the wound. It is said that even anthrax has been transmitted to a wound by im- perfectly sterilised catgut. This material has, however, many advantages in favour of its use for buried sutures : it is strong, pliable, easy to manipulate, and is eventually absorbed and is hence very ganerally employed. Fortunately, though it cannot be sterilised by boiling in water, there are other very effective methods of sterilisation which render it quite safe and reliable. (6) hifeetion hy Water. There is less danger of infection from water than might have been supposed, for though ordinary tap water may con- tain many bacteria, cocci and other organisms are chiefly saprophytes, and hence do not grow in living tissues. Sej^tic organisms such as the Bacillus coli and various forms of streptococci and staphylococci may, how- ever be found, but in good tap water, such as is supplied in London, these organisms, if present, occur only in very small numbers. The water may, however, be contaminated by dirty taps or by contact with improperly prepared vessels. In the operating theatres of Guy's Hospital the water, both hot and cold, which is used for preparing lotions and saline solutions for irrigation and other purposes, is filtered through Berkefeld filters. This water is regularly examined bacteriologically, and organisms of any description are only found on rare occasions. Cleansing or renewing the internal mechanism of the filter then results in their disappearance. If tap water is boiled for a few minutes, or if antiseptics in the pr.oportion required for making the ordinary lotions are added, all organisms are quickly destroyed. Boiled tap water may thus be quite safely used for the preparation of lotions, or of saline solutions for infusion or irrigation. Indeed, for the former purpose boiled tap water is preferable to distilled water, which usually contains many organisms and may on this account be decidedly toxic. (7) Auto-inoculation. Infection of the wound by organisms conveyed by the patient's own blood-stream may certainly occur. It is, however, unlikely, and though its frequency cannot be ascertained, it is probably a very rare cause of suppuration compared with local infection of the wound. This is shown by the rarity of suppuration after an injury which does not wound the skin — a simple fracture for instance. When it does occur there is nearly always some obvious local septic focus such as pyorrhoea alveolaris, a septic throat, or some septic ulcer or sinus, 16 OPERATIONS ON THE UPPER EXTREMITY On this account it is highly desirable that any such trouble should be recognised and efficiently treated before the operation. It will now be necessary to consider the precautions which must be taken to guard against infection. Sterilisation may be effected either by the action of heat or by the use of chemical antiseptics. The former is the more effective method but cannot always be employed. The skin and other living tissues, for instance, can only be cleansed by the mechanical processes of washing and irrigation, and by the use of anti- septics. It must be remembered that strong antiseptic lotions may have a very serious effect upon living tissues, the vitality of which is probably already lowered by injury or disease. The skin may be irritated, or even a severe dermatitis may be produced ; delicate tissues may slough or have their vitality so depressed that their power of resistance to infecting organisms is greatly diminished. A. Preparation oJ the Skin of the Patient. Two methods must be described. (1) By antiseptic comipresses. This method is now but seldom employed. After careful shaving for some distance around the proposed incision, the surgeon, having first carefully cleaned his own hands, then thoroughly scrubs the skin with a sterilised nail-brush and hot soap and water to which a little dilute liquor potassse has been added. The process is then repeated with an antiseptic lotion such as lysol 1 per cent, or carbolic lotion 1 in 40. A compress, consisting of several layers of lint, which after sterilisation by boiling is soaked in the same antiseptic solution, is then applied. This is covered with a» layer of gutta-percha tissue and is then bandaged in position. The compress remains in position for twelve or twenty-four hours, or even longer before the opera- tion. In the latter case it is usually changed and a fresh compress similarly prepared applied every twelve hours. Unfortunately this treatment not infrequently defeats its own object. The mechanical effect of the brush combined with the irritant action of the antiseptic may produce severe irritation of the skin or even an acute dermatitis. When this occurs, infecting organisms are certain to be present and the operation must be postponed until the skin has recovered. It is now recognised that all irritation of the skin is harmful and that thorough washing with soap and hot water is the most effective and least irritating means of cleansing the skin. This will not destroy the organisms in the deeper layers, though the mechanical effect of the washing will, to a considerable extent, remove the secretion of the glands. Alcoholic solutions of antisepti-cs, such as biniodide of mercury 1 in 1000, have however a powerful action in destroying these cutaneous organisms, probably because the alcohol dissolves fatty substances and thus secures greater penetration of the solution. (2) The Iodine Method. Within the past few years it has also been recognised that an alcoholic solution of iodine has remarkable powers of destroying the cutaneous organisms. The strength of the solution should be between 2 per cent, and 5 per cent. The tincture of iodine (B.P.) contains 2| per cent, iodine and answers admirably. A solution of iodine in methylated spirit should not be used, since the iodine readily evaporates from this and causes intense irritation of the eyes of those present in the room. A most important point to remember when iodine is used, is that for its efficient action the skin must be dry. This has led some surgeons to dispense with preliminary shaving of the skin. Hair is, however, of such importance in collecting dust that shaving is PREPARATION OF THE PATIENT 17 certainly desirable. It may be carried out by means of a sharp dry razor without wetting the skin, or if the razor is used after washing and lathering, the skin should be thoroughly dried with a sterilised swab and then treated with alcohol or ether before the application of the iodine solution. The sterility of the skin may be tested by examining bacterio- logically a thin snip through its entire thickness from the margin of the operation incision. In one series of thirty-five consecutive cases, in which tincture of iodine was the only antiseptic used, only three on cultivation showed the presence of any organisms, and in each of these the Staphy- lococcus albus was found, ^ The exact details of this mode of skin preparation naturally vary somewhat in different hospitals and with different surgeons. It is, however, generally agreed that it should, whenever possible, be carried out before the patient is removed to the operating room. By this means much mess and unnecessary loss of time may be avoided. The entire preparation, however, may in an urgent case be carried out with ad- vantage in the operating room. If the former method is decided upon, the surgeon, after carefully washing and preparing his own hands, shaves the skin of the patient for an area considerably beyond the limits of the proposed incision : should this be in the groin or the abdomen the pubes should always be completely shaved ; it is not sufficient to remove the hair from the side of the incision only. The shaved area is then thoroughly washed with soap and hot water for at least five minutes, A boiled nail-brush should be used, but not too \agorously, and the dirty soap and water must be frequently washed away. Soft soap may be used, but ether soap or a solution of soap in spirit is preferable.^ The skin is dried as thoroughly as possible with a sterilised swab and then washed over with ether. When this has evaporated, tincture of iodine is freely applied to the whole prepared area. Special care is directed to the umbilicus or to any skin fold such as the axilla or the groin. The prepared area is then covered with a sterilised pad or towel, which is secured in position by a bandage. The patient is now ready to be transferred to the anaesthetising room. Before the commencement of the operation the pad is removed and a final application of tincture is made.^ When in urgent cases the entire preparation is carried out in the operating theatre, this procedure must be modified. In a cleanly patient the skin may be shaved with a sharp dry razor, and then, after washing with ether, the iodine solution is applied. If the skin is devoid of hair the shaving may be omitted ; if it is obviously dirty it must be first scrubbed with ether soap and hot water, then thoroughly dried with a sterilised pad, and finally, after treatment with ether or alcohol, is painted over with the iodine solution. When septic ulcers, sinuses, fistulae, or granulating surfaces are present, it is impossible to sterilise them or the adjacent skin. The use of a nail-brush under these circumstances is liable to be actually harmful, as by this means infective material may 1 Hec Lancet, 1911, vol, 1, p, 73.3, 2 A solution of two parts of soft soap in one of methylated spirit may be used. Ether soap (B.P.C.) has the following composition: oleic acid, .^vij ; potassium hydroxide, saturated solution, a sufficient quantity ; alcohol, giij ; oil of lavender, iq xx ; methy- lated ether to 5xx. ^ A 1 per cent, solution of picric acid in rectified or methylated spirit has also been strongly recommended for sterilising the skin. It is applied in the same way as the tincture of iodine. This solution is much cheaper and is said to penetrate much more readily to the deeper layers of the epidermis than the iodine solution. SURGERY I 2 IS OPERATIONS ON THE UPPER EXTREMITY be rubbed into and thus infect the sldn. Septic sinuses and fistulse may be plugged with gauze, but should if possible be covered by steriHsed towels or pads during the operation. Masses of granulation tissue or fungating growth may sometimes with advantage be sterilised by the use of the actual cautery. B. Preparation of the Operating Room. In every properly equipped hospital or nursing institution one or more rooms are specially constructed and set apart for the performance of operations. A modern operating theatre need not be described here in detail. It should, however, be a large, well- ventilated room which can be quickly heated. The floor should be of some material such as mosaic or concrete — not of wood — which is free from cracks and joints and can readily be cleaned. The walls and ceiling should be tiled, or made of some smooth material which will not collect dust and can easily be washed. All corners and angles should be rounded, and there should be no ledges, cracks, or crevices in which dust can collect. Needless to say there must be no unnecessary furniture, only the operating table, smaller tables for in.struments, dressings, and aneesthetic apparatus, and if desired, stools for the operator and the anaesthetist. These should all be constructed as simply as possiVjle of metal and glass and should be kept scrupulously clean. It will sometimes be impossible to move the patient, and the surgeon will then have to operate in a room .in a private house. In this event all unnecessary articles of furniture, as well as all pictures, curtains, carpets, and rugs, should be removed from the room most suitable for this purpose. It is desirable that these preparations should be carried out on the preceding day. so as to allow time for thorough dusting of the room and scrubbing the floor. Immovable articles of furniture should be covered over with sheets which have been sprinkled with carbolic lotion. Most modern operating rooms are provided with a small adjoining room in which the patient is anaesthetised, and another in which the surgeon and his assistants prepare for the operation. No one thus enters the operating room until he is fully prepared and is wearing a sterilised overall, cap, and mask. C. Preparation oi the Surgeon and his Assistants. The hands of the surgeon and his assistants are undoubtedly a very likely source of wound infection. Their preparation thus demands the greatest care. At the present day thin rubber gloves, which can be sterilised by boiling, are almost invariably worn. This, however, does not render careful preparation of the hands any the less necessary. During the operation the glove may be pricked or torn ; septic fluid will then exude through the puncture and infect the wound unless the hands have been thoroughly sterihsed. Exactly the same precautions must be taken by all assistants, otherwise instruments, sutures, or dressings may be infected by contact with their septic hands. If the surgeon has any suppurating or infective lesion on the hand or fingers he ought not to operate, for it is impossible to sterilise such an area which is thus a source of great danger. The nails should be cut as short as possible to facilitate cleansing of the underlying groove. The skin of the hands must be kept smooth, for any roughness, from the repeated use of lotions or other cause, means innumerable minute cracks and depressions in which organisms may collect, and which render sterilisation a matter of great difficulty or even impossibiUty. The hands should be cleaned by thoroughly scrubbing them with a boiled nail-brush and hot soap and water for at least five minutes. The water must be as PREPARATION OF TIIK PATIENT 19 hot as possible and should flow as a continuous stream or spray. If a basin is used for washing, the water should be changed several times during the cleansing process. The hands may then be rinsed in weak lysol and finally are immersed in an alcoholic solution of biniodide of mercury (1 in 1000). The gloves, which have been rendered sterile by boiling for five minutes, are now put on. The surgeon then takes an overall, a cap and a mask, all of which have been previously sterilised. The case containing these is opened by a nurse, and care is taken that neither the overall nor the surgeon's hands touch the edge of this receptacle. The overall should be of sufficient length to reach to the ankles, and it should be provided with sleeves which are not too loose and can be buttoned at the wrist. The cuff of the glove should be turned up over the sleeve of the overall so that no part of the forearm or wrist is left exposed. Short-sleeved overalls should not be worn, as they leave a considerable area of forearm uncovered which is probably imperfectly sterilised and is certain to come into contact with towels or instruments. The cap, which ought to completely cover the hair and fit fairly tightly to the head, may be placed on the head by an assistant. The mask, which consists of several layers of gauze, should cover both the nose and the mouth, and if the surgeon wears a moustache or beard these also. It is desirable that clean rubber overshoes should be worn over boots while in the operating theatre. Otherwise mud and dirt from the streets, which is swarming with organisms and can easily be disseminated as dust, will certainly be brought into the theatre. D. Sterilisation of Instruments. Instruments should be sterilised by boiling them in a metal steriliser for at least five minutes, care being taken that the instruments are completely immersed. A teaspoonful of ordinary washing soda may with advantage be added to each pint of water. This shghtly raises the boiling-point and also prevents the instruments rusting. Most sterilisers are provided with a perforated tray which may be removed and the instruments tipped into a sterilised dish containing carbolic lotion (1 in 20), lysol 2 per cent., or boiled water, according to the wish of the operator. If there is no perforated tray, the instruments should be removed one by one with a pair of boiled forceps. Before the operation the instru- ments may be arranged upon a sterilised towel spread out upon and completely covering a small glass table set apart for this purpose. Cutting instruments are liable to be blunted by this treatment. If boiled they should be wrapped in gauze to prevent contact with other instruments, or they may be effectively sterilised by leaving them in carbolic lotion (1 in 20) for fifteen to thirty minutes, or in absolute alcohol for about the same time. Though instruments should not be needlessly prepared, all that are required or are likely to be required should be sterilised before the commencement of the operation : if any instrument is unexpectedly required the process of sterilisation is apt to be hurried and hence imperfect. After the operation the instruments must be carefully washed and scrubbed to remove all traces of blood and discharge. They are then boiled and dried before being put away. E. Sterilisation of Sutures and Ligatures. Many materials have been employed for sutures and ligatures. Those in common use at the present day are silkworm gut and horsehair for the skin, and celluloid thread, silk, and catgut for uniting deeper structures. Michel's metal clips are also frequently used for bringing the divided edges of the 20 OPERATIONS ON THE UPPER EXTREMITY skin into apposition. Silver wire, though occasionally used for suturing bone, is but seldom used for approximating soft parts. AU the above with the exception of catgut can be sterilised by boihng ; silk, however, requires special precautions. Short lengths should be unwound from the wooden reels on which it is supphed and rewomid on small glass reels or rods, taking care that the threads are nowhere more than two or three deep. These are boiled for twenty to thirty minutes immediately before the operation and are then transferred to a sterilised vessel containing 1 in 20 carboUc or other antiseptic lotion. The sterihsation of catgut is a matter of much greater difficulty. This material is made from the intestines of sheep, and though the mucous membrane is supposed to have been scraped away this is by no means perfectly carried out. Raw catgut is thus certain to contain many organisms, and unless effectively sterilised is very likely to infect woimds in which it is used. It is destroyed by boiling in water, and hence other more complicated and lengthy means have to be employed. Catgut has the crreat advantage that it is eventually absorbed ; it is also strong, phant- and easy to manipulate. Thus, in spite of difficulties in sterilisa- tion, it is a favourite material for deep or buried sutures. Most instru- ment makers supply catgut already sterilised in sealed tubes. If supphed bv a good firm these are thoroughly rehable. The tubes should be hermetically closed ; any information as to the size of the contained threads or the mode of preparation should be etched upon the glass ; there should be no paper labels either within or outside. Before break- ing open the tubes their outer surface should be sterilised by prolonged immersion in an antiseptic lotion. Many methods have been suggested for the sterilisation of catgut. Most of these are comphcated. and the result is often uncertain. The following are simple and effective. In all cases the raw material should first be thoroughly washed in water, and then soaked in ether for twelve hours to remove all grease. Mayo Robson recommends that catgut should be sterilised by placing the washed strands in a strong metal vessel proArided with a screw top containing xylol. This is immersed in boiling water for half an hour, at the expira- tion of which the catgut is transferred to a 5 per cent, solution of carboUc acid in alcohol. Moynihan recommeniJsthat the catgut,which has been previously cleaned and wound on glass reek, should be boiled for twenty minutes in a saturated solution of ammonium sulphate, the boiling-point of which is 128" C. It is subse- quently washed in boiled water to remove excess of the salt, and is then placed in a solu- tion of iodoform 1 part, ether 6 parts, in absolute alcohol 14 parts. By either of these means catgut may be raised to a tem- perature of KiO- C. or above without being destroyed. Another simple and effective mode of preparing catgut is by prolonged immersion in a solu- tion of iodine : either of the ,, , . -it * t * _„ following mav be emploved. Fig. 1. A convenient form of sntore forceps. ,i . t j- , * * *• ~ '^ (1) Iodine 1 ounce, potassium iodide I ounce, water 5 pints. (2) Tincture of iodine 1 part, alc-ohol (45 per cent.) 15 parts. In either case it should not be used until it has soaked for eight days. PREPARATION OF THE PATIENT 21 Sterilised sutures of all descriptions, and especially silk and catgut, should be handled as little as possible. The assistant who has charge of them must exercise the greatest care to ensure that they do not touch the outside of the vessel in which they are contained, and that the ends do not come into contact with any septic object as he hands them to the operator. Special forceps with smooth blades that vdW not fray the material (Fig. 1) should be used for their manipulation, especially for keeping the tlir^ad taut duriiitr the iiisprtiou of a continuous suture. F. Preparation oJ Towels and Overalls. A number of sterilised towels will be required for every operation. They are arranged around the prepared area in such a way that, though this is adequately exposed, the patient and all blankets. &c., over him are completely covered. Should the operation be in the region of the thorax, head, or neck, the towels must be arranged so as to shut off the anaesthetist and his apparatus from the field of operation. This may be accomplished by fastening a towel round the patient's neck and then raising it over a hoop, or, in some cases, by securing a large sterilised pad across the patient's face.^ All towels should be securely fastened in place by means of sterilised clip forceps. Towels and overalls should be sterilised by steam under high pressure. Unless this precaution is adopted it is found that the folds of the towels interfere with the due penetration and action of the steam. They are taken from the steriliser in air-tight cases, from which thev are removed in the operating room by an assistant who has alreadv prepared himself in the manner described above. If circum- stances render it impossible to obtain towels sterilised in this way. they mav be effectivelv prepared by boiling in water for half an hour. G. Preparation of Dressings, Swabs, &c. Dressings may be di\'ided into two classes : [a) those which contain no antiseptics but are sterilised by heat ; (b) those which are impregnated with antiseptics. The former include gauze and pads which are made of gamgee tissue cut into squares of convenient sizes and enclosed between layers of gauze. These, together with absorbent wool and bandages, may be sterilised in the same manner as the towels. \'iz.. by steam under pressure. The latter group includes iodoform, sal-alembroth. and cyanide gauzes. Though impregnated with antiseptics, these materials are liable to collect dust, and so may contain many infecting organisms. They are accordingly kept in some such antiseptic lotion as formalin (1 in 500). which soon renders them sterile. Immediatelv before use they are wTung out in sterilised water to remove the formalin. Sal-alembroth and salicylic wools are also occasionally used, but onlv as an outer covering for the sterilised dressings in actual contact with the wound. Pads and swabs, which are used for spongmg, are sterilised in the same way as the towels and dressings. Before the commencement of the operation the sterilised instruments, sutures, and swabs mav be arranged by an assistant, whose hands have been pre- pared and gloved, upon one or more small tables, the glass tops of which are completelv covered by sterilised towels. THE OPERATION Before commencing the operation the surgeon should have carefully thought out his mode of procedure. Each assi-stant should have his particular duties assigned, and care must be taken that all instruments, ^ See also the method described for operations on the Thyroid Gland, p. 620. 22 OPERATIONS ON THE UPPER EXTREMITY dressings, and other accessories which are likely to be required are quite ready. In this way only can rapidity and neatness be assured. Generally speaking, the more quickly the operation is completed the better for the patient, though of course care and thoroughness must not be sacrificed for speed. Careful planning and organisation are essential for success in modern surgery. The Administration of the Anaesthetic. Details about the various kinds of anaesthetics and their administration will not be given here, though it is desirable that the operator should have a thorough knowledge of this most important subject. Full information may be obtained from one of the special text-books on angesthetics. Needless to say, the surgeon should always have the fullest confidence in his anaesthetist, and, at any rate in difficult cases, should secure the services of a skilled administrator of anaesthetics. Under these circumstances the operator, after a preliminary consultation, leaves the anaesthetic and its administration entirely in the hands of the anaesthetist, who will call his attention to any unusual or serious symptoms which may arise during the course of the operation. The patient should not be anaesthetised while he is in bed. If this be done, dangerous symptoms may arise while he is being transferred to the operating room. The ideal arrangement is, that he should be anaesthetised on the operating table in a small room, specially set apart for this purpose, adjoining and opening into the operating theatre. When the patient is unconscious, the table flan then be wheeled in without distracting the attention of the anaesthetist. When this arrangement cannot be carried out, the patient should be anaesthetised either upon the table in the operating room or, in the case of a nervous or sensitive patient, upon a trolley which can easily be wheeled in and the patient then transferred to the table. Bandages and pads are then removed by a nurse, the towels are arranged in the manner already described, and the skin receives its final application of tincture of iodine. The Technique of the Operation. No particular operation will be described here, but it wall be as well in this place to give a few general rules and instructions which apply to all operations. Necessary special instructions will be given in the description of each individual operation. It will first be necessary to discuss the position of the patient during the operation. In the great majority of cases he lies flat upon his back. Sometimes, however, for the satisfactory exposure of the diseased parts some other position is required. The following are frequently employed : (a) The Prone Position. The patient is here turned over so that the face looks downwards. One arm may be placed under the chest while the other rests along the opposite side of the body, which may be supported by a small pillow. This position may be adopted for operations on the vertebral column, or in certain cases of empyema where it is thought undesirable to allow the patient to rest upon the sound side of his chest. (b) The Lateral Position is frequently employed. Here the patient is turned upon his side, left or right as the circumstances of the case demand. The arm of the side upon which he rests is placed under the chest, while the legs are flexed both at the knee- and the hip-joints. This position may be used for some operations on the perineum or anus, for empyema and for kidney operations. In the latter case an air-pillow is also placed beneath the loin to render prominent the region of the incision. (c) The Trendelenherg Position. Here the patient rests upon his back, but the pelvis is raised above the level of the head to a height of from POSITION OF THE PATIENT 'j;i a few iiK'lies to as nmch as two feet. All modern operating tables are provided with a mechanism by which the body is easily made to assume this position. The intestines and other abdominal viscera will then tend to gravitate from the pelvis towards the diaphragm, thus greatly facili- tating operations in which a clear view of the depths of the pelvis is desirable. In an exaggerated Trendelenberg position the patient will be almost vertical. If this is maintained for any length of time, grave disturbances of the circulation may occur, and the continued pressure of the viscera upon the diaphragn may seriously embarrass the action of the heart when that organ is not perfectly healthy. (d) In other operations, upon the gall-bladder for instance, it may be desirable to displace the intestines from the upper part of the abdomen and cause them to gravitate towards the pelvis. This may be effected by tilting the operating table so that the head and the upper part of the trmik are at a higher level than the pelvis. (e) The Lithotomy Position is essential for most operations upon the rectum or the perineum. This may be conveniently arranged either by means of a Clover's crutch, or by resting the patient's hams upon two adjustable vertical supports attached to the lower end of the operating table. (/) For special operations the affected part may be steadied or raised by means of sand-bags or pillows placed beneath the towels, as has been seen in the case of the kidney. Also in operations upon the gall-bladder a small cushion beneath the lower part of the thorax throws the liver forward and thus renders both the ducts and the gall-bladder itself much more prominent and easily accessible. For operations upon the hand or fingers the arm mav often with advantage be abducted and allowed to rest upon a small table at the side of the operating table. As a general rule the patient should be anaesthetised in the dorsal position and then be placed in the special position required for the operation. The skin incision should be carefully planned so as to give a good view of the deeper parts and at the same time to avoid important structures. If the incision has to be made in the neighbourhood of large vessels or nerves, it should always be made parallel to and not across them. Whenever possible, the incision, especially if upon the face, neck, or other exposed part of the body, should follow the line of natural folds or creases of the skin. In this way subsequent disfigurement is minimised and the resulting scar, if the wound heals by primary miion, will be a scarcely noticeable white line. An excellent example of this is the remarkably small deformity after excision of the upper jaw where the incision follows the natural folds at the side of the nose and beneath the lower eyelid. To ensure healing by primary union, the sldn should be clean cut with a sharp knife, avoiding all lacerations and irregularities. Care should be taken that the incision is not too short ; a long skin incision does not, for instance, weaken the abdominal wall, and the more thorough exposure of deep parts frequently enables the operation to be completed with less injury to these more importa nt structures. Similar rules are to be followed in the di^^sion of deeper structures. AVhen the deep fascia is reached it should, before it is di\dded, be fully exposed by separating the superficial fascia and the skin on each side ■R'ith a few touches of the knife. All aponeurotic and fascial layers should be divided by clean-cut incisions. Muscles ought if possible to be drawn to one side ; if this is impracticable, their fibres should be separated by some blunt instrument, after the sheath has been 24 OPERATIONS ON THE UPPER EXTREMITY opened, rather than be divided by the knife. There is. however, in the great majority of cases no reason why a muscle should not be cut across, provided that the cut ends are identified and subsequently carefully united by sutures. These points are illustrated by two of the common methods of opening the abdomen. Separation of muscular fibres is often used in the " muscle-splitting" method of opening the abdomen in the operation of appendicectomy. Another method which also inflicts but little damage is to incise the anterior layer of the rectus sheath, retract the rectus muscle, and then incise the posterior layer of the sheath. The greatest care must be taken to avoid unnecessary injury to large vessels. Smaller vessels should be secured between two pairs of Spencer Wells forceps and then divided. It is of even greater importance to avoid injury to nerves. Di^^sion of a large nerve-trunk is a serious matter, for it will certainly lead to para- lysis and muscular atrophy, which in spite of suture may be permanent. Division of smaller muscular nerves should also be avoided, for such an injury will result not only in partial or complete paralysis of that muscle, but also atrophy, which together may cause considerable disfigurement and disability. At the conclusion of the operation all hemorrhage must he stopped. Each bleeding-point in the course of the operation is secured by Spencer- Wells forceps, care being taken as far as possible to clip the bleeding vessel alone without taking up masses of surrounding tissue. Small superficial vessels will be probably quickly occluded. Small or medium- sized arteries may be sealed by torsion, care being taken to give the vessels six or seven half-t^^^sts and not to twist the forceps completely off. Other vessels will require to be ligatured with fine catgut. General oozing may be checked by irrigating with sterilised saline solution at a temperature of 130° F. Deep structures should be closed in layers, the divided edges being accurately brought together. For instance, in abdominal operations separate layers of sutures are used for the peritoneum and for each muscle or aponeurosis that has been divided. Continuous sutures of silk or catgut are employed, or celluloid thread if a stronger material is recjuired. The cut edges of the skin are united by continuous or interrupted sutures of horsehair or silkworm-gut, or Michel's m':?tal clips may be employed. Care must be taken that the edges of the skin are not turned in. Should this occur, epithelial surfaces are held in contact instead of the raw edges, with the result that when the stitches are removed some gaping will take place, lea^^ng a small area which has to heal by granulation. Special care to secure accurate apposition must be taken when the incision is on the face or neck. The question of drainage frequently demands careful consideration. If the operation is essentially septic, for instance opening an appendicular abscess, drainage is certainly necessary. When, however, the operation is aseptic, but a large ca\"ity in which blood and serous exudation can collect is necessarily left, drainage is still often desirable, otherwise the cavity will probably fill up with blood-clot and coagulated exudation, which form an admirable medium for the growth and multiplication of organisms. A few cocci of a not very virulent type which would soon be destroyed by healthy li\dng tissues may easily infect and cause suppura- tion in such an inert mass. When such a space exists, as in the axilla after the removal of the AFTER-TREATMENT 25 breast and axillary contents for carcinoma, or the scrotum after a radical cure for hydrocele, it is best to insert a small drainage-tube to allow such exudation to escape. Though such a wound may appear perfectly dry and free from blood at the termination of the operation, it is almost certain that some oozing will occur as the effect of the anaesthetic is passing off. A rubber drainage-tube may pass to the deeper parts of the wound between the stitches, or the original wound may be completely closed and the tube inserted through a small stab wound in close proximity to it. This method allows drainage to take place and the wound to heal com- pletely — -a point of great importance where the abdominal wall has been di\'ided, as in an operation for acute appendicitis. For draining a large suppurating cavity, several lateral holes should be cut in the tube or a layer of gauze may be wrapped round it. Efficient drainage may also be secured by cutting the tube open and inserting a wick of ribbon gauze. For smaller cavities one or more strips of gauze may be employed, while small superficial wounds may be drained by inserting a few strands of silkworm-gut between the stitches. If a drain is employed in an aseptic wound to allow the escape of blood and serum, it may be removed at the end of forty-eight hours and then will in all probability not have to be replaced. After-treatment of the Wound. This will depend upon the aseptic or septic character of the operation and whether drainage has been necessary. An aseptic wound which has been completely and carefully closed will heal by primary union ; under these circumstances the temperature and the pulse will remain normal, and when the patient has recovered from the effects of the anaesthetic there will be no constitutional disturbance. An aseptic wound should be painless or nearly so. since inflammation is the most common cause of pain in a wound. Unless the dressings or bandages require re-adjustment, such a wound need not be dressed until the stitches are removed, which is usually done between the eighth and the tenth days. All dressings must be carried out with strict aseptic precautions. The dresser must carefully prepare his hands, and all instruments, dressings, and towels are sterilised as carefullv and thoroughly as at the original operation. An aseptic w^ound is, when the dressing is removed, dry and free from all redness, swelling, and induration. A septic wound ^\"ill require more frequent dressing, usually every day, or if fomentations are used, these ought to be changed every four hours. If a drainage-tube has been used, the time of its removal will to a great extent depend upon the situation and cause of the suppuration. If super- ficial it may be removed at the end of forty-eight hours, and after cleansing and boiling be replaced. If the septic focus is deep, as in acute appendix or gall-bladder cases for instance, it may be left in situ for three or four days or even longer. In either case at subsecjuent dressings it should be gradually shortened, and. as the wound closes, a smaller tube should be substituted. When the suppuration diminishes the tube is omitted and a gauze drain used in its place. Treatment of a Wound which has become Septic. Occasionally, in spite of all precautions, the wound may become infected and suppurates. Usually this points to some failure in the preliminary preparations ; some- times, however, it is due to the dressings becoming soiled or displaced, or they may be disturbed either consciously or unconsciously by the patient. When infection does occur, it is of great importance that the septic nature 26 OPERATIONS ON THE UPPER EXTREMITY of the wound shall be recognised and treated as soon as possible. Other- wise the septic process may extend deeply in and around the wound, and even invade the vessels and lymphatics. The most important information as to the occurrence of sepsis is afforded by the temperature chart, which should be carefully watched after every operation. A slight rise of temperature (99° or 1C0°) is not infrequently noticed immediately after operations which run a perfectly aseptic course, and hence need cause no anxiety. A more considerable rise (up to 102'^) on the second or third evening is. however, of more serious import and should lead to an immediate and careful examination of the wound. When suppuration occurs, pain is usually experienced in the region of the wound. Its intensity varies greatly. It may be very severe and throbbing in character, but on the other hand it may be entirely absent or the patient may com- plain of discomfort only. In the latter case, organisms of comparatively slight \'irulence. such as the Staphylococcus albus, have probably infected a collection of effused blood. In these cases, too, there may be little or no pyrexia. If sepsis is suspected the wound must at once be inspected. The dressing must be carried out with the same precautions and care as in the case of a clean wound. The reason for this is that infection may be due to comparatively harmless organisms ; the tissues are. however, in the most favourable condition for the growth of any organism, and hence the greatest care must be taken not to introduce any of a more virulent type. A septic wound will appear swollen, red, and cedematous ; pus may also be exuding from the incision or stitch holes. Sufficient sutures must be removed to release all tension and to open the wound sufficiently to ensure a free exit for all pus and discharge. If necessary one or more ad- ditional incisions must be made to provide free drainage. The wound may then be gently swabbed out with sterilised saline solution or dilute antiseptics such as carbolic lotion (1 in 60) or hydrogen peroxide 10 per cent. Strong antiseptic lotions should not be used. These cannot destroy all the organisms present, and are likely to damage the tissues and thus hinder their normal reaction against the invading bacteria and their toxins. The wound must now be drained ; its situation and depth will enable the surgeon to decide as to whether rubber drainage-tubes or gauze should be employed. A dressing of antiseptic gauze (cyanide, iodoform or sal-alembroth) should then be applied. If the inflammation is acute, hot fomentations may be used with advantage. Several layers of lint wrung out of hot boracic lotion or perchloride of mercury (1 in 4000) may be used for this purpose. To obtain the maximum amount of benefit, the fomentation must be applied as hot as possible and be changed fre- cjuently. Pain is relieved by the heat, pus and toxic materials are readily discharged, and the antiseptic hinders the growth of the infecting organ- isms. Should the wound be in the arm or leg. immersion of the limb in a metal bath containing hot boracic or other lotion may often be carried out with advantage. The lotion in the bath must be kept hot and clean ; this may be ensured by allo^^^ng a continuous stream of hot lotion to flow slowly through the bath. Constitutional symptoms may be severe, and hence general treatment is of great importance. The strength of the patient must, in severe cases, be maintained by frequent administration of small quantities of suitable nourishment, and alcohol, preferably in the form of small doses of brandy, may also be of service. Free and regular action of the bowels must also be secured. When the wound is opened up. a specimen AFTER-TREATMENT 27 of the pus should be collected on a sterile swab for e:xaminatioii and identification of the infecting organism. Should signs of septicemia appear or should the condition of the wound not quickly improve under the above treatment, a suitable serum (antistreptococcic or antistaphylo- coccic) may then be injected if the cause of the infection is known. Or, if thought desirable, a vaccine may be prepared by the bacteriologist from the actual organism. General After-treatment. At the termination of the operation the patient is likely to be cold as the result of the necessary exposure, and after a prolonged or severe operation to be to some extent in a state of shock or collapse. He should therefore be quickly removed to bed and kept warm with the help of hot-water bottles and blankets. He is usually placed at first flat upon his back ; some one must be at hand to turn the head to one side and draw the jaw forwards in the event of vomiting occurring, otherwise vomited material may be drawn down into the larynx or the lungs. There is, however, no reason after most operations why the patient should not be propped up on one side, which is more comfortable and renders the inhalation of regurgitated material less likely. Later, after recovery from the effects of the anaesthetic, he ay, according to the nature and the situation of the operation, be kept in the dorsal position, be propped on his side (lateral position), or turned upon his face (prone position). Elderly patients, and those suffering from general peritonitis, may often with great advantage be propped up in the semi-recumbent (Fowler's) position. This, in the latter, aids the drainage of pus to the lower part of the abdomen, and in the former throws less strain upon the action of the heart and lungs. Shock. Shock is a condition of the greatest importance to the surgeon for it frequently occurs, and is a common cause of death after severe operations. Much excellent work has been done in recent years with reference to its nature, cause, prevention, and treatment, but a great deal still remains to be done. Shock may be defined as a condition produced by injury in which the action of the vital organs is seriously depressed. A brief outline of the mechanism of its production is all that can be given here.^ When shock occurs there is always a great fall in blood-pressure. This has been shown by Crile to be due to dilatation of the splanchnic veins. This leads to the withdrawal of so much blood from the systemic circulation that the blood pressure is greatly reduced. Crile has further shown that the fall in blood pressure is not due to cardiac failure, but to exhaustion of the vaso-motor centre. At first the fall in pressure may be rectified to a certain extent by the increased activity of the vaso-motor mechanism and increased action of the heart. Eventu- ally, however, as the result of repeated violent afferent stimuli, the vaso-motor centre becomes exhausted, \nth the result that there is a still greater fall in blood pressure and the blood collects in the large venous trunks generally. The heart is now, o\\dng to the small amount of blood 1 For further information on this subject reference may be made to the following papers and lectures: G. W. Crile, "An Experimental Research into Surgical Shock and Collapse {Trans. Coll. Phys. Philadel., 1901, vol. xxiii, pp. .59-82); P. L. Mummery and W.L. Symes, "The Specific Gravity of the Blood in Shock" (Trans. Physiol. Soc, 1907, p. 15); P. L. Mummery, " Hunterian Lectures on the Treatment of Shock and Collapse" (Lancet, 190.5, vol. i, pp. 696, 776, and 846); H. Cushing, "On the Avoidance of Shock in Major Amputations bv Cocainisation of the Large Nerve Trunks preHminary to their Division" {Trans. Med.' Soc. Wisconsin, 1902, p. 361 ; H. Tyrrel Gray^nd L. Parsons {Brit. Med. Journ., 1912, vol. i. pp. 938, 1004, 1065, 1120). 28 OPERATIONS ON THE UPPER EXTREMITY brought to it, unable to efficiently carry on the circulation, even though for a time it attempts to do so by more forcible and rapid action. Sooner or later the heart will become exhausted and death then occurs, or insufficient blood may be supplied to the vital centres in the medulla with the same result. The essential thing in shock is thus a great fall in blood pressure brought about by failure of the vaso- motor mechanism caused by exhaustion of the vaso- motor centre owing to repeated violent afferent stimuli. Shock may follow any severe injury or operation, but is especially likely to occur if the thoracic or abdominal viscera, the testicle or urethra is involved. With regard to abdominal operations, shock is most likely to be severe when the viscera in the neighbourhood of the solar plexus, especially the duodenum and stomach, are interfered with. Collapse is a condition closely allied to shock, from which it cannot always be distinguished ; indeed, the two may occur together or shock may follow collapse. Collapse is also associated with a low blood pressure, but Crile regards this as due to inhibition of the vaso-motor centre, which is the essential distinction from shock. It may be brought about by sudden loss of a large quantity of blood or by mental impressions, or violent afferent impulses may produce a sudden inhibition of the centres. Symptoms of Shock. The onset is usually sudden, though by no means always so. The pulse is rapid, weak, of very small volume, and may be irregular. The respirations are shallow and occasionally show the Cheyne-Stokes rhythm. The surface of the skin is cold and pallid, and the temperature is subnormal. There is great muscular relaxation and weakness, and though consciousness is not lost the mental faculties are dull. The pupils are moderately dilated and their reaction to light is sluggish. Prevention of Shock. Prophylactic measures are especially called for in all cases where, from the nature of the operation or the con- dition of the patient, shock is likely to occur. Most important is a thorough preliminary examination, especially of the kidneys, and careful preparation extending if necessary over several days, during which the patient is got into as good condition as possible, and attention is directed to the treatment of any visceral disease. Care must be taken that the patient is kept warm during the operation, which is completed as rapidly as possible, and that he is then quickly returned to bed, where hot bottles and blankets are used to guard against chill. It has been pointed out that shock is produced by the effect of violent afferent stimuli on the vaso-motor centre. Any means of preventing or diminishing these stimuli will thus be of service. For this reason an injection of morphia (I.M.H. gr. I) may with advantage be given about twenty minutes before the commencement of the anaesthesia. Crile insists on the importance of the injection of cocaine into the large nerve -trunks which supply the region of the operation. The effect of this is to block the transmission of sensory impulses and thus to lessen the likelihood of shock. Spinal anaesthesia also will have the effect of blocking afferent impulses, and may therefore be chosen in cases which are in other respects suitable in which severe shock is anticipated. The importance of this is emphasised by Tyrrel Gray and Parsons {q.v.). The question often arises as to the desirability of operating upon a patient who is already in a state of shock or collapse, the result of some severe injury or acute disease. No invariable rule can be given ; each individual case must be considered upon its merits. If when a patient AFTER TUKATMENT 29 is first seen, after a severe railway crush of the leg or with acute general peritonitis for example, it is thought that the pulse and general condition may possibly improve, it will be well to allow an interval of some hours to elapse while he is kept warm, infused, and treated with stimulating nutrient enemata. Should it on the other hand be considered that improvement is unlikely to ensue, immediate operation gives the only chance, though possibly a faint one, of success. Treatment of Shock. A patient suffering from shock should always be kept warm by the use of hot bottles and blankets ; the foot of the bed should be raised so that the head is lower than the feet. Stimulants and other drugs administered by the mouth are of little use, for their absorption by the stomach is unlikely. Hot and stimulating nutrient enemata may, however, be employed with advantage. They should be administered through a tube introduced as far into the bowel as possible. Strychnine and other stimulants, whether given by the mouth or hypodermically, are useless in shock though they may be of service in collapse. In the former condition they only stimulate the heart when that organ is already making increased efforts to maintain the circulation with the diminished quantity of blood at its disposal. Thus, though stimulants may tem- porarily improve the pulse, they soon increase the tendency to cardiac failure. Crile points out that in shock there is a deficiency in the output of the heart owing to the stagnation of the blood in the large veins brought about by the failure of the vaso-motor mechanism. He suggests, therefore, that the treatment should be directed to supplying the heart with additional fluid to compensate for the diminished intake, and to restore that peripheral resistance which has been lost as the result of the vaso-motor failure. The first of these is effected by infusion, the second by mechanical means and by the use of adrenalin. Infusion is best carried out by allowing sterilised physiological saline solution to flow through a cannula which has been inserted into a vein, usually the median basilic. It may also be given subcutaneously, when the needle is usually inserted beneath the deep fascia into the loose tissues of the axilla, or by means of repeated or continuous rectal injections. The first method is, however, best. With a view to causing contraction of the small arteries and thus increasing the peripheral resistance, he suggests the addition of adrenalin to the saline solution. As this is rapidly oxidised by the tissues he advises its continuous administration by adding sufficient adrenalin hydrochloride to the saline to make a solution of 1 in 50,000 or 1 in 100,000 (5] adrenalin to 1 pint of saline). The circulation may be improved mechanically by gentle abdominal massage and by firmly bandaging the abdomen and limbs over a layer of cotton- wool. Care must be taken that respiration is not impeded and that the bandages do not in any other way inconvenience the patient. Inhalations of oxygen may often be given with advantage, and Lockhart Mummery advises gentle artificial respiration which does good by drawing blood into the large veins which open into the heart and by increasing the oxygenation of the blood. Injections of atropine may also be good. If a patient remains in a condition of shock for some considerable time, plenty of fluid should be given by the mouth, and in these circumstances it may be necessary to give nutrient enemata. Should severe symptoms of shock appear during the operation, it should be completed as rapidly as possible or if thought desirable abandoned. 30 OPERATIONS ON THE UPPER EXTREMITY Feeding. The question of feeding after an operation, though naturally of great importance, will depend upon the age and actual condition of the patient, the duration of the ansesthesii, and the nature of the operation. A few general rules and instructions may, however, be given. After an operation of any magnitude the patient usually requires but little food. The thing is to give plenty of fluid, either by the mouth, by infusion, or by saline enemata. After a comparatively slight operation a little light food, such as a cup of weak tea and a little bread and butter, may be allowed at the end of six or eight hours, provided that there is no vomiting and that the patient feels inclined to take it. After abdominal or other severe operations, small quantities of hot water may be given at frequent intervals during the first twenty-four hours. At the end of that time, fluid nourishment may be allowed at regular intervals in gradually increasing quantities. Milk is often given, but is by no means essential. Some patients are unable to assimilate it, and it may cause flatulence and thus lead to much discomfort. There are a numlser of fluid foods, some of which are partially digested, prepared by well-known firms, which may be used with advantage ; while chicken or mutton broth, or even light solid food, may be allowed in suitable cases. After the bowels have acted 1 he nature and variety of food are gradually increased, until the patient is on ordinary diet, care being taken that all nourishment is light and easily digestible. The feeding of old people and of young children demands close attention. The former are liable to suffer from exhaustion, and hence small fluid feeds should be started as soon as possible. The latter are liable to be upset by any change of diet, Lad hence should be given the food to which they have been accustomed as soon as they have re- covered from the anaesthetic. Should vomiting persist, or should feeds cause nausea, nutrient enemata may be desirable in these patients. In most cases it is advisable that the bowels should act on the second or third day. It is sometimes desirable that the action should occur even earlier, while occasionally — after operations on the rectum for instance — • it may be necessary to keep the bowels confined for a longer period. Drastic or irritating purgatives ought to be avoided, especially when exhaustion is present. As a general rule an ounce of castor oil is a satisfactory aperient for an adult. This may be followed by a soap and water enema, or an oil enema composed of castor oil §iij and olive oil §iij may be tried. Another useful method of getting the bowels to act is to give small doses of a saline purge, such as Mag. Sulph. ~,i], at intervals of an hour until an action occurs. Small doses of calomel repeated hourly are sometimes employed, but it must be remembered that this drug, if not quickly successful, may set up a serious and troublesome colitis. Vomiting. This is a very common and troublesome post- anaesthetic complication. It may occur after any general anaesthetic, even after nitrous oxide, but is especially prone to occur after ether or chloroform. It is more common after the former, but the more serious cases of per- sistent vomiting usually occur when the latter has been employed. In either case it is far less likely to be troublesome if the patient has been carefully prepared and the stomach is empty at the time of the adminis- tration. Vomiting after the use of ether appears to be due to the presence of the drug in the stomach, since the vomited material consists of thick mucus with a strong ethereal odour. This ether is to a great extent swal- lowed with saliva, but there is also considerable evidence to show that this drug is also excreted by the gastric mucous membrane. Vomiting is AFTER-TREATMENT 31 also often caused after operations on the nose, moutli, and throat by the presence of swallowed blood in the patient's stomach. Jolting, or other disturbance after the operation, is also very liable to start vomiting ; the patient should thus be transferred from the oper- ating table to his bed as quietly and gently as possible. If the vomiting does not cease after a few hours some treatment becomes necessary. A simple and effective method is to give half a pint of hot water. This will probably cause immediate vomiting, but the washing out of the stomach thus brought about is likely to remove the cause of the trouble. Bicarbonate of soda grs. xv may with advantage be dissolved in the water. In more troublesome cases it may be necessary to pass a soft tube and thoroughly wash out the stomach. Hot strong cottee is sometimes effective in stopping vomiting, while in other cases a little champagne is quickly successful. Small doses of tinctureof iodine, n\j or ll\ij in ,-^ij of hot water, given hourly for four or five hours is often very effective in obstinate cases. Hewitt recommends an enema of Pot. Brom. grs. xx dissolved in water §ij for persistent vomiting in neurotic patients. Retention of Urine. This is by no means an uncommon sequela. It may occur both in men and women after abdominal operations, but is particularly common after operations on the perineum, rectum, especially hsemorrhoids, and the pelvic organs ; it is also a frequent complication after operations for hernia and varicocele. This post- operative retention is usually regarded as reflex in origin. In some cases it appears to be due to unwillingness on the part of the patient to make the effort owing to the pain or discomfort of the necessary strain. In other cases the presence of dressings and bandages mechanically render micturition a matter of difficulty, especially if the bladder has been allowed to become over- distended. Lastly, when the retention persists for some days, the neurotic element is probably an important factor in its causation. The urine should be drawn off by a carefully sterilised soft rubber catheter. Should this be necessary on more than one occasion, change of position may be successful in terminating the trouble. A male patient can be rolled over on to his side, while a female should be propped up in the sitting posture. Pulmonary Complications. These are usually a sequela of the anaes- thetic rather than of the operation ; they occur more frequently after ether. Bronchitis is the commonest trouble ; it is most likely to occur in patients who are predisposed to this disease. In rare cases a typical attack of lobar pneumonia may occur— the so-called " ether pneumonia." In other cases inhalation of particles of vomit, blood-clot, or septic material from the mouth or upper air-passages may set up a broncho-pneumonia There is no doubt, however, that many cases regarded as pneumonia or pleurisy are really the result of infarction {vide infra). In elderly patients, the bases of the lungs, where the circulation is likely to be impaired owing to the recumbent position and the action of gravity, may become con- gested and eventually consolidated — a process known as " hypostatic pneumonia." This complication, which is often fatal, is best avoided by getting these patients up as soon as possible and by keeping them well propped up during the necessary stay in bed. Sometimes when vomiting has been excessive the patient may complain of a severe pain in the lower part of the chest. This is muscular in origin, and due to the excessive strain, but its situation and occurrence when a deep breath is taken may 32 OPERATIONS ON THE UPPER EXTREMITY suggest the existence of pleurisy. In rare cases where there is some latent tuberculous trouble at the apices the administration of an anaesthetic may be followed by obvious signs and symptoms of phthisis which may not have been previously suspected. ■ Thrombosis and Embolism. These are both conditions of great gravity which occasionally occur after operations : the latter, which is always preceded by the former, may lead to sudden death without any premonitory symptoms. Thrombosis is most likely after operations upon the abdominal or pelvic organs. The coagulation may take place at the site of the operation, but often occurs in the left femoral vein though the field of operation may be some distance away — an appendi- cectomy for instance. The cause of the thrombosis is often uncertain. Some cases are undoubtedly due to sepsis, but in the majority not only does the clotting take place at some distance, but the wound heals by primary union and shows no evidence of infection. Any of the following conditions may play an important part in its causation. (a) Thrombosis is likely to occur after prolonged operations upon anaemic patients or those suffering from some wasting disease. (6) When excessive haemorrhage has occurred either before or during the operation, (c) Traumatism either by contusion of the wall of the vein by rough manipulation or traction, or by the application of a ligature to a small vein close to its junction with a large venous trunk, {d) Tight bandaging, especially a spica bandage which may press upon the femoral or the internal saphenous veins in the groin, (e) Prolonged rest upon the back after an operation, especially if the legs are flexed and kept at rest by a large knee pillow. (/) A prolonged milk diet is stated to cause an increase of calcium salts in the plasma and thus to increase the coagulability of the blood. The interval between the operation and the onset of the thrombosis varies from a few days to a few weeks. In a series of 66 cases collected by R. G. Anderson ^ the average interval was 13-3 days. The onset is generally sudden, though as a rule for some days before the occurrence of any local symptoms there is slight pyrexia and some malaise. The patient then complains of more or less severe pain in the leg. On examination the limb is found to be swollen and tender, especially along the course of the affected venous trunks, which may be palpable as hard cords. Later the oedema increases and the limb will then pit on pressure. The great danger of thrombosis is that the clot may become detached ; it will then be eventually carried by the blood stream to the pulmonary artery, when it must produce pulmonary embolism ^ or infarction of the lung. Displacement of the clot is likely to be brought about by some sudden movement or exertion. The patient must therefore, when thrombosis is known to have occurred, be kept at rest until the clot is firmly adherent to the wall of the vein. This will take from two to three weeks in aseptic cases ; but when the thrombosis is of septic origin a longer period is required, since there is considerable danger of embolism occurring during the process of softening of the clot. The affected limb, which should be kept slightly raised on a pillow, may be loosely bandaged over cotton- wool. Sandbags may be used to steady the leg, but splints and tight bandages 1 Guy's Hosp. Gazette, New Series, vol. xix, p. 9G. 2 Reference may be made to a paper by Louis Blanchard Wilson on "Fatal Post- operation Embolism " {Aim. of Surg., 1912, vol. Ivi, p. 809). AFTER-TRKATMEXT S'S should be avoided. The patient must be told of the necessity of re- fraining from all movement. Purgatives should not be given, but regular action of the bowels nuist be ensured by means of enemata. After a few weeks the swelling usually disappears and the circulation is completely restored. In the event of the swelling persisting, massage will be of service, but this method of treatment must of course only be employed in the later stages and even then with caution. Embolism usually occurs after some movement or exertion, often of a very trifling nature such as sitting up or turning over in bed. The preceding thrombosis may have taken place in some deep vessel without any signs or symptoms and thus may have been entirely unrecognised. The sudden unexpected death which may then take place in a convalescent patient who is apparently out of danger after the operation is one of the most terrible accidents in surgery. Should the clot be of such size as to block either the whole pulmonary artery or one of its main branches, usually the left, death will almost certainly occur. Should, however, the clot be small enough to be carried into one of the smaller terminal branches, the patient may recover. In this event physical examination of the chest a few days later will probably reveal an area of solid lung and a patch of pleurisy. When embolism occurs the patient is suddenly seized \^ath a most acute pain in his chest and at once becomes collapsed. There is very severe and distressing dyspnoea ; the pulse is feeble, flutter- ing, and very rapid (120-160). The face is cyanosed, and subse- quently the whole surface of the body may have a greyish tinge. Oc- casionally there may be one or several convulsions. As the result of the obstruction to the pulmonary circulation the whole of the systemic venous svstem becomes excessivelv engorged. Venesection mav therefore be carried out with advantage, and often affords great relief. The patient should be propped up in a sitting position and oxygen freely administered. This will cause an improvement in the colour and also relieves the dyspnoea. An injection of strychnine should also be given to stimulate the heart's action. In very acute cases artificial respiration should be tried when the breathing has stopped. SURGERY I CHAPTER II INFUSION. TRANSFUSION. SKIN-GRAFTING These may be considered together here, since infusion is frequently employed after operations in the treatment of the general condition of the patient, and skin-grafting in the subsequent treatment of a granulating wound. I. INFUSION While this method had been occasionally made use of by several different workers for many years — e.g. the Littles in the cholera epidemics at the London Hospital in 1848 and 186G, and many others, sporadically, at most of our hospitals — it was Dr. William Hunter who, in 1889, by his Arris and Gale Lectures ^ again drew the attention of the profession in this country"^ to the great importance of the injection of saline fluid in sustaining life, if only sufficient fluid was employed to keep it in circulation. Further, it was Sir Arbuthnot Lane who, applying the above experiments to surgery in two brilliantly successful cases,^ again drew the attention of the profession to the value of this method more forcibly than had been done before. In his three lectures, Dr. Hunter, after contrasting the advantages of transfusion and infusion, arrives at the following most important conclusion : " For practical purposes all the advantages to be gained by transfusion may, I believe, be equally well and more readily obtained by infusion of a neutral saline, such as a f per cent, solution of common salt (about 1 drachm to the pint)." With regard to the direct transfusion of blood, he clearly shows that the nutritive value of serum is so small that its chief value must depend upon its physical properties, and these are in no respect greater than those of a corresponding quantity of normal saline solution. With regard to the red corpuscles the same authority writes : " The greater the quantity of blood transfused, the longer are red corpuscles likely to remain within the circulation, and the more likely is their haemoglobin and the iron which it contains to remain within the system. Over this factor, however, we can exercise but little control. The quantity of blood transfusible in man can rarely be more than about 5 per cent, of the bl od already in the body. And the life duration of the red corpuscles under such circumstances is 1 See Brit. Med.Journ., vol. ii, 1889, pp. 117, 237, 305. 2 About the same time the late Dr. Woolridge, in experiments unpublished owing to his untimely death, was also proving that after haemorrhage suff cicnt to be fatal, enough haemoglobin still remained to sustain life, if only sufficient fluid were added to keep it in circulation. Dr. H. Spencer, who successfully infused a patient the subject of post-partum haemorrhage as long ago as 1888, suggests that Golz (Virch. Arch. Bd. xxi and xxix), and Kronecher and Sander {Berl. klin. Woch. 1879, No. 52), were the first to suggest saline infusion and explain its action. 3 One of the cases is published {Lancet, vol. ii, 1891, p. 626). 3-t TXFT^SIOX 35 probably to bo rockonod by a period of hours."' After the greatest loss of blood sufficient red corpuscles always remain for the absorption of oxvgen from the lungs, provided that the circulation is maintained. After a sudden loss of l)lood. the source of danger is not the want of red corpuscles, but the disturbance of the relation between the vascular system and its contents, or, in other words, the fall in the blood pressure to a point where the circulation is unable to be maintained. These conclusions have been amply confirmed by modern experience, so that direct transfusion of blf)od is now practically never employed, its place being taken 1)\- infusion of a saline solution. The chief indications are : (1) Acute traumatic anaemia, such as occurs as the result of excessive haemorrhage after operations, or after accidents where a large vessel has been divided, such as a cut throat, or as the result of a ruptured extra-uterine gestation, or post-partum haemorrhage. The results here are particularly satisfactory. It is. of course, essential that the source of the haemorrhage should be found and the bleeding vessel secured by ligature, or in some other way. When this is successfully accom- plished judicious treatment, especially infusion, renders recovery possible, or even likely, however desperate the condition of the patient. (2) In cases of collapse, other than those produced by a sudden haemorrhage. It has been mentioned before (p. 28) that in cases of collapse we have a low blood pressure, the result of inhibition of the vaso-motor centre, in many instances brought about by the loss of fluid from the blood, a severe haemorrhage, for example. Dr. Beddard, in "Some remarks on Transfusion and Infusion"^ and in a clinical lecture on " Transfusion." - discusses this and several other points in a very helpful way and with the authority of a physiologist as well as a physician. He thus explains this loss of fluid. " In many cases of collapse, however, the way in which fluid is lost from the vascular system is not so obvious at first sight as in the case of haemorrhage. For instance, in cases of burn or scald it is a familiar fact that the prognosis is determined, not so much by the degree as by the area involved. Thus, a patient with one finger badly charred and another scalded slightly all over the body are both at first in a condition of shock. • The patient with the severely burned finger comes out from the condition of shock and recovers ; the scalded patient may or may not recover temporarily from the shock, but passes gradually into a condition of collapse and dies. Again, a patient has a blow in the abdomen which ruptures his gut. he may recover from the initial shock and even keep about for a time feeling comparatively well, then he passes into a condition of collapse. It must now be asked how have these patients lost fluid from their circulation and become collapsed. Whenever a tissue is damaged, whether mechanically or by inflam- mation, it becomes oedematous \^^th fluid taken from the vascular system. Three distinct stages can be distinguished. (1) Fluid is rapidly poured out into the damaged tissues from the vessels. An equal quantity, however, passes from the miinjured tissues to the blood. (2) During the second stage more fluid is passing to the injured tissues than can be got from the uninjured ones : hence there is now less than the normal quantity of water in the circulating blood. For a time this condition does not' affect the blood pressure and pulse because it is 1 Guy's Hosp. Beps.. vol. Iv. p. 29. 2 Guy's Hosp. Gazette, July 29, 1905. 36 OPERATIONS ON THE UPPER EXTREMITY temporarily compensated for by vaso-constriction of blood-vessels. (3) In the third stage, the drain of fluid into the damaged tissues still goes on, the specific gravity of the blood rises continuously, the vaso- motor centre can no longer keep up the arterial blood pressure, which falls progressively till the death of the patient from failure of the cerebral and coronary circulation. It is very important to note that this final stage may set in with great suddenness and the patient die before any- thing can be done for him. Collapse may develop in exactly the same way from the continued loss of fluid by severe vomiting and diarrhoea, as seen in cholera, the summer diarrhoea of infants, ulcerative colitis, uraemia, in cases of irritant poisoning, and many other like conditions." Thus, in cases of collapse, from whatever cause, when the patient has shrunken features pointing to loss of fluid, whatever other treatment he may require, he certainly requires infusion. (3) Shock. It has been shown (p. 28) that shock is essentially due to exhaustion of the vaso-motor centre as the result of excessive afferent impulses reaching the centre : The blood thus stagnates in the large veins especially those in the splanchnic area. The low blood pressure is due, not to there being too little fluid in the vessels, but to the blood being improperly distributed. If salt solution be infused into a vein of a patient suffering from shock, it may improve the blood pressure temporarily since it increases the intake of fluid by the heart and con- sequently its output into the arteries. The greater part of the fluid will find its way through the dilated arteries into the abdominal veins and accumulate there, or it may pass through the walls of the capillaries into the tissues. On these grounds we should not expect infusion to be of much use in the treatment of shock. In adrenalin, however, we have a drug which raises the blood pressure by acting upon the peri- pheral arteries when given either subcutaneously or intravenously. Adrenalin is quickly oxidised and destroyed by the tissues. Crile therefore suggests the infusion of saline solution to which adrenalin hydrochloride has been added to the proportion of 1 in 50.000. When given intravenously the effect of adrenaline is instantaneous. Dr. Beddard recommends that it be given subcutaneously. when a dose of from 20 to 30 minims of a 1 in 1000 solution may be safely employed. Its effect upon the blood pressure comes on within a very few minutes, and disappears in about an hour, therefore the injection has to be repeated hourly until the shock has passed off. (4) Rarer indications are diabetic coma and septicaemia ; in the latter on the ground that it facilitates the removal, especially by the kidneys, of the micro-organisms and their toxins. In the former the object is to neutralise the acid intoxication by the alkali as well as to dilute the poison in the blood. With this object a solution of sodium bicarbonate is employed. The strength to use is 4 drachms of the salt to a pint of water. (5) In the case of certain poisons, e.g. carbolic acid, Dr. Oliver of Newcastle^ drew attention to the insuificiency of washing out the stomach when once a poison like carbolic acid has got into the blood, and to the need of infusing with saline fluid, as this is in great part rapidly excreted by the kidneys and carries much of the poison away with it. Dr. Powell describes a most successful case.^ 1 Professor AUbutt's /S?/5/em o/'il/etii'cme, vol. ii, pt. I, ]). 1017. 2 Lancet, 1898, vol. ii, p. 1326.' INFUSION 31* A woman, a^t. 21, vvlio had. about throc-quartors of an hour before her admission, swallowed 7 drachms of ordinary eommercial carbolic, was biought in, in a state of coma and collapse. While the stomach was being washed out, the left internal saphenous vein was o|)ened and 8 ounces of blood removed. Four pints of a saline solution, at a temi)erature of 100" were then injected. The pulse and respiration gradually imjjroved. Glycerine in drachm doses was given frequently to allay the burning sensation in the pharynx and cesophagus. For three days the urine was dark green, but never contained albumen. Recovery was rapid and complete. (6) Another condition which, from its urgent gravity, deserves mention here, is gas-poisoning. This appears to be more common in America, both in private and in hospital practice, than with us. Dr. Taylor ^ gives his conclusions from ninety cases, in twelve of which necropsies were obtained. He considers that venesection and saline infusion, usually combined, should be promptly employed. Where the pulse is vigorous, venesection followed by infusion is the remedy. Where in an un- conscious patient the pulse does not justify venesection, infusion alone should be made use of. How the two remedies act is uncertain. (7) For the intravenous induction o£ anaesthesia. This method. which is still on trial, certainly seems in some cases to offer many advan- tages. A 5 per cent, solution of ether appears to be more satisfactory than hedonal or isopral, which were first employed. The method is certainly convenient in operations on the head, neck, and mouth, where the ordinary apparatus may be very much in the way of the operator. It is said to lessen the probability of pulmonary complications in those patients suffering from or liable to bronchitis. Also, when shock is anticipated or is already present, the saline will be beneficial and a small quantity of anaesthetic will be employed. Intravenous ana'sthesia was first employed by Burkhart.2 Rood,^ who first employed the method in this country, describes the technique, apparatus, and mode 'of induction. He gives an account of twenty-one cases in which it was successfully employed. Preparation of the solution. In the preparation of the solution ordinary boiled tap water may be quite safely used. Indeed, this is preferable to distilled water, which is usually far from sterile and may contain traces of deleterious materials derived from the copper stills into which it is generally condensed. With regard to the materials to be used. Dr. Beddard regards dextrose as eminently suitable, being a normal constituent of the blood, and sufficiently non-poisonous to be injected in large quantities. A 6 per cent, solution of dextrose is theoretically isotonic with human blood- plasma. The material most frequently employed is sodium chloride, the strength of which should be 1| drachms to the pint, or roughly one tea- spoonful. This has the advantage of always being readily obtainable. Such a solution is, however, far from being non-toxic, and while this fact does not prevent its use, the symptoms of possible poisoning by a sodium salt should be remembered. " They are stimulation of the nerves and muscles from slight twitchings up to severe con\^lsions, pyrexia up to hyper- pyrexia, rigors, feeble and rapid pulse." It is further pointed out that certain cases are much more liable to poisoning bv sodium chloride than others. " All the serious cases of sodium chloride poisoning which I have seen have been cases of uraemia, diabetic coma, or cholaemia, and it is easy to understand why. In these toxaemias 1 Med. Record, July 9. 1904. - Mun. Med. WocL, 1909, No. W. 3 Brit. Med. Journ., 1911, vol. ii, p. 974. 38 OPERATIONS ON THE UPPER EXTREMITY the patient has lost no salts from his vascular system ; he has all he ought to have, and you by treatment make a considerable addition to this amount. Therefore he is comparatively easily poisoned. But in cases of collapse, such as peritonitis, diarrhoea, and vomiting, &c., the patient, besides water, has lost large quantities of salts as well, and therefore you would have to inject very large quantities of sodium chloride to poison him severely." Better than a solution of common salt is a physiological solution which is iso-tonicwith bloodrplasma. The following fulfil this requirement: Locke's solution. Sod. Chlor. -9 grm., Calc. Chlorid. -024: gim.. Potass. Chlorid. •042 grm.. Sod. Bicarb. -01 gim., Dextrose -1 gim.. Aqua 100 c.c. (2) Sod. Chlorid. -9 grm.. Potass. Chloras. -03 grm., Calc. Chlorid. -01 grm., Aq. 100 c.c. These should be used with distilled water. The following forms a physiological solution when added to tap water : Sod. Chlorid. 80 grs.. Potass. Chloridi. 3| grs.. Dextrose 9 grs., Aq. Dest. ad 4 drachms. The ingredients are dissolved in distilled water and then sterilised by boiling. One tablespoonful added to each pint of boiled tap water gives a solution ecjuivalent to Locke's solution. In any case the fluid should be sterilised by boiling and then cooled to a temperature of 115° F. by the addition of sterilised water, or, in cases of emergency, of ordinary cold tap water. The greatest care must be taken to see that the solution is not too cold when it reaches the patient. The method of infusing. There are three possibilities : (1) Directly into a vein ; (2) subcutaneously ; (3) into the bowel. The alimentary canal is often impossible for obvious reasons. When the circulation has almost failed, absorption will be too slow "and imperfect to be of any real value. In less serious cases, however, when it is employed more as a precaution to guard against a comparatively slight circulatory failure becoming more severe, it may be employed with advantage. Under these circumstances it is better to slowly inject a pint, and then should the condition of the pulse render it advisable, repeat the injection after an hour's interval. The fluid should slowly flow through a soft rubber catheter passed well into the bowel. Subcutaneous injection is open to somewhat similar objections : when severe circulatory failure has occurred the fluid may not be absorbed at all. On the other hand, in less severe cases, the solution is absorbed with remarkable rapidity and the pulse quickly improves. In urgent cases then, after a severe haemorrhage for instance, when it is essential to get fluid into the circulation with the least possible delay, the intravenous method is indicated. In other cases infusion by the subcutaneous or ali- mentary routes may be preferred. The rate at which fluid should be allowed to flow into a vein is an important question. Dr. Beddard, in his paper, quoted above, directs attention to the danger of over- distending the right side of the heart. " I have certainly seen cases where intravenous infusion has caused death in this way. It is difficult to say at what rate fluid can be run into a vein without this danger to the heart. That an apparently small difference in the blood-flow along the veins may make a great dift'erence to the right heart is clearly shown by venesection. Here, in the course of several minutes, we abstract at most a pint of blood from the arm and produce a very real effect upon the condition of the right ventricle. Conversely, it is easy to understand that the injection of fluid into a vein may be serious to INFUSION .39 tlic heart. There can he no douht that the moic slowlv the fluid is run ill the better, and as a maxinial rate I would su<^<^est a pint in ten minutes. This rate may appear to err on the side of safety, but I do not think it does. It is necessary to remember that often when intra- venous infusion is used the right heart is far from normal." He next points out tiiat the choice of route also de])en(ls upon the solution to be used. "A solution of dextrose is not suitable for any but intra- venous injection. Large (piantities given by the bowel may not be retained or may set up diarrha^a. and when injected subcutaneously may cause sloughing. A solution of sodium chloride may be given ill any of the three ways. It is the best to use for subcutaneous or rectal infusion. In diabetes, a solution of sodium bicarbonate should not be given subcutaneously because of its liability to produce sloughing." Method. Now that the indications for saline infusion are known to be so numerous, and are so often followed by excellent results, every practitioner should be prepared to employ this mode of treatment, remembering the critical nature of the cases which call for it, and the suddeni\ess with which the call is liable to come. The apparatus should be as simple as possible. A glass funnel, several feet of rubber tubing of suitable size, and blunt cannula? and sharp-pointed hollow needles of various sizes are all that are essential. All these can be readily sterilised by boiling. If the subcutaneous method is to be employed, the skin is cleansed and a sharp needle pushed through the deep fascia into the lax tissues of the axilla. A Y-shaped junction may be used so as to permit of simultaneous infusion into both axillae. In intra- venous infusion the skin over the vein selected is first sterilised. The vessel chosen is usually the median basilic or the cephalic. Either is exposed by an oblique incision to the inner or the outer side of the biceps tendon. Where there is any difficulty <'^ in finding a vein here, owing to their collapsed state or to the arrange- ment not being normal, a skin flap should be turned up, or gentle pressure made on the basilic or the cephalic a little higher up, and the trunk exposed here. Or the patient's leg may be allowed to hang down and the internal saphe- nous opened just in front of the malleolus. Two catgut ligatures are now passed beneath the exposed vein. One is drawn to the lower angle of the wound, tied round the vein and cut short. The freed portion of the vein being raised with dissecting forceps, a small nick is made in it with scissors, care being taken not to sever it completely. The cannula is next introduced into the vein in an upward direction and tied by the upper ligature, the ends of which are left long (Fig. 2). The blood now" flows down the cannula, and when it is full, the tubing, previously attached to the funnel and filled with saline solution at a temperature of 1 10° to 1 1 5° F. and prepared in one of the above-described Fig. 2. Method of inserting the cannula for intra- venous infusion. 40 OPERATIONS ON THE UPPER EXTREMITY ways, is fixed to it. The funnel is now raised to a height of about 4 feet, and as the solution flows it is replaced by more poured from a jug held close to the funnel to avoid the formation of bubbles. When sufficient has been infused the cannula is removed. The vein is cut completely across, and the upper end tied with the ends of the ligature which have been left long. From four to six pints of the infusion fluid should be at hand. It should take at least from 20 to 30 minutes to inject two to three pints, the amount usually required. Occasionally five or six pints are needed : the more slowly the fluid is then infused the better. Two or three infusions of a smaller amount are often better than the single rapid injection of a large quantity. The chief guides are the return of the pulse, with increase in volume and diminution in rate (say, a fall from 130° to 90""). return of colour and fulness to the face, increase in con- sciousness, &c. Care must be taken, while the fluid is being injected, that no air enters, and that there is no blocking of, or leakage from, the apparatus employed. The rate of flow may be regulated by the height above the patient at which the funnel is held. Though the apparatus de- scribed above has the ad- vantages of simplicity and portability, it has certain dis- advantages, especially for subcutaneous infusion. This is naturally a longer process, and unless great care is taken the temperature of the fluid will fall very considerably be- fore it reaches the patient's tissues. To overcome this and other disadvantages, various other forms have been devised. (1) The vessel containing the fluid stands in a water bath, the temperature of which is indi- cated by a thermometer, or, as suggested by Moynihan, is heated by a spirit-lamp placed beneath. The apparatus rests on a stand at the side of the patient's bed, the height of which can be adjusted. (2) Lane's apparatus (Figs. 3 and 4). This consists of a rubber bag containing the infusion fluid. It can be suspended from a hook at any desired height above the bed or operating table. ^ (3) The principle of the " Thermos flask " has been applied to the construction of a receptacle for the fluid, which is thus kept at a prac- tically constant temperature for a considerable time. Mr. N. S. Carruthers, writing on this subject ^ insists on the importance of the fluid being hot, especially when children are infused for collapse after epidemic summer diarrhcea. He finds that though the temperature of the fluid in the receiver "is 120°, that it may be only "5° when it reaches the neetUe in the course of a slow infusion. This may lead to an increase in the collapse. To remedy this he has Fig. 3. Lane's !subciitanet)us Infusion Appai-atus. 1 Brit. Med. Joum., 1911. vol. ii, p. 725. INFUSION 41 dosigncd the foUowiiifj; a!)i>;ira(us. "The essential part is a vacuum flask, tlio ncH^k of whicl* is fitted with a rubber cork and three glass tubes, one long and extending to the bottom of t!ie bottle, the other two short. The case in which the flask is lield is fitted with a handle, and on each side a glass tube is securely fixed and graduated by exi)eriment in ounces. To one of the short glasses passing through the cork a piece of rubber ])ressure tubing is attached to convey the saline to the ])atient. To the other glass tubes fitted in the cork suiall i)ieees of rubber tubing are attached, and when the bottle is filled and corked these short tubes are connected uj) with the graduated glasses, oik; on each side. The result of having them both graduated is that it matters little which tube is attaclied to which glass, for either will register. This simplifies the appli- ance somewhat. " When till' flask is inverted and the saline running, air is carried to the top of the bottle by jneans of the long glass tube, and, the fluid escaping into the glass tube of the opposite side, acts as a i-egister. The register can be graduated to record the amount in the flask, or, as i prefer it, the amount the patient has received. The solution is conducted to the patient by a short length of rubber pressure tubing which prevents the loss of heat, since rubber is a poor conductor. " This, like most appliances, is fitted with a Y-piece, so that it can be connected to two needles and the patient infused in two places at the same time. Ordinary infusion needles are used, and screw clips to regulate the rate of flow. The total length of the rubber tubing to each needle should not exceed ten inches. When in use the apparatus is hung on a hook, or it may be put on a suitable stand." Infusion is now employed so often and in such a variety of cases that it will be well to point out that if injudiciously used it may be actually harmful. In all cases a watch must be kept on the pulse and on the general con- dition of the patient. Possible dangers are as follows : (1) Sepsis. It is of course essential that the fluid injected shall be sterile. Care must also be taken to keep the small wound in front of the elbow aseptic. Any thick scar in front of the elbow- joint will embarrass its move- ments, and infection may lead to thrombosis Fm. 4. Lane's Infusion Bag and embolism. In subcutaneous infusion anv suspended from a stand, ... . .... , , . 1 1 •" with Y junction and two failure m sterdismg the solution or the skm needles for simultaneous may lead to extensive cellulitis or sloughing. infusion into both axilla;. (2) As already pointed out, too rapid intravenous infusion may lead to dilatation of the right side oi the heart. (3) (Edema of the lungs occasionally occurs, and may be the cause of a fatal result. It is especially likely to occur when very large quantities are injected. Any development of dyspnoea is an indication for at once stopping the infusion. (4) If too weak a solution of salt is employed the tissues will attract more fluid from the blood-vessels, the very thing that infusion is meant to correct. A weak solution is also likely to cause the breaking up of a number of the red blood corpuscles. 42 OPERATIONS OX THE UPPER EXTREMITY Transfusion. Direct transfusion of blood from a healthy individual to the patient has been replaced by infusion of a saline solution. As. however, in recent years traiLsfusion has been employed in a few cases of pernicious anaemia, a brief account of the method will be given here. Dr. Avelings method, modified by Mr. Cripps, is .simple, inexpensive, and has the advantage of measuring the blood sent. viz. 2 drachms at each squeeze of the bulb. The apparatus (Fig. 5) consists of twocannulse connected by a short length of rubber tube in the centre of which is a rubber bulb, the capacity of which is 2 drachms. The skin ha\ing been cleansed, the veins exposed and probes passed beneath them, the apparatus is filled with a warm sterihsed normal saline solution, and a clip placed at either end. The arms of receiver and donor being brought close together, the vein of the receiver is opened with sharp scissors, and pressure being made just below the opening in the vein, so as to prevent blood obscuring the opening, the cannula is inserted. The other cannula is then inserted into the vein of the giver, and both are held steadily by an assistant. Traasfusion is then performed as follows : " The chips having been removed from the tube at either end, the operator makes the necessary valve to prevent regurgitation by compressing with the finger and thumb of one hand, the tube between the central ball and the giver. He then Fig. 5. Aveling's Transfusion apparatus with two cannulse and two niotal stopcocks. slowly squeezes the ball, with the effect of driving the water it contains gently into the vein of the recipient ; then, ha\ing compressed the tube between the ball and the recipient, he removes the finger and thumb from off the tube on the opposite side, allowing the ball to expand with the blood coming into it from the arm of the giver. When the ball is full the manipulation just described is repeated, and the blood passers into the vein of the receiver. In this manner, each time the ball is compressed, 2 drachms of blood are injected into the veins of the patient. Should the syringe appear to become blocked, or work unsatisfactorily, it can be detached and washed out without removing the cannulfe from the veins.'" Needless to say the operation is accompanied bj' considerable risk, especially from thrombosis and embolism. II. SKIN-GRAFTING Skin-graftmg is employed in the treatment of ulcerating or granu- lating surfaces, with a \'iew to obtain rapid and sound healing with a minimum amount of contraction. Three methods. Thiersch's. Reverdin's, and Wolfe's, will be described. (1) Thiersch's method is often called for where large open surfaces are left to heal, e.g. after burns, removal of the breast on wide lines for carcinoma, ulcers of the leg. extensive lupus, and the like. The following steps must be considered : (a) Preparation of the patient and the surface to he grafted. The patient must be in a satisfactory condition, and one who can be relied upon to keep the affected parts at rest. The surface must be either a recently made wound, or. if an ulcer of anv kind, one in which healing has SKIN-GRAFTING 43 begun. It is useless to graft while active ulceration is going on. Above all. the surface must be aseptic. Should the raw area be covered with foul discharging granulations, there is nothing better than curetting once or twice with the aid of eucaine if needful, followed by the use of hot boracic fomentations and the occasional application of silver nitrate or pure carbolic acid. In any case the ulcer and surrounding surface must be carefully prepared. The adjacent skin nuist be shaved over a sufficient distance from the ulcer, and then thoroughly scrubbed and cleansed. Hot fomentations, which are changed four-hourly, are applied to the prepared area. This treatment is continued until the ulcerated surface is covered with healthy granulations, when it is fit for grafting. {b) Preparation of the area from which the grafts are to be taken. The grafts may be taken from the skin of the arm, the forearm, or the thigh. The first two have the advantage that the skin is usually less hairy, but in extensive cases, e.g. burns, grafts will be required from more than one region. The surgeon should always see that the area prepared is con- veniently situated in relation to the surface to be grafted. The day before the operation the selected area is carefully shaved and cleansed, and is then covered by sterilised pads which are not removed until the time of the operation. (e) The actual grafting. The patient having been anaesthetised, the prepared skin and tho ulcor are exposed with all aseptic precautions. Fig. G. Scale 2 Thiersch's skin grafting knife. Should the former be covered with red, healthy, non-exuberant granu- lations, the grafts may be directly applied. It is better, however, to remove by gently curetting with a sharp spoon all the watery super- ficial layer of granulations until the deeper, firmer layer of newly formed fibrous tissue is reached. The healing edge of the ulcer should also be scraped away. These proceedings are followed by free oozing which must be stopped by pressure with sterilised swabs wrung out from saline at a temperature of 120^. Should removal of the pads cause fresh haemorrhage a piece of sterile green protective, which is non- adherent, may be used to cover the surface before the pressure is applied. (n troublesome cases a few drops of adrenalin hydrochloride (1 in 1000) may be poured on the oozing surface. The prepared area of skin is now moistened with sterile normal saline solution.^ and the grafts are cut as follows : The operator, with his hand placed under the hmb, stretches the skin from side to side, while assistants, if necessary, keep it on the stretch above and below. With a broad and heavy razor (Fig. 6) the grafts are now cut. The blade, which is kept wet with sterile saline solution, is placed at such an angle to the skin that when it is entered and carried along it will remove a very thin shaving of the epidermis, filmy and greyish-white, falling at once into delicate folds as it is cut, and exposing, and only just exposing, the 1 The usual strong antiseptic lotions may injure the vitality of the grafts and hence should not be used. If any have been used in the jireparation of skin or instruments they must be removed bv freelv washing with saline solution. 44 OPERATIONS OX THE I PPER EXTREMITY tops of the papillaD. It is then carried on with a rapid to and fro lateral sawing movement. Both the skin, which must be kept carefully en the stretch the whole time, and the razor must from time to time be wetted with a few drops of sterile salt solution. With practice grafts may be cut four or five inches long and one or two inches wide. They should consist of the horny and the superficial part of the malpighian layer, the tops of the papillae being only just trenched upon.^ When the cutting of each graft is finished, an assistant should set it fi-ee by one cut with a sharp pair of scissors. All layers of clot, oozing, or other liquid must be carefully removed from the surface to be grafted, with dossils of sterilised gauze. The grafts should then be transferred directly on the razor, or on a histological section-lifter, laid down each with their cut surface in contact with the raw area, and then gently and evenly flattened out with needles. Sir W. Watson Cheyne and Mr. Burghard give the two following useful hints : " The grafts should overlap the edges of the skin, and also each other, so that no part of the raw surface is left exposed, for granulations always spring up on the uncovered parts ; furthermore, a thin scar, which may subsequently break down, is left at these points. In spreading out the gi'aft it will be found that air bubbles collect beneath it. and also that some amount of oozing goes on, and the bubbles and clot may prevent complete adhesion of the graft. Hence, the next pro- cedure is to get rid of them by pressure. If that be attempted by means of sponges the grafts are apt to be displaced. The following is the best plan : strips of protective about an inch in breadth, and long enough to overlap the edges of the woimd, sterilised in 1 in 20 carbolic lotion, and subsequently rinsed in saline, are applied firmly over the grafted surface, begiiming at the lower part. Each strip should overlap the one below, just as in the case of strapping, and they should extend well on to the skin at each end. If each strip, as it is put on, be grasped by the two ends and firmly pressed down, the pressure thus applied suffices both to expel the air bubbles and blood, and also to arrest further oozing." A dressing of iodoform or cvanide oauze and absorbent wool is then applied with firm even pressure. If the surface be on a Hmb, this must be kept at rest on a splint. When the oozing has been stopped satisfactorily before the grafts are appHed, so that risk of their dis- placement on this account does not exist, the follo-^Tug dressing will give excellent results. Two thicknesses of sterilised gauze are cut of such a size and shape as to cover the grafted area and extend in every direction for two inches on to the healthy skin. The gauze, evenly spread out, is placed over the grafts, and is secured in position by painting its edges 'U'ith collodion, none of which should come within half an inch of the wound. When the collodion has set, a warm saline fomentation is put on. Any discharge from the wound can readily escape through the meshes of the gauze and is absorbed by the fomenta- tion which can be changed as often as is necessary without danger of disturbing the grafts. In either case the dressing on the grafted surface should be left for five or more days, if possible. Its removal must be effected with much care. If successful the grafts should have a pink colour and be adherent. If white or greyish in tint they are no longer alive. 1 A test of the proper depth cut into by the razor is shown bj- the nature of the bleeding, and the rate at which this occurs. It should be minutely punctiform, very slight, and slow in making its appearance. SKIN (iUAFTIXU 45 The surface from which the grafts were taken may be dressed with a roll of sterilised gauze, which may be removed after a week or ten days. Should it be necessary, grafts will retain their vitality for a con- siderable time in normal saline at a temperature of 100, and may be conveyed in this solution to be used for a patient at some distance from the one from whom the grafts were taken. The technique of grafting a fresh wound is in all essential points similar to the above.' (2) Reverdins method. While undoubtedly inferior to that of Thiersch, this method has still a place in surgery as, for example, in completing the healing of a large burn or lupus of the face. Owing to its not needing an anaesthetic it may be employed for elderly patients, or when an anaesthetic is considered undesirable. A small portion of the skin, which has been sterilised, is picked up with a needle and is quickly removed with small, sharp, curved scissors. The tiny grafts thus obtained are arranged at close intervals over the granulating surface. Otherwise, as in the case of Thiersch's grafts, granulations will spring up in the intervals between, and gradually destroy them. The epithehum from each graft may be expected to grow to about the size of a sixpence and then stop, so that unless they are sufficiently close complete heahng of the area will not be attained. A useful and convenient way of cutting these small grafts is to freeze the skin by means of an ethyl chloride spray, and then to remove small, thin portions of the frozen skin by a sharp razor. Freezing does not interfere with the ^dtaUty of the grafts, and owing to its anaesthetic action, renders the operation practically painless. In either case a gauze and collodion dressing may be employed as described for Thiersch's method. (3) Wolfe's method. Here the whole thickness of the skin and sub- cutaneous fat is removed without any pedicle from the most vascular area available. While the percentage of failures is much greater than in Thiersch's method, cases occasionally present themselves in which a trial of this method is indicated, e.g. when a thicker covering is required than is afforded by Thiersch's method, as in the palm of the hand. When this method is successful, its results are most satisfactory. While part of such a flap may perish, enough may sur^dve for the surgeon's purpose. Mr. Keetly thus describes Wolfe's method.^ When such a graft has been cut out, half a dozen Lane's tissue forceps should be attached around its edges. '' Place it, raw surface upw^ards, on a sterilised towel and a convex surface, usually the thigh or chest of the patient. Stretch the flap in every direction by pulling at the forceps. Shave off all the fat. Stretch the flap again to take the tendency to curl up out of it. Swing it into place. Secure it with a few sutures. But cut away all the forceps with sharp scissors so as to leave no bruised skin behind, the most rigid asepsis being desirable to secure success." Mr. Kennedy, of Glasgow, has published^ some figures which show excellently what Wolfe's method may effect in cases where it has been necessary to fill up gaps left by the removal of cicatrices from the fingers and hand. ^ To take one particular instance. Any one who has to face the diiBculties presented by a case of avulsion of the scalp will find useful information in a paper by Dr. Mellisb {Ann. of Surg., 1904, p. 664). 2 Lancet, March 4, 1905. » Brit. Med. Journ., April 29, 1905. CHAPTER III SOME GENERAL POINTS WITH REGARD TO AMPUTA- TIONS, THE LIGATURE OF ARTERIES, AND THE SURGERY OF BLOOD-VESSELS AND LYMPHATICS Owing to the improvements in modern surgery, especially the general adoption of the principles of asepsis, amputations are less frequently called for, and occupy a position of far less prominence than in former days. This is largely owing to the fact that, with modern methods, conservative treatment is possible after even very severe injuries, and also in many cases of disease, of bones or joints. Amputations, how- ever, are still necessary in a number of conditions, chief among which are the following: (1) For severe injuries, especially bad crushes with compound comminuted fractures involving articular surfaces, or associated with injuries to main vessels and nerves. (2) In many cases of gangrene. (3) For malignant growths, especially of bone. (4) For some cases of suppuration, such as acute septic osteomyelitis with threatening pyaemia or septicgemia. (5) For advanced and intractable cases of tuberculous disease of bone or joint. In every amputation the aim of the surgeon should be to secure a sound stump, free from disease, and capable of supporting a suitable artificial limb. The soft parts should form an ample covering for the bone and the scar should be so placed as to escape all unnecessary pressure. These ideals must be borne in mind in every amputation. In former days " set " amputations were the rule. At the present time it is usual to consider the merits of each individual case according to the situation of the disease and the position of healthy tissues in the forma- tion of the flaps. A satisfactory stump, then, should be composed of healthy tissues ; it should be painless, capable of supporting an artificial limb, and in the case of the lower extremity, able to bear very considerable pressure. It will now be necessary to consider some of the causes of painful or otherwise unsatisfactory stumps. First of all, the scar may be ■painful, tender, and prone to ulcerate. This is especially likely to be the case if the flaps were cut too short, so that there was some tension on them as they were brought together over the divided bone. Under these circumstances the scar is likely to be adherent to the deeper structures, and is then very apt to break down. It must therefore be remembered in all amputations that the flaps must be cut long so that they come together quite loosely and without the slightest tension, and that as far as possible they must be so shaped that the scar is not subjected to pressure. The opposite fault is, of course, also to be avoided, for if the flaps be cut too long, the blood-supply is likely to be inadequate ; sloughing 46 AMPI'TATIOXS 47 may tliou occur and ajzain lead to a painful ami aillierent cicatrix. Sliould the severed ends of the hirge nerve trunks be involved in the scar, the latter will be extremely tender and sensitive on even the slightest pressui'c. In other cases the ends of the large nerves may become swollen and bulbous, a condition sometimes known as a " traumatic neuroma, " ; such a swelling will also probably render the stump in- capable of bearing any pressure. Both these troubles may be avoided by cutting the large nerves as short as possible. Pain may also be caused by chronic osteitis, usually due to sepsis. To avoid this it has been advised to cut a flap of periosteum so as to provide a covering for the sawn surface of the bone. Conical Stump. In this condition, which often renders the stump painful and useless, its extremity is shrunken and pointed so that it has a conical shape, the end of the bone projecting at the apex of the stum]) where the superficial tissues are tightly stretched over it. Conical stump may be the result of sloughing of the flaps, or these may have been cut too short at the operation. It not infrequently occurs in children as the result of the continued growth in length of the bone from the epiphyseal line after the operation. The treatment for this condition is re-amputation at a higher level, care being taken that the flaps are of sufficient length and that the bone is sawn through as high as possible. An otherwise excellent stump may occasionally be func- tionally a failure owing to stiffness or want of mobility. This is especially seen in amputations of the fingers through the first inter-phalangeal joint, where the want of any attachment of the flexor tendons may result in a stift" projecting stump which is useless or even a source of annoyance to the patient. METHODS OF AMPUTATING These will naturally depend upon the situation and nature of the disease requiring treatment and also upon the position of healthy tissues. The various methods will be described in detail in the descriptions of amputations in the different regions. A brief summary of the chief methods may, however, be given here : (1) The circular method (Fig. 87). This is the simplest of all am- putations. The skin and the superficial fasciae are divided by a circular cut round the limb in a plane at right angles to its axis. With a few touches of the knife a cuff, consisting of skin and fascia, is turned up for a distance of about two inches in the case of the upper limb, and for three or four inches, according to its size, in the case of the lower. The muscles are then divided by a similar series of circular cuts at the level of the upper limit of the cuff. The soft parts are thoroughly retracted and the bone sawn through at as high a level as possible. The circular method is especially adapted to those situations where there is a single bone uniformly surrounded by a thick layer of soft tissues, as in the thigh and the arm. Such an amputation can be performed quickly, and gives a good covering to the end of the bone ; the chief objection is that the scar necessarily is placed at the end of the stump. (2) The modified circular method. Here two small, equal flaps of skin and subcutaneous tissues are cut in place of the cuff described above. A reference to Fig. 89 will make this modification clear. 48 opp:rations on the upper extremity (3) The elliptical method. This resembles the circular, but the knife instead of passing transversely round the limb is made to divide the tissues obliquely. The advantages of the modification are : the scar can be made to occupy a position where it will escape pressure ; and healthy tissues on one side of a limb can be utilised when an injury has extended more on one side of the limb than the other. This method can be employed for disarticulation through a joint. (4) The racket incision. This is very commonly employed for dis- articulations. Aji incision is made in the longitudinal axis of the limb, commencing above the joint and extending vertically down to a sufficient distance below it. It is then carried in an elliptical fashion round the limb back to the point from which it originally diverged from the longitudinal incision (Figs. 16, 17 and 99). It will thus be seen that the racket incision is a combination of a longitudinal and an oval incision. (5) Flap methods. Here flaps fashioned from the soft parts are employed to cover the sawn end of the bone. They are of various shapes and sizes, and can be cut according to the situation of the injury or disease, and also in such a way as to secure a satisfactory covering to the bone and a convenient position of the scar. Flaps may be equal or one may be larger than the other. They may be antero-posterior, or lateral, or intermediate between these. In cutting flaps care must be taken that they are not pointed. They should be broadly rectangular with the angles rounded off, or U-shaped. They must be of sufficient length to come together ^vdthout tension, but must not be too long, for then the blood-supply may be inadequate and sloughing is likely to occur. The tendency for the muscles to retract must also be remembered and also that the flexors retract more than the extensors. Flaps are usually cut so that at first only skin, superficial and deep fascise are taken up ; the knife then is made to enter the muscle obliquely so that at the base of the flap the whole thickness of the muscle down to the bone is included. In other cases skin flaps are employed. Here the flap is composed of skin, superficial and deep fasciae only ; special care must be taken to include the latter in order to ensure a good blood-supply. To make certain of this, a few muscle fibres should be seen on the deep aspect of the flap. The muscles are then divided at a higher level by a circular sweep of the knife. Flaps are occasionally cut by transfixion, i.e. by passing a long knife through the thickness of the limb at the situation of the base of the proposed flap and then cutting from within outwards so that the skin is divided after the other soft parts. This is a very rapid method, and, before the days of anaesthesia was on this account much employed. Though seldom made use of at the present day, when rapidity is of less importance than the certainty of a satisfactory stump, it can occasionally be made use of \\'ith advantage, for instance, when the flap contains numerous tendons and but little muscle as in the forearm (Fig. 72). When flaps are cut by tran.sfixion a long knife measuring one and a half times the diameter of the limb is required. In all other cases a shorter knife, not more than three or four inches in length, is all that is necessary. LIGATURE OF ARTKKTKS 49 111 all amputations care must be taken to control tiie bleeding during the operation. Generally this is elTected by some form of tourniquet. In some instances where the amputation is close to the junction of the limb and the trunk for example, a tournicjuet cannot be employed. The means for controlling haemorrhage under these circumstances is described in the accounts of amputations through the shoulder and hip joints. As a general rule in amputations, drainage should be secured by a tube inserted between the flaps. LIGATURE OF ARTERIES Ligature of an artery in its continuity is another operation which, owing to the developments of surgery, does not occupy the position of importance which it formerly held. As a test of manipulative skill, and for the knowledge of surgical anatomy for which it calls, it is a favourite ex- amination test and nnist on that account receive clos3 attention in the operative surgery class-room. It will be well therefore to give some general rules for the ligature of arteries. Generally speaking, though there are exceptions to this rule as in ligature of the posterior tibial, the incision should be made in the line of the artery. The length of the incision ^vill depend upon the depth of the vessel to be secured. Though it must not be unnecessarily long it should be of sufficient length to allow of the ready identification of the deeper structures. This is of special importance when the artery is deeply placed, as, for instance, the lingual. Fascia) should be divided by clean cuts with the knife ; muscles should, when possible, be separated, deeper planes being reached through the intermuscular septa. If it is necessary to divide a muscle it should not be cut across, but its fibres should be separated by a blunt instrument. If the artery to be ligatured is situated in the forearm or in the leg below the knee, it is accompanied by companion veins which form a more or less complicated anastomosis around it. Any attempt to separate the veins from the artery is sure to result in injury to and troublesome haemorrhage from the former structures. They should therefore be included in the ligature. In the larger arteries it is of the utmost importance that the companion vein should not be injured. In the case of these larger arteries the sheath should be opened by a short longitudinal incision, and the vessel cleared from this by a blunt instru- ment. An aneurysm needle of suitable curve and shape is then gently insinuated around the vessel, care being taken that the instrument is between the vessel and its sheath, and that it does not pierce the latter. Generally speaking, the needle should be passed from the side on which the companion vein is situated, in order to minimise the possibility of injury to this structure. The aneurysm needle should be passed unthreaded. An examination is made with the finger to ensure that the artery, and the artery alone, has been included. The needle is then threaded with a thread of the material to be employed. Carefully sterilised silk or catgut may be employed, the former is, perhaps, prefer- able for a large artery in an aseptic wound. In the case of a small vessel when the needle has been withdrawn, the thread is tied tightly so as to divide the internal and the middle coats. In the case of large arteries Ballance and Edmunds {see p. 714) advise that the thread should be tied so as to occlude the artery without division of the coats. They advise that the first thread should be tied so as to arrest the circulation. One or more further strands are then passed and again tied in a single knot so as SURGERY I 4 50 OPERATIONS ON THE UPPER EXTREMITY to occlude the artery without division of its coats. The two ends of each of the two threads are then taken and tied together so as to com- plete the knot. In the living subject an artery can be easily recognised by its pulsa- tion. In the dead body this help is, of course, absent. In this case, when there is any doubt, the artery may be recognised by compressing it between the finger and the aneurysm needle. An artery may then be recog- nised by the way in which it flattens out. like a ribbon, with a distinct longitudinal groove. A nerve-trunk feels like a rounded solid cord. ARTERIORRHAPHY It is now realised that it is possible to close wounds in arteries, or even to unite the ends of completely severed vessels, by means of sutures, without obliteration of the lumen, and without permanent interference with the circulation. The feasibility of suture of arteries has been amplv proved by the experimental work on animals of a number of workers, especially Carrel and Guthrie,^ and Watts.^ The possibility of suture was first indicated by Murphy and Senn. It is obviously of the greatest importance to know from the clinical point of \dew that this procedure is possible. An injured vessel may be of such magnitude and importance that its obUteration may mean the practical certainty of gangrene, or death from disturbance to the circulation. There is still a great deal to be done vnth. regard to the employment of arterior- rhaphv in clinical surgery, but it has been, or may be, of use mider the following circumstances : (1) Wounds of large vessels, e.g. the carotid, femoral, or iliacs. Thus Dr. Lund, of Boston,^ reports a case in which he successfully sutured the femoral artery and the femoral vein in a girl set. 14, both vessels having been perforated by a stab from a knife. Dr. Lund considers that suture of the vessels undoubtedly saved the leg and foot of the patient. (2) A large artery may be incised for the purpose of remo\dng an embolus and the wound subsequently sutured. Mr. Handley describes an interesting case in which he attempted the removal of an embolus from the femoral artery in the Brit. Med. Journ., vol. ii, 1907, p. 702. (3) The reversal of the circulation in a limb for threatened or actual gangrene where this is due to interference with the arterial blood-supply as in senile gangrene. In such cases it is possible that more blood could reach the extremity through the healthy vein than through the diseased artery, and that in this way extension of the gangrene could be prevented. That this operation can be carried out in dogs has been proved by Carrel and Guthrie.^ It has also been performed on several occasions on patients viith gangrene with some success.^ It is, however, open to question to what extent and in what cases it should be employed.^ (4) In Matas's operation for aneurysm {vide infra). 1 Johns Hopkins Hosp. Btdl., vol. xviii, January 1907. 2 Ann. of Surg., 1907, vol. xlvi, p. 373. 3 Ann. of Surg., 1909, vol. xlix, p. 394. * Ibid. 1906, vol. xliii. p. 203. 5 Hubbard, Ann. Surg., 1906, vol. xliv, p. 559; Wieting. Deutsch. Med. Woch., 1908, July 9; G. P. Muller, Ann. Surg., 1910, vol. li, p. 256 ; Morriston Davies, .47in. Swr^., 1912, vol. Iv, p. 864. * A paper by Dr. Bertram Bernheim (Am. Surg. 1912, vol. Iv, p. 195. may be consulted. Here will be found a review of the literature of the subject with an account of a number of SUTURE OF ARTKRIKS 51 (5) Carrel aucl Llutliiie {vide supra) have shown experimentally that a portion of vein may be grafted so as to form a junction between the widely separated ends of a divided artery. (()) For arterio-venous aneurysm, as in case described by Dr. Gilbert Kemp.' The operation. In the suture of arteries the most rigid asepsis is absolutely essential. The vessel must be exposed for a distance of two inches above and below the injured spot. Ha;morrhage must be controlled by some method which avoids injury to the wall of the artery. Crile's clamps may be employed (Fig. 7) or a piece of sterilised tape may be slipped beneath the artery ; an assistant then places the tip of his finger on the artery and by gently drawing on the ends of the tape controls the flow of blood. The outer connective-tissue coat is first gently clipped away, as otherwise shreds of this are certain to be drawn in between the other coats, thus preventing their exact approxi- mation. The finest rounded needles must be used ; both straight and curved should be at hand, though the former are, as a general rule, to be preferred. The material for the suture should be extremely fine silk, which should be impregnated with sterilised vaseline in order to facilitate FullSize Fig. 7. Crile's artery clamp. its passage through the vessel wall. The artery must always be handled with the utmost gentleness, any rough treatment from forceps being especially undesirable. The sutures must be passed so as to bring the surfaces of the inner coat into absolute apposition and at the same time to avoid the projection of the silk into the lumen of the vessel. This may be accomplished in one of the following ways : (a) Dorrance's methodr The following description is taken from Burghard's " System of Operative Surgery," vol. i, p. 263 : " When suturing a longitudinal incision the thread is first entered about an eighth of an inch from one end of the incision, made to penetrate only the outer and middle coats, brought out again and tied, the free end being left long. The needle is now made to penetrate all the coats of the vessel from without inwards on one side of the rent and as near the edge as possible ; it is then carried through the walls of the vessel on the opposite side of the rent from within outwards. It then re-enters the arterial wall from without inwards, passes across the incision and penetrates the opposite side from within outwards, thus making a mattress stitch. The sutiu'e, however, is not tied in the usual way, but is continued as shown in the diagram throughout the length of the wound ; at every third loop the suture is carried back a stitch's breadth, as shown in the diagram, in order to maintain the steadiness of the approximation. On emerging at the other end of the incision the thread is passed through the outer two coats of the vessel (Fig. 8) and there is tied in a single knot. The continuous mattress suture thus formed is reinforced by a second continuous runrung stitch taking up the edges of the incision between the loops of the mattress sutiu-e ; when this reaches the point at which the original suture commenced, the two ends are tied together and the suture is complete. " When an end-to-end suture has to be made, the first suture is a mattress suture, the needle being passed through all coats of the vessel from without inwards on the proximal side, and from within outwards on the distal side, and back in the 1 Proc. Roy. Soc. Med. (Surg. Sec.) 1913, vol. vii, p. 83. 2 Ann. of Surg., 1906, vol. xlv. 52 OPERATIONS OX THE T'PPKR EXTREMITY reverse direction. This gives a mattress suture with the ends projecting from the distal end ; these are fimJy fastened together so as to evert the ends of both seg- ments. The remainder of the suture is comj^Ieted by the continuous mattress stitch ah-eady described with the throw-back at every third stitch. When this has com- pletely encircled the vessel the end of the suture is fastened to the free end of the first mattress stitch. A continuoas running stitch is carried all round, joining together the lips of the wound outside the first suture." Fig. 8. Dorrance's method of suture of a longitudinal wound of an artery. (b) Dr. Sweet^ gives the following technique for end-to-eud anastomosis of vessels : '■ Three tension sutures of fine silk are then laid at equidistant points of the circum- ferences of the ve.ssel ends. An assistant then applies traction to two of these guides in turn, stretching the portion between the two sutures into a straight line, facilitating the lading of the continuous suture, and preventing a narrowing of the lumen. If at this time the third tension suture is weighted by a ha-mostat the circumference of the vessel will be arranged in the form of a triangle, the points of which are deter- mined by the three traction sutures, and there will be no danger of catching the opposite wall while inserting the suture. The suture is a continuoiLS overhand stitch, through all the coats ; the separate stitches should be drawn just tightly enough to secure absolute approximation, but not too tightly lest the tissues be everted ; they must be placed verj- close together. After the completion of the; sutuje and the removal of the clamps there will often be some haemorrhage ; if this is too free a few interrupted stitches may be inserted, but a considerable hjemorrhage will almost always stop under gentle digital compression." 1 Ann. of Surg., 1907, vol. xlvj, p. 358. MATASS OPKKATION 53 Matass Operation, or Endo-aneurysmorrhaphy. This operation, since it involves tlio principal of arterial sutnre, may be described here. It was first described bv Dr. Matas^ in li)0."5 after an experience of four cases. Tit,. 9. Dorrance"s uk thud ..f ciid-to-cnd anastomosis of vessels. Since then it has been ^^^dely adopted, especially in America, and has given very satisfactory results. In this operation the sac, after the circulation has been controlled by a tourniquet or other convenient form of pressure, is laid freely open. Xo ligatures are applied to the main artery, but the circulation in the sac is arrested and haemostasis is secured solely by suturing the arterial orifices fomid in the interior of the sac. The ca\dty of the aneurysm is then obliterated by inverting or infolding the walls, with the attached over- lying skin. The flaps thus formed are sutured to the bottom of the cavity, so that no space is left to in^"ite suppuration or secondary complications. Dr. Matas states that the operation is applicable to all aneurysms in which there is a dis- tinct sac and in which the cardiac end of the main artery can be provisionally controlled. "It is especially applicable to all forms of peripheral aneurysms of the larger arterial trunks (carotid, axillary, iliac, brachial, popliteal) ; and. while the author has had no experience with similar lesions of the large visceral trunks, the principle suggested would appear to be applicable to aortic abdommal and other accessible forms of abdominal aneurysms." The operation is based upon the follow- ing principles : (1) The sac is regarded as a large diverticulum or prolongation of the parent artery ; (2) the fining membrane of the sac is a continua- tion of the intima which lines the interior of the artery ; (3) that the sac itself, when not disturbed from its vascular connections, is capable ^ Ann. of Surg., 1903, vol. xxxvii, p. 161. Fig. 10. Endo-aneurysmor- rhaphy, (Matas.) 54 OPERATIONS ON THE UPPER EXTREMITY of exhibiting all the reparative and regenerating reactions which characterise the endothelial surfaces in general. The operation is described by Dr. Matas under the following heads : (1 ) Prophylactic hsemostasis. This may be effected by a tourniquet or Esmarch's bandage, by compression by Crile's clamps (Fig. 7), by a traction loop {see p. 51), or by direct pressure from the finger of an assistant. (2) Incision of the skm and exposure of the sac. This must be thoroughly ex- posed by a free incision exhibiting it from one end to the other. (3) Opening of the sac and evacuation of its contents, recognition of the type of sac, number of openings, &c. A free incision is now made opening the sac from one end to the other. The contained blood and clots are evacuated and the interior of the cavity displayed by free retraction of its edges. In a fusiform aneurysm two large openings will be seen separated by a variable distance, though often connected by a shallow groove representing the floor of the parent artery. A sac- cular aneurysm shows a single open- ing which connects the sac with the main artery. Search must also be made for the openings of branches springing from the sac, which if not sutured would give rise to trouble- some haemorrhage. If there is any l)leeding from the orifices as a result of the free collateral supply, the closure of these openings by suture should be at once proceeded with. Laminated clot is then cleared away by gently scrubbing the interior with sterile gauze soaked in saline solution. (4) Closure of the orifices in the fusiform type of sac (Fig. 10). The systematic closure of all visible orifices should nov/ be proceeded with. Either silk or chromicised cat-gut may be employed. Full curved intestinal needles are best. In the larger openings the needle should penetrate at least one-sixth or a quarter of an inch beyond the margin of the orifice, and then, after reappearing at the margin, dip again into the floor of the artery, and continue to the opposite margin as in the start. When the openings must be closed qiiickly the dip of the needle into the floor of the vessel may be omitted, and the margins brought quickly together with a con- tinuous suture. In all cases intima must be brought into exact contact with intima. A second row of sutures to bury the first is often advantageous. (5) The saccular aneurysm with a single orifice. Reconstructive suture with the view of preserving the lumen of the parent artery (Fig. 12). The intrasaccular euture of the orifice not only permits of the radical cure of the aneurysm by closing its orifice but also allows the restoration of the affected artery to its functional and anatomical integrity. The same needles and materials should be used as in the previous case. The sutures should be inserted at a sufficient distance from the usually thick and smooth margins of the opening in order to secure a firm and deep hold of the fibrous basal membrane. The needle should be made to appear just within the lower edge of the margin, care being taken that when the sutures are tightened the calibre of the artery will not be encroached upon so as to obstruct its lumen, and that the threads will not be brought in contact with the blood in the lumen of the vessel. Greater care must be exercised in securing accurate co-aptation in this class of cases than in the fusiform type. (6) Removal of constrictor and test of sutures. When all visible orifices have been closed the provisional expedient for controlling the circulation is removed. The interior of the cavity should now be perfectly dry. If there be any oozing of the capillary points these will usually be. stopped by pressure and by the means adopted to obliterate the cavity. (7) Obliteration of the sac. This is effected by turning the relaxed flaps of skin into the interior of the cavity. If the sac has not been previously dissected from its surroundings, the skin flaps will be lined on their inner surfaces by the smooth sac walls thus constituting an aneurysmo-cutaneous flap on each side. These Fig. II. Endo-aneurysmorrhaphy. (Matas.) LYMPHANGIOPLASTY flaps can tlun be ''.eld douii in the bottom of the cavity by two relaxation sutures on each sith;. These salures are best applied by a large full-curved intestinal needle which should penetrate the entire thickness of the sao gras[)ing a consideraljlc portion of the sac wall. In this way a loop is forincHl, tlu; two ends of which arc carried through the skin flaps by transfixion with a straight Reverdin's needle, and then tied firmly over a pad of gauze after the flaps have been carefully in position The edges of the skin which then come into contact in the adjusted mid-line arc united by a few interrupted sutures. Where the bulging tumour previously existed there will be a dej)ression varying in depth according to the size of the original sac ; no cavity is left and there is no need for drainage. The collateral circulation, which is usually important in the vicinity of an aneurysm, is also respected, and in this way the best condition for the maintenance of a healthy nutrition in the sac and in the parts beyond the aneurysm are assured. Dr. Matas suggests that in iliac and other abdominal aneurysms the peri- toneum covering the sac should be utilised in the same way as the skin in external aneurysms in the process of obliterating the sac. Residls of the Operation. A number of successful cases have been recorded in the various medical journals. Dr. Matas, in a paper read before the American Medical Association in 190*^,'- collected a total of 85 cases. Of these 7 died after the opera- tion, though in 5 of these the operation was only very indirectly the cause of death. Of the remaining 78 cases there were only 2 cases of secondary haemor- rhage, 4 of gangrene and only 4 relapses, all in re- constructive operations. u OPERATIONS ON THE LYMPHATICS The operation of lymphaiigioplasty may be described here. This was originally intro- ^^«- ^^ha S"''%aTa7f '"°'" duced by Mr. Sampson Handley in 1908^ for napiy- I a as.) the relief of the condition known as " brawny arm," which not infrequently appears in the late stages of carcinoma of the breast and is the source of great suffering to the patients. Mr. Handley points out that the lymphatic obstruction is due to the permeative spread of growth cells along the lymphatics and a peri-lymphatic fibrosis which is thus produced. " The plug of cancer cells within the lymphatic, continuing to proliferate, finally splits up the lymphatic. Around the micro- scopic trauma thus caused a vigorous round-celled infiltration occurs, to be replaced later by a capsule of newly formed fibrous tissue, which contracts upon, and ultimately strangles, the enclosed cylinder of cancer cells. The original lymphatic vessel is replaced by a solid, microscopic, fibrous cord, and the process of peri-lymphatic fibrosis is complete." The method which Mr. Handley employs consists in intro- ducing into the subcutaneous tissues of the affected limb a number of buried silk threads, running upwards from the wrist and terminating above in the healthy tissues in or beyond the axilla. " The operation is closely analogous to the drainage of a marshy field by lines of buried pipes." The operation is a simple one. An incision is made near the wrist. Through this a long probe provided with an eye is thrust upwards ^ Journ. Amer. Med. Assoc, vol. li, p. 1667. Dr. Matas has also published a later and more complete list of cases {Trans. Amer. Surg. Assoc, 1910, vol. xxviii, p. 4). A dis- cussion on the Surgical Teratment of Aneurysm, opened by Mr. Gilbert Barling before the Surgical Section, Roy. Soc. Med, (Travis. Roy. Soc. 3Ied., Snrg. Sect., June, 1912, p. 159) may also be read with advantage. 2 Hunterian Lectures, Lancet, 1908, vol. i, p. 1207. 56 OPERATIONS ON THE UPPER EXTREMITY as far as possible through the subcutaneous tissues. The point is then cut down upon. A long silk thread is threaded through the eye of the probe, which is drawn through the upper incision. The end of the thread at the lower incision is then secured by a pair of forceps to prevent it being pulled out of view. The probe is then again introduced for its whole length in an upward direction and the silk again drawn upwards. The process is repeated until the upper end of the silk reaches healthy tissues. The wounds are then all closed and the silk thread is left completely embedded. Any number of threads can be introduced by repeating the process. Stout silk threads remain unabsorbed for years, and the absence of organisation and coagulation in the interior ensure the retention of its capillary power. The follo\ving is one of the cases described by Mr. Handley in the paper quoted above : The patient, a woman aged 56 years, v/as admitted to the cancer wards of the Middlesex Hospital on January 18, 1908. In 1894 a portion of the right breast was removed at the Chichester Hospital for carcinoma. In 1896 recurrences in the breast and axilla were removed at St. Marj^'s Hospital. In 1903 two or three small recurrent growths were removed from the axilla. In 1905 the right arm became swollen ; it slowl}" became paralysed, and has been the seat, during the past three years, of excruciating pain which frequently kept her awake at night. On admission there was no e\ndence of cancer in tlie body in the form of palpable tumours. The right nipple still remained intact and was not indrawn, and there was no lump in what remained of the right breast. The chest and abdomen were free from deposits. The growth was evidently an atrophic scirrhus, which had under- gone an almost complete process of natural cure. The right arm and hand below the deltoid were greatly swollen. The oedema pitted slightly on pressure, though it approached the solid variety. There was complete paralysis of the limb, save that the third and fourth fingers could be moved slightly. The hand was warm and of natural colour. Flexion of the elbow was only possible through 15° or rather less. On February 1, under chloroform, a number of silk threads, each ruiuiing up- wards from the wi'ist to the loose tissue upon the chest-wall just below the axilla, were buried in the subcutaneous tissue. The operation produced no general dis- turbance of note. On the next day it was obvious that the bandages were loose and tlie strapping on her fingers was in the same condition and had to be frequently replaced. On the 6th it was noted that the arm and hand were quite flabby and much reduced in size. The skin was much -WTinkled and luuig on the fingers in folds. On the 7th the patient remarked that she saw her knuckles for the first time for years. The movements of the fingers were beginning to return and she was able to grasp very feebh'. On the 1 0th the forearm and hand began to present an almost normal ajipearance, but much swelling of the upper arm remained. On the 24th the limb was continuing to diminish in size though less rapidly than at first. Unfortunately measurements of the limb previous to the operation were not taken, so that no accurate record remains of its rapid and marked subsidence in the earliest days after the operation. However, between February 6 and February 24 the circumference at the wrist diminished from 7^ to 6^ ; just below the elbow from 10^ to 9| ; and 8| inches below the acromion from 11 to 9f. The jiain disappeared and flexion of the elbow increased from 15° to llO''. The movements of the hand improved so that the patient could hold a pin between the finger and thumb. Mr. Handley also suggests that this operation will be found of use in other cases of lymphatic obstruction, such as elephantiasis.^ 1 Proc. Roy. Soc. Med. Clin. Sec, February 1909. CHAPTER IV AMPUTATIONS OF THE FINGERS. OPERATIONS ON THE HAND. TENDON-GRAFTING AND TRANSPLANTATION Practical anatomical points. I. Positions of the joints (Fig. 13). This has to be renienibcred : (a) in front ; (b) behind. (a) In front. Three sets of creases correspond here, though not exactly to the joints. Of these, the lowest crease is just above the joint, the middle is opposite to the inter-phalangeal joint, the highest nearly three-quarters of an inch below the metacarpo-phalangeal joint. (6) Behind. It is to be remembered (1) that in each case it is the upper bone which forms the prominence, viz. the knuckle is formed by the head of the metacarpal bone, the inter-phalangeal pro- ^' __ minence by the head of the first phalanx, and the distal one by the head of the second ; (2) that the joint in each case lies below the prominence, the distal joint being one-twelfth of an inch, the inter-phalangeal one-sixth of an inch, and the metacarpo-phalan- geal joint about one-third of an inch below. 1 II. Shape of the joints. In the distal and the inter-phalangeal the joint is concave from side to side, and presents a concavity towards the tips ; in the metacarpo-phalangeal joints, on the other hand, the convexity is towards the finger-tips. III. TheTheca. This fibrous tunnel, which extends downwards to the bases of the distal phalanges and upwards to the palm, is lined by a synovial sheath and transmits the flexor tendons. The sheath of the little finger is directly continuous with the palmar bursa which encloses the tendons of the flexor sublimis and the flexor profundus digitorum and extends upwards into the forearm. The sheath of the thumb also extends into the forearm and usually communicates with the palmar bursa. The theca gapes widely when cut, and hence there is, especially in the case of the thumb and the little finger, a channel along which infection can easily travel to the palm and even to the forearm. Care should thus be taken to keep even such a small amputation as that of a finger perfectly aseptic. The flaps of an amputation through damaged parts should not be too closely sutured ; tension should be avoided and drainage provided. 1 The terms " above " and " below " mean nearer to and farther from the trunk. 57 Surface markings of the joints of the fingers. 58 OPERATIONS ON THE UPPER EXTREMITY OPERATIONS FOR AMPUTATION OF THE FINGERS As the rule is always to remove as little as possible, the actual method adopted will always depend upon the aspect of the finger from which undamaged soft parts can be obtained. The following amputations should therefore be practised, of which the first two are the best : (1) Long palmar flap (Figs. 14, 16 and 20). (2) Long palmar and short dorsal flap (Figs. 18 and 20). (3) Two lateral flaps (Figs. 17 and 20). These may be (a) equal; (b) unequal. (4) One long lateral flap. (5) Two equal antero-posterior flaps. ^ Of these, the palmar flap is usually the one made use of. Though, as the hands are by far most frequently held in the prone position, a dorsal flap falls more easily into place, and gives a more concealed scar a palmar flap has the greater advantages of a scar which is not pressed upon when anything is held in the hand, of possessing finer sensitiveness in touch, and better nutrition ; furthermore, this flap is available even in the last phalanx, where, from the presence of the nail, a dorsal flap is not obtainable (Fig. 14). Amputation o£ a Distal Phalanx by a Palmar Flap (Fig. 14). First Method. The hand, to- gether with the sound fingers, should be completely covered by a sterilised bandage. The hand then being well pronated and the adjacent fingers well flexed, the surgeon, having placed his left forefinger just below and behind the joint, and flexed the phalanx strongly with his thumb (a step not always easy with infiltrated tissues), cuts- with a slightly semi-lunar sweep and drawing the blade from heel to toe, straight into the joint. To effect this neatly, the convexity of the sweep should pass one- twelfth of an inch below the prominence or angle produced by flexion, the sweep being made by laying on the whole edge of the knife, while with the point, as this incision begins and ends, the lateral ligaments are partly cut. The joint being thus freely opened, the knife is in- sinuated in front of the base of the phalanx (a step which is facilitated by depressing and pulling on the phalanx), and then, being kept close to and parallel with the bone, cuts, with a steady sawing movement, a flap well rounded at its extremity about two-thirds in length of the pulp of the finger.^ Second Method. The hand being supinated, the finger to be operated on extended, and the others flexed out of the way, a palmar flap is cut ^ These will produce a stump with an exposed scar. 2 The knife in all these finger amputations should be narrow, short, and slender, yet strong. 3 If the flap is insufficient, the head of the second phalanx must be removed. In this and in other amputations in the hand, owing to the soft parts cut through being often infiltrated and fixed, the flaps are easily made too short, from the desire of the surgeon to leave as much as possible. AMPUTATION OF THE FINGERS 59 by transfixion, the knife being entered just below the palmar crease, the joint being then opened from the dorsum as before, and the phalanx lastly disarticulated. To cut flaps by transfixion, however, is not satisfactory in amputations of the finger. Sir F. Treves sums up this question in the following words : "In no operation upon the fingers is it well to cut the flaps by transfixion. In cutting a palmar flap by this means there is danger of slitting up the digital arteries. The flap, moreover, is apt to be pointed and scanty, and to contain fragments of tendon." Third Method. If the surgeon has no narrow knife by him, he may modify the last method by cutting his palmar flap first, but from without inwards ; he then opens the joint from the dorsum, and disarticulates. As a rule no vessels require ligature. Any tendon that is jagged should be cut square. Difficulties and mistakes in amputation of a Distal Pfialanx. (1) The flap may, of course, be made too short ; it is often made too pointed. I would take this opportunity of pointing out that as the bones of the hand are large in relation to their soft parts, the flap or flaps should always be cut sufficiently long. It is, indeed, a golden rule in all amputations that the flaps should be of sufficient length to fall together easily over the end of the bone and to come together without the slightest tension. If the flaps fit at all tightly it will be found when cica- trisation has occurred, that the scar is adherent, painful, or prone to ulcerate, or the bone may tend to make its way through the skin when pressure is made up in the stump. The student must then in this, his first am putation, fix upon his mind a rule which must be followed in all amputations, large or small — to measure with the eye whether the flap or flaps will be sufficient, just before each is finally cut. (2) If the phalanx be not sufficiently flexed, or if the site of the joint has not first been marked out with the nail, the latter mil not be readily opened. It is very common for students, forgetting that in the case of each joint this lies below the corresponding prominence (Fig. 13), to cut above the level of the joint here, their knife sawing against the neck or head of the second phalanx. (3) It is often difficult to pass the knife readily round the base of the phalanx, especially in cases wliere the blade is too broad, or where, as in well-developed hands, the base of the phalanx is strongly tuberculated. (4) If there be any hitch in passing the knife behind the phalanx, the outline of the flap is very likely to be jagged, and sloughing may then ensue. Amputation through, or disarticulation of, the Second Phalanx (Figs. 16, 17, 18). This, as a rule, should be performed through the phalanx, and, whenever this is possible, at or beyond its centre, so as to leave the upper half or third of the phalanx, and thus ensure the preservation of some at- tachment of the flexor sublimis. While the rule not to amputate a finger at the joint between the first and second phalanges, and a fortiori through the first phalanx, is a sound one, as there is a risk of leaving ';4i^' Fig. 15. a. Flaps after amputation of terminal phalanx, b. Flaps after amputation through second jjhalanx. c. Amputation of second phalanx (Heath). In each case antero-posterior flaps have been made. In b the flexor tendon, and in c both flexor and ex- tensor tendons, should be sutured as directed above, having been first cut long. 60 OPERATIONS ON THE UPPER EXTREMITY a stump stiff and incapable of flexion, there is no doubt whatever that, where rapid heahng has been secured, this amputation has been followed by the flexor tendon taking on a fresh and sufficiently firm adhesion, and so leaving a longer and, withal, a mobile stump. In the following special cases the whole or part of the first phalanx may be left, and in all of them the severed flexor tendons, pre\nously cut long, should be carefully stitched to the cut theca and periosteum, or into the flaps before these are adjusted. Another plan is to suture Fig. 16. Amputations of the fingers and the thumb. The surface marking of the superficial pahnar arch is also shown. together the flexor and extensor tendons (cut long and square) over the end of the bone (Waring). (1) In the case of the index finger the proximal phalanx will be a useful opponent to the thumb, as in holding a j)en. (2) In the case of the little finger, leaving the proximal phalanx will give greater symmetry- to the hand when this is fixed, and it may on this account be left. (3) In amputations of all the fingers the proximal phalanx of one should, if possible, always be left to oppose to the thumb. (4) Where a patient insists on having the proximal phalanx left, after the risk of stiffness has been explained to him. Provided that the divided flexor tendon is carefully sutured to the theca or to the extensors, the more the stump heals, and the younger the patient, the greater will be the movement gained.^ 1 Dr. Tiffany, of Baltimore (Trans. Amer.Surg. Assoc, vol. ii, p. 826), says that he has been in the liabit " for a number of years " of passing the stitches which unite the skin through the tendons and their sheaths in amputation at the joint between the first and second phalanges. •' I have never failed, as far as I can remember, to secure quite as good movement as if Nature had originally made an attachment there for these tendons." AMPUTATION OF THE FINGERS 61 Methods. ( 1 ) By a long palmar or dorsal flap (Figs. 17 and 18), or by dorso-palniar flaps, the flaps being equal, or the palmar one the longer (Fig. 17). {I) Bi/ Dorso-palmar Flaps. The surgeon, having marked with his left forefinger and thumb the spot where he intends to divide the bone, cuts between these points a short, well-rounded dorsal flap of skin ; he then sends his knife across below the bone, making it enter and Fig. 17. Amputation of the fingers and the thumb. emerge at the base of the first flap, and cuts a palmar flap about two- thirds of an inch in length, and not pointed. The flaps are then re- tracted, the bone cleared with a circular sweep of the knife, and divided in the manner given below. While long palmar and short dorsal flaps will give the best result, equal flaps, or a long dorsal flap, may be employed if there is more extensive damage to the soft parts on the anterior aspect of the finger. (2) By Lateral Flaps (Figs. 16 and 17). The site where the bone is to be sawn having been marked by the left forefinger and thumb placed on the dorsal and palmar aspects of the finger at this level, the surgeon, looking over the finger, enters his knife in the centre of the palmar aspect, and carries it, cutting an oval flap, about two-thirds of an inch in length, to a corresponding point on the centre of the dorsum, and then from this point down again over the side of the finger nearest to 62 OPERATIONS ON THE UPPER EXTREMITY him, to the point where the knife was first inserted. The flaps being • dissected up as thick as possible, and the remaining soft parts severed with a circular sweep, the bone is divided with the saw or bone-forceps. If the situation of the damaged tissues renders it desirable, one flap can be cut longer than the other. In using the bone-forceps the concave sur- face is always to be turned away from the trunk ; if this precaution is taken, and the bones severed c^uickly with a sharp instrument, the section will be clean and not crushed. But a fine saw is nnich the better instrument. Amputation of a Finger, e.g. second or third at the Metacarpo- phalangealJoint (Figs. 17, 18 and 20). This, the commonest amputation in the hand, being required for severe crushes, tuberculous disease, and some cases of whitlow, should be often practised. Before it is employed Fig. 18. In the second finger amputation through the second phalanx is shown, the bone beng divided below the insertion of the flexor sublimis. In the index finger amputation through the second phalanx by short dorsal and long palmar flaps is figured. The flaps for amputation of the index finger at the metacarpo- phalangeal joint are also shown, the straight part of the incision being placed rather to the radial side of the head of the metacarpal bone. In the thumb the flaps for amputation at the carpo-metacarpal are indicated. ** Show where the radial artery may be wounded in this amputation. Ligature of the radial artery at the back of the wrist is also represented. {See p. 124.) for an injury, the remarks on the conservative surgery of the hand [see p. 71) should be consulted. It is usually performed by the modified oval method, the en raquette of Malgaigne. Lateral flaps may also be employed. Other methods, to be used according to the extent of damage to the soft parts, are described below (Fig. 20). The hand having been pronated, the radial and ulnar arteries con- trolled by a tourniquet, an Esmarch's bandage, or the fingers of an assistant above the wrist, some sterilised gauze wrapped round the damaged finger, and the adjacent ones flexed out of the way or held aside with strips of sterilised gauze, the point of the knife is inserted three-quarters of an inch above the head of the metacarpal bone, sunk down to the bone itself, and then carried down in the middle line till it gets well on to the base of the phalanx ; then diverging to one side, the knife is carried obhquely well below the web ^ across the palmar >■ Cutting into the web will lead to much more ha^.morrhage and it.may be difficult to secure the vessels. The incision should pass about half an inch below the web otherwise there will be difficulty in bringing the flaps together unless the head of the metacarpal is removed. Even then there is likely to be tension on the sutures, and thus alow and painful healing. AMPUTATION OF THE FINGERS 63 aspect of the first phalanx below the palm and then around the other side of the phalanx (also below the web) so as to join the straight part of the incision which lies over the head of the metacarpal bone. Lateral Flaps (Fig. 20). In practice, especially in the country, where an ana?sthetic is not always easily available, it is much preferable, because quicker, to make two separate incisions, each beginning three- quarters of an inch above the head of the metacarpal bone, and meeting again on the centre of the base of the palmar aspect of the first phalanx, well below the palm, instead of carrying the knife continuously round the finger. Thi^ method is not only quicker,^ but it does not leave, as in the first method, a small tongue of tissue on the palmar aspect, which is a little difficult to adjust satisfactorily, and behind which discharges may collect. Sir W. Watson Cheyue and Mr. Burghard ~ point out that where any such projection is present, as in a working man's hand with a very thick palmar skin, the removal of a V-shaped portion here, after the completion of the amputation, will cause the entire disappearance of the projection. Whether the method by lateral flaps or en raquette be employed, the knife should be used boldly, the extensor tendon severed in the first incision over the head of the metacarpal bone, and the soft parts at the sides cut to the bone. Then, the finger being now extended, one Hp of the cut tissue is taken up with the finger and thumb, the flaps are dissected up as thick as possible, tendons cut clean and square, the lateral and anterior ligaments severed with the point of the knife, and the joint opened by recollection of its site well below the projecting knuckle {see p. 57. Fig. 13). Disarticulation will be facilitated by twist- ing the finger, first to one side, and then to the other, so as to render tight the parts which remain to be cut. On no account should the knife needlessly enter the palm. This vnW only lead to troublesome bleeding, especially in in- flamed parts, and perhaps to the spreading of infective inflammation. A caution may be given here which applies to all amputations, but especially to those performed for accidents., where it may not have been possible to secure absolute sterihsation of the parts concerned. It is very easy for the tendons, where they are drawTi down in order that they may be cut short and square, to carry up infection as they retract into their sheaths. At this stage especially it is important thoroughly to irrigate either ^vith sterihsed saline solution or with some weak anti- septic lotion, such as carbolic 1 in 40. Where strength has to be considered rather than appearance, the '^ Because it avoids the hitch usually met with in carrying the knife around the base of one finger between two others. 2 Manual oj Surgical Treatment, vol. ii, p. .512. Fig. 19. Amputation of the middle finger by lateral flaps (Heath). The neck of the bone should be more fully cleaned, the tendons sepa- rated, and the bite of the forceps pressed more securely round the neck of the bone. 64 OPERATIONS ON THE UPPER EXTREMITY head of the metacarpal bone should be left, whatever be the rank in life of the patient, as the transverse ligament is thus less interfered with, the hand less weakened, and the palm not opened up. But where appearance is the most important point, and the mutila- tion is to be hidden as much as possible by the approximation of the fingers, the head of the bone should be removed by a narrow-bladed saw or by bone-forceps ^ (Fig. 19). In either case the section should be made obliquely from above downwards and from behind forwards, so as to remove more on the dorsal than the palmar aspect. In such cases, after a little practice, it is not necessary to perform disarticulation, the metacarpal bone being severed after the flaps have been dissected upwards to the proper level. Here, too, care must be scrupulously taken not to in- terfere with the tissues in the palm. After removal of the finger and the Esmarch's bandage, one or more digital vessels lying rather deeply opposite the web of the finger will require liga- ture.^ In the case of the thumb, index (Figs. 20 and 21), or little finger, the straight part of the oval incision should be placed to the ulnar side of the meta- carpal bone, rather than in the dorsal mid-line, as the line of in- cision will be better concealed. In these cases the saw or bone- forceps should be applied ob- liquely from without inwards and from within outwards re- spectively, so as to leave no projecting bone on the radial or ulnar aspect of the hand, and, in the case of the index, to allow of the thumb being readily approximated to the second finger. It may be worth while to add the following hints with regard to the after-treatment: (1) Not to bandage the adjacent fingers too closely or too long together, otherwise a tendency to cross at their points will be noticed later on. (2) In this and all other dis- articulations where, in spite of copious irrigation with sterile saline or other solution, a co-existing infective condition cannot be got rid of with certainty, the cartilage should be removed. Tedious exfohation is otherwise certain. As already advised, there should be no close suturing in these cases, and boracic fomentations may be employed from the first. In this and many other amputations of the ^ With the precaution given at ii. 02. A saw, avoiding splintering, is preferable. - Care should be taken to seeure these vessels, especially where they are enlarged in any iniiammatory condition, otherwise profuse bleeding may take place a few hours after the operation. Fig. 20. Different methods of amputating the thumb and fingers at their metacari)o-phalan- geal joints. In the case of the thumb a long palmar flap has been made ; in the index a pal- mar and external flap ; in the middle finger a circular incision and a straight dorsal cut (a modification of the method en raquctte) have been employed ; the ring finger has been re- moved by two lateral flaps, and the little one by an internal and palmar flap. (Farabeuf.) AMPrTATIOX OF TIIK FINCiERS 65 hand, peifonitecl zinc, which can be easily boiled, is the best material for splints. Disarticulation by a Circular Incision with a Straight one on the Dorsum ( Fi,u. I'D). This method, a modilication of the one en rnqncltc, is pieferred by Farabeuf as simpler and sacrihcini^ less skin. The hand being completely supinated, and the other fingers bent out of the way, the surgeon cuts across the root of the finger in the digito-palmar fold, going down to the bone, and encroaching as far as possible on the sides of the finger. The hand being pronated, the ends of the circular incision ai'c prolonged up to the middle line of the dorsal aspect of the finger, where a straight cut. beginning a little above the level of the joint, is drawn to and perpendicular to the first. By this means two right- angled flaps are marked out. These are raised and the bone disarticu- lated, by the steps already given. Amputation by a Single Flap. Where, owing to the state of the soft parts, thismetiiod is re(juired. Fig. '10 indicates how it may be employed. Amputation of a Finger, together with Removal (complete or partial) of its Metacarpal Bone. This operation is easily performed by a modifi- cation of the method en raquette or that by lateral flaps just described. Fig. 21. Amputation of little finger and its metacarpal by the oval method. It is only needful to prolong the dorsal part of the former incision or the apex of the latter as far as the carpo- metacarpal joint. Disarticulation, w^hen the parts are much swollen, will be safely performed here by carefully prolonging back the dorsal incision in a wound kept bloodless till the joint is felt and seen, suitably manipulating the finger so as to put the structures attached to the metacarpal bone on the stretch, remembering the insertions of tendons into some of these bones, severing the ligaments of the articulations with careful touches of the knife, and not sinking this into the palm for fear of wounding the palmar synovial sac or the deep palmar arch. Wherever possible, the extensor tendons should be drawn aside and carefully preserved. In infected cases, the greatest care must be taken, e.g. irrigation with sterile saline solution or with a dilute antiseptic lotion. In the case of the little finger (Fig. 21), the ulnar border should be chosen for the incision, or, if the dorsal tissues are much damaged, a palmar and internal flap may be made. In clearing the metacarpal the knife-point must be kept very close to the bone. If only a portion of the bone needs removal, this should be divided with a ?aw and not ^\ith bone-forceps. Farabeuf gives the very practical hint that primary union should 1 Manual of Surgical Tnatment, vol. ii. p. 514. SURGERY I t; 66 OPERATIONS ON THE UPPER EXTREMITY be secured by the flaps meeting readily without tension. Otherwise the contraction of the scar will drag upon the next finger, and cause it to stick out from its fellows in a very ugly fashion. Where a metacarpal bone is removed for sarcoma, Sir W. Watson Cheyne and Mr. Burghard ^ advise that the adjacent bones on one or both sides be removed as well, to avoid the risk of lea\'ing disease behind. They add : " When more than one metacarpal bone is removed, it is well to take away at least one finger in order to preserve the full use of the hand. Unless this be done, the fingers are apt to be crowded together as the wound contracts, and considerable interference with their usefulness may ensue." " Amputation of two or three contiguous Fingers. When (a very rare contingency) two or more fingers require removal at the same level, i.e. through their metacarpo-phalangeal joints, or higher up — the modified racquet or lateral flaps may again be employed, the apex of the dorsal incision starting between the fingers when two, and over the central metacarpal bone when three, fingers have to be removed. AMPUTATION OF THE THUMB Amputation of Phalanges of Thumb. Very little need be said about this operation, as it is very rarely performed. Owing to its numerous muscles, the thumb is extremely mobile, and thus escapes injury. Thanks to its abundant vascular supply, trimming of the soft parts after an injury will generally leave more of the thumb to oppose to the fingers, and thus is to be preferred to any set operation. In cases of necrosis after whitlow, Mr. Jacobson has twice removed both phalanges, the soft parts consolidating usefully^ with the aid of the periosteum that was left. For further remarks on the importance of preserving the thumb, see Excision of the Thumb, p. 68, and Con- servative Surgery of the Hand, p. 70. Operation. Amputation of the phalanges of the thumb may be performed, in the case of the distal one, by a long palmar flap, as in the case of a finger (Figs. 14 and 20); of the first phalanx, by antero- posterior, lateral, or a modification of the circular incision. In the lattsr case, a short longitudinal incision should be made on the radial rather than upon the dorsal aspect as in this way less damage will be done to the tendons. In any case the incisions should be carried well on to the phalanx to ensure sufficient flaps to cover the head of the metacarpal bone, together with the sesamoid bones, which should never be removed. The line of the metacarpo-phalangeal joint is very nearly transverse, and lies just in front of the knuckle. After amputation of, or through, the phalanges, the severed end of the long flexor, pre\aously cut long, should be carefully stretched into the angle of the flaps and to the extensor, and also, if possible, into the theca and periosteum as well. Amputation of the Thumb at the Carpo-metacarpal Joint (Figs. 16 and 22). Indications. This operation is rarely called for on the living subject.'^ Gunshot injuries, some growths, especially chondromata of the phalanges and metacarpal bone, epithelioma of a scar, and melanotic sarcoma occasionally call for it. ^ This is strongly indicated in those eases where it is especially important to leave the thumb long for holding a pen or any delicate instrument. * It is not infrequently used as an examination test. AMPUTATION OF THE THUMB 67 Operation. The position of the joint between the trapezium and metacarpal bone, its shape, with two saddle-like articular surfaces fitting into each other by mutual coaptation, and the position of the radial artery passing over the back of the styloid process of the radius just above this joint (Figs. 18 and (i.'i), and again, when perforating the first interosseous space, lying close to the metacarpal bone, must be remembered. The operation is usually performed by a modification of the method en raquette. An Esmarch's bandage, or tourniquet, having been applied above the wrist, the hand held midway between pronation and supina- tion, and the thumb held over-extended so as to relax the parts, the surgeon inserts the point of a strong narrow scalpel just above the joint. This lies a full finger's breadth below the tip of the styloid process. Its position can usually be made out by tracing up the meta- carpal bone with one finger along its inner and the thumb along its outer margin, the .thumb being alternately abducted and adducted. The knife, entering the narrow interval between the tendons of the extensor ossis metacarpi and primi internodii, should avoid la " tahatiere anatomique " and the radial artery. Where there is much swelling comparison must be made with the sound thumb. The incision is then carried along the dorsum of the bone as far as the base of the first phalanx, where it passes (in the case of the left thumb) obliquely to the ulnar side below the web, and then around the palmar aspect of the phalanx, along the radial side, to join the dorsal incision again. Taking up first one edge of the incision and then the other, the surgeon dissects up the soft parts from the bone, keeping the knife-point close to this, especially on the inner side, where it is in close proximity to the radial artery. The extensor tendons and the short muscles of the thumb being severed, the joint between the trapezium and the metacarpal bone is felt for and opened from behind, the whole thumb being strongly flexed into the palm ; the thumb is now removed by putting the remaining tissues on the stretch by twisting the metacarpal bone in different directions. Amputation of the Thumb at the Carpo metacarpal Joint by Transfixion (Fig. 22). The hand being held as before, and the parts relaxed by sHghtly adducting the thumb, an incision is made (in the case of the left thumb) from the base of the metacarpal bone rather to its palmar aspect, along its dorsum, and then obliquely to the ulnar side of the base of the first phalanx ; the knife, a long narrow bistoury, is then pushed from this point, at the junction of the web with the thumb, through the thenar eminence to the point where the incision started, over the carpo-meta- carpal joint. By cutting outwards, along the line indicated in Fig. 22, a flap is formed of the tissues in the ball of the thumb, the knife being kept close to the bone at first, but directed more superficially afterwards, as it comes out through the skin over the sesamoid bones and base of the first phalanx, to prevent its being locked here. This flap being held back, the metacarpal bone is dissected out by keeping the knife close to it, the joint opened, and the thumb removed as before. On the right side it is better to cut the palmar flap by transflxion first, making Fig. 22. 68 OPERATIONS ON THE UPPER EXTREMITY the knife enter and emerge just as desci-ibed above. The blade of the knife is then drawn from the base of the first phalanx obliquely across the dorsum of the meta- carpal bone, from one extremity of the transfixion incision to the other. The operation is completed as before. Whatever method is employed the radial artery should not be seen ; only its digital branches should require ligature. In practice, total removal of the thumb is one of the rarest amputa- tions. Part of the metacarpal bone should always be left if possible. Even if stiff, it will be most useful when the fingers are opposed to it. The long flexor should always be sutured to the theca or otherwise secured. PARTIAL EXCISION OF THE THUMB Removal of Phalanges. Owing to the exceeding value of the thumb, a phalanx should always be preserved if possible not only in whitlow necrosis, but in the case of the first or proximal phalanx when it is the seat of an enchondroma. By this, not only is appearance saved by less shortening, but the use of the long flexor, in particular, is preserved. Mr. Royes Bell ^ published a case in which he excised the proximal phalanx in a woman, aged 19, for a huge enchondroma of sixteen years' growth, the joints being movable. The phalanx was excised by two semi-lunar incisions over the tumour, the knife being kept close to the bone, and the joints opened. No tendons were cut. Eighteen months later the condition of the thumb was excellent, both for all general movements and for writing. In 1897 Mr. Jacobson performed a simUar operation on a patient aged 33. The first phalanx of the right thumb was removed, by a single dorsal incision, for an enchondroma of twelve years standing, and the base of the distal one resected for a similar but much smaller growth. The long flexor was stitched to the portion of the distal phalanx left. Healing was complete in three weeks ; active and passive movements were then assiduously carried out. When the patient was last seen six months after the operation, the thumb was much shortened and also somewhat weaker than its fellow, but it was steadily gaining in strength and usefulness, and its movements were almost completely restored. Removal of Metacarpal Bone. This should always be excised, wherever possible, in preference to sacrificing a part of such incalculable value as the thumb. A straight incision, which reaches one-fourth of an inch beyond each extremity of the bone, ha\dng been made along the dorsum, the tendons are drawn aside ; the distal end and joint are next cleared and opened, when the bone can be used as a lever whilst it is freed from the soft parts on the palmar aspect and then disarticulated. Removal of this, as with the other metacarpals, is sometimes facilitated by dividing the bone in the centre and then removing it in two pieces. In young subjects, the epiphysis, if healthy, should be left. If possible, the periosteum should always be preserved. The position of the radial artery, both on the ulnar side of the metacarpal bone and above the carpo-metacarpal joint, must be borne in mind. Excision of the Phalanges and Joints of the Fingers. Only excision of joints need be alluded to here, as, save in the case of removal of the distal phalanx (or the last two in the case of the index) for necrosis, excision of a phalanx leaves a very useless finger. Excision of an ititerphalangeal joint may be required in some very rare cases of " snapping " or " clasp-knife " finger, where the trouble is believed to be due to irregularity of the joint surfaces. Also in those 1 Lancet, 1872, vol. ii. p. 846. DISLOCATION OF Tlir. TIIUMH GO cases ol c()u<,'ciiital contraction ol tlie linj^er, where the lateral ligaments are much shortened. At p. SS it is pointed out that, in some cases of needles deeply situated in the palm, a dorsal incision and partial removal of a metacarpal bone affords the best way of fretting at the foreign l)()d\-. Reduction of Dislocations of Thumb and Finger at the Metacarpo- phalangeal Joint. Excision of the Metacarpo-phalangeal Joint. The difficulty often met with in reducing a metacarpo-phalangeal dislocation in the case of the thumb has long been recognised. Mr. Battle has shown with instructive cases ^ that like difficulty, due to similar causes, may, though more rarely, be met with in the case of a finger. es])ecially the index. Other papers by the late Mr. Davies-Colley and Mr. Symonds ^ and Mr. Jordan Lloyd '^ will repay perusal. Any, or several, of the following factors may be the cause of the above difficulty : ( 1 ) The buttonhole-like slit with which the two heads of the flexor brevis and their sesamoid bones now, in their altered relations, embrace the head of the metacarpal bone ; (2) the lateral ligaments ; (3) the interposition of the torn anterior or glenoid ligament, between the base of the phalanx and the head of the metacarpal bone ; (4) the contraction of the numerous muscles around the dislocated joint ; (5) the shortness of the leverage afforded by the dislocated bones ; (6) the tendon of the flexor longus pollicis may be displaced and form a tense band to the inner side of the joint, winding round the neck of the metacarpal. The chief cause, however, is the displacement of the glenoid or palmar ligament of the carpo- metacarpal joint. This structure, which is a thick -plate of fibre- cartilage, occupies the interval between the lateral ligaments with which it is continuous on the palmar aspect of the joint. It is intimately connected with the sesamoid bones, and, while firmly united to the phalanx, is but loosely attached to the metacarpal. When dislocation backwards occurs as the result of violent hyper-extension of the joint the displaced phalanx tears through the weak attachment, carrying the ligament backwards with it over the head of the metacarpal bone. Remembering then that the anterior and lateral ligaments — forming one continuous structure — aie the chief impediments to reduction, mani- pulation should be tried first and always with an anaesthetic. In the case of a finger, the displaced phalanx is well tilted back on to the dorsum of the metacarpal, in order to bring the glenoid ligament and other structures already mentioned well in front of the anterior margin of the articular surface of the phalanx before flexion is employed. This, with firm pressure of the thumbs against the base of the displaced phalanx, generallv causes it to slip into place. In the case of the thumb reduction should be tried on the same lines, the whole thumb being first adducted towards the palm. The displaced phalanges may, if necessary, be grasped }>y special forceps to give greater leverage. Should manipulation fail, as it very likely will, one of the following operations should be employed : (I) Tenotomy. A tenotome is introduced on the dorsal aspect to one side of the mid-line so as to avoid the extensor tendon. It should be carried down to the base of the phalanx and then be made to cut upwards along the neck of the metacarpal. By this means the glenoid ligament will be split longitudinally. A repetition of the manipulations will then 1 Lancet, 1888, vol. ii. pp. 1222, 1271. 2 IbicJ. vol. i, p. 522. ^ Lancet, 1892, vol. i, p. 469. 70 OPERATIONS ON THE UPPER EXTREMITY generally be successful. Occasionally the tenotomy knife is introduced on each side of the extensor tendons and, the phalanges being extended, the structures between the bones are divided transversely. In this way the short flexor is cut and unnecessary damage may be done. Should the simpler procedure fail, it is better to perform an open operation. (2) By a Palmar Incision. A median incision two inches in length is made over the anterior aspect of the joint through which the head of the metacarpal is freely exposed. If the tendon of the long flexor has slipped to the inner side of the metacarpal it may be replaced by means of a strabismus hook ; the tendons of the flexor brevis may be hooked aside, and the torn glenoid ligament may be drawn from between the articular surfaces by suitable hooks or forceps. Aftei extension the head of the bone can then be replaced. If possible a few catgut stitches should be used to close the tear in the capsule ; the wound is then closed and the thumb put up on a perforated zinc or a moulded splint. (3) By a Dorsal Incision. The dislocation is exposed by an incision to the radial side of the dorsum of the joint. The glenoid ligament can then be replaced and any tense band be divided. The want of room and the close connection of the extensor tendons with the capsule always render this small operation one of some difficulty. The palmar incision should, as a rule, be employed. (4) Excision of the Metacarpo- phalangeal Joint. This is especially in- dicated when the dislocation has remained unreduced for a long time. The head of the metacarpal should be exposed through a palmar incision, as described above. The soft parts are freely retracted, and the end of the displaced metacarpal ha\'ing been cleared by keeping the knife- point closely applied to it, sufficient is then removed in situ by a narrow saw, which is preferable to bone-forceps. Free resection of the one bone will probably suffice, if sufficiently free ; merely paring off the articular cartilage is likely to lead to a stiff joint. Only if, owing to the amount of matting, or previous inflammation, there be additional risk of ankylosis, should the base of the first phalanx be removed as well. C'are must be taken, before this is done, to detach carefully, as com- pletely as possible, the tendons inserted into it, together with the periosteum, and since two freshly sawn surfaces are left additional precautions must be taken against ankylosis. Any tendon accidentally cut should be sutured. The patient must be prepared for some shorten- ing, especially if the epiphysis of the phalanx has been removed. CONSERVATIVE SURGERY OF THE HAND While each case requires individual consideration, it is hoped that the following hints may be of ser\'ice to the surgeon when called upon, suddenly, to form what is a very important decision. (1) The question of trying to unite a totally separated part is alluded to at p. 78. The question of palmar haemorrhage is considered at p. 88 ; and the treatment of injuries to tendons and nerves will be found under these headings respectively. (2) After injury, except in rare cases, where the combined com- minution of bone, injury to tendons, and stripping of? of skin is extreme, no set amputation is to be performed. In the case of a part of such incalculable value, and so well supplied with blood as the hand, the surgeon should remember Verneuil's words and not " approach these cases with the bistoury." He is to render the part as aseptic as CONSERVATIVE SURGERY OF THE HAND 71 possible, and then to wait and watch what Nature will do towards the uUinude restoration of usejulness. This, of course, entails risks of suppuration, sloughing, and even worse ones, such as tetanus. Assiduous attention to the advice at p. 73 alone justifies running these risks. Speaking generally, these cases, in which the decision has to be made between too conservative surgery and in removing too much, fall into two groups. A. Injuries limited to the Fingers. Here conservative surgery is less rigidly indicated than in complicated and extensive injuries to the hand. \i the injury to the finger, especially the third or fourth, be such that useful function will be lost, it will be wiser to amputate it, and not hold out any hopes of usefulness, which will only, after prolonged and tedious treatment, prove illusive. If it be the index which is most damaged, the surgeon will remember that a freely movable middle finger will steadily improve in sharing with the thumb the loss of the index. And if the head of the metacarpal bone has been removed, a new interdigital space will gradually be developed, which may be very useful for a working man. B. Complimted and extensive injuries to the Hand. Here the difficulty of estimating the extent of the damage, the power of ultimate recovery in a part like the hand, and the amount of loss of function, together with the hopelessness of any really useful artificial substitute, should make conservative surgery the rule, and the surgeon should wait and see how much antiseptic baths and dressings, together with the other aids given below, will save from destruction. (3) Later Amputation. But while it is a cardinal principle to preserve every inch of the hand, a single finger or a thumb alone being far more useful than the most elaborate artificial limb that can be made, and while to gain this end it is frequently advisable to trim up an injured part and to remove bone in preference to doing any set amputation, it must always be remembered that a part may he capable of being saved, and yet ultimately be useless unless it be at least partially movable. Again, atrophy of a part, at first promising in usefulness, may set in some time after the injury, brought largely by trophic disturbances. In either of these cases a rigid cicatricially contracted claw, or a pointed, sensitive, and shrunken part may call, later on, for amputation. (4) Amongst the very exceptional cases ivhich call for primary amputa- tion are those where (1) one or more fingers are mangled and pulped out of all shape or recognition ; (2) where all the tendons are torn through, especially if this has happened at more than one place, as in the fingers and in the palm also, and where, with these injuries, there is much opening of the joints as well as fracture of the bones and ripping off of the skin ; (3) where the fingers are extensively split longitudinally ; (4) another condition, which surgeons in large manufacturing centres are certain to meet with, requires grave consideration, i.e. where a hand is flayed, owing to its having been caught between rollers which hold, but do not crush ; here, as the patient draws back, the skin is stripped off, like a glove, from the WTist. If, in addition, bones are crushed, the palmar thecae opened, amputation, leaving part of one finger, if the thumb is intact, or through the wrist- joint, should be performed at once ; and Billroth ' advises this step where the skin is completely stripped off without other injury, fingers entirely deprived ^ Led. on Surg. Pathology and Therapeutics. Syd. Soc. Trans., vol. i, p. 207. 72 OPERATIONS ON THE UPPER EXTREMITY of their skin almost invariably becoming gangrenous, and the result being " under the most favourable circumstances, nothing more than an unwieldy cicatrised stump." The following case ^ is a good instance of the above : " The hand of a little boy was caught in the rolling machine of a bakery, and the skin divided at the wrist just as cleanly as if it had been done by intention, and an entire glove of the skin taken off. Wlien I saw it. it was held on by the tips of the fingers only. There was no injury other than that described. I felt satisfied that amputation was proper ; but the patient iasisted that he was willing to take the risk if amputation was not performed, and I replaced the flap, and stitched it in several places, believing that it w'ould slough. It did slough, and he lost his fingers up to the knuckles, and the only part that was saved was a small portion of the thumb, and the metacarpal portion of the hand. This, of course, was a cicatricial surface, which I covered with grafts, and it finally healed. The boy can hold a pen in a little groove by the side of the thumb, and it is probable that the remnant of the hand will finallj^ become useful." The explanation of the certainty with which the stripped-ofi skin dies in these cases, and the uselessness of the most careful stitching, lies in the fact that not only have the vessels passing from the deep parts to the skin been torn through, but the skin itself has been submitted to an enormous strain and dragging. In such cases where it is clear the glove-like skin must go, but the deeper parts are uninjured, an attempt should be made by skin-grafting, after Thiersch's method {see p. 42), or by pedunculated flaps (see p. 7-4), to pro^^de a covering and prevent the sloughing of the deeper parts. (5) Skin-grafting is especially to be made use of where, after an injury to the hand, it may be possible to save one or two fingers only, or. particularly, the thumb and index finger, by taking skin, if possible, or a pedunculated flap, from the damaged hand, the opposite arm. or the abdo.iien. In slighter cases the large grafts taken by Thiersch's method iq.v.) from the arm will be employed. Dr. Schreiber- advises skin- grafting in smaller injuries. Thus, if the skin be torn away from the dorsum of a finger, over-extension will follow when the wound is healed unless it is grafted. On the other hand, if it be the pulp that is torn away, successfid grafting will give a rounded, sensitive, fleshy end, instead of a thin, sensitive, pointed one. The surgeon must, of course, prepare his patient for disappointment. The grafts may die. and the injured part be reduced to a claw, active movement largely disappearing. Skin-grafting may also be made use of later on if one or more fingers become contracted, and division of the cicatrix leaves a gaping wound. The above remarks refer to skin-grafting for small areas on the fingers, and the back of the hand only. The case of the palm and the employ- ment of pedunculated flaps is referred to later [see p. 74). In some cases the method of desossement of French surgeons will be useful in supplementing or replacing skin-grafting. Supposing that in a case of severe laceration, in which it is determined to try and save the hand, one finger requires amputation, by turning out the bone. removing the nail and tendons, some of the soft parts thus left may be utilised in filling up any large gap below. The incision, eti raquette, is made along the dorsum or palmar aspect according as it is desired that the soft parts of the finger should fall into place along the back or front of the hand. ^ Dr. Gregory, of St. Louis, U.S. Trans. Amtr. Surg. Assoc, vol. 2, p. 232. 2 Munch. Med. Woch., Aug. 19, 1892. (ONSEHVATIVE SURGERY OF THE HAND 73 Mr. C. B. Keetley, wliose iiigeniiity is well known, made use of the soft parts in a different way.^ A young woiuiui liad all the (ingers of the right hand ciiishcd and torn, and on the ])alinar surface burnt, by the hot I'oller of a machine-rnangle. "Nearly every inter-phalangeal joint was open on the palmar as|)oet. All the flexor tendons of the middle and ring fingers were destroyed. But their dorsal tendons were intact. 1 therefore amputated tlie ring finger, jireserving all its dorsal soft struetures. These being then brought round and fixed to the previously refreshed ])alinar surface of the phalanges and joints of the middle finger, the extensors of the ring finger assumed the duties of Hexors of the middle finger. The results, both as regards appearance and function, were surprisingly good." ((")) Injury to Joints. Where the tendons are uninjured, or can be sutured, where there is no extensive comminution of bone or great injury to the skin, the finger will, of course, be saved. If expectant treatment is adopted, even if the parts heal quickly, the surgeon will l)e fortunate if he manages to preserve for his patient half the natural iaiiii;e of movement of the joints affected. And, to do this, splints — • of perforated zinc, not of wood alone — will have to be frequently changed, the part being put up for a short time, flexed, then extended, massage assiduously employed, &c. Probably excision of a joint which has been freely opened will restore better movement if the patient is brave and persevering. It should certainly be tried — and removal of the bones carried out sufficiently widely to prevent ankylosis — in the case of the joints of the thumb {see p. 68). (7) Injury to Tendons. This is fully considered at p. 93. (8) To sum up the chief points : Primary amputations, especially what may be called formal operations, are only to be made use of under the very rarest circumstances ; any surgeon who makes use of them will almost always find that he has overstepped what was absolutely needful. The part should be thoroughly cleansed (with the aid of an anaesthetic) by means of turpentine and soap, with a sterilised nail-brush and lotion, these solutions, if necessary, being used continuously in an arm-bath. A word of warning may not be out of place here. In his desire to obtain asepsis the surgeon should remember possible effects of over- strong, irritating chemicals, such as formalin, carbolic acid, &c. The vitality of the soft parts is much lowered, and in the case of the fingers, they are, on three aspects, thin and easily compressed against closely adjacent bones. The hopelessly damaged soft parts should be trimmed and drainage provided. It is only by great care here that the surgeon is justified in submitting his patient, during the attempt to save a mangled part, to the danger of infection, gangrene, tetanus, &c. If there is any doubt as to the completeness of the cleansing, the part should be kept in an arm-bath with a weak aseptic lotion constantly renewed. But it is always advisable to get the wound sweet and safe under a boracic acid fomentation and at rest as soon as possible. If any part must be amputated, a flap of skin or tendon that may be useful is to be transferred to the parts that are being saved. So, too, later on, if a surface is left, which by cicatrising slowly will lead to distortion, or if tendons exposed have fibrillated and died, an attempt must be made to cover the one by flaps taken close by or from a distance, and replace the other by distance-sutures {see p. 100). Secondary 1 Lancet, March 4. 1905. 74 OPERATIONS ON THE UPPER EXTREMITY operations will also include removal of any painful stumps, especially those which interfere with the approximation of the thumb to another finger. Fig. 23 is an excellent instance of what may be effected by conserva- tive surgery of the hand. It represents the remains of a hand, consisting of the thumb, stump of the index, and of the Httle finger, and also shows of how much flexion the shortened index is still capable.^ Value of Pedunculated Flaps in Injuries of the Hand. This method, which we owe to Dr. Fenger, is described in a lucid article by Dr. Schroeder, of Chicago. It is pointed out that Thiersch's method does not give either the elasticity or resistance which are especially needed in the palm ; the resulting scar is also prone to break down. It may, however, be usefully employed on the dorsum. Dr. Schroeder's patient was aged 30, the right hand, contracted into a fist, had been left untreated since a burn in infancy. Its functions were ahnost entirely lost (Fig. 24). The hand and right liip were most carefully prepared for two days. The operations were six in number. First Operation. The cicatricial tissue was dissected off the palm, fingers, and thumb. This left a wound extending from the carpo-metacarpal Joints to the distal phalanges (Fig. 25). The deformity of the thumb was corrected, but the new position was maintained with difficulty. The first finger was still flexed by the shortened anterior ligament of the first interphalangeal joint, which was ruptured in extending the finger. The hand was now placed upon the hip and incisions made in the skin as guides. The upper flap was made wide enough to cover the denuded space above the first row of digital furrows, having an anterior and posterior pedicle, the distal end of the thumb passing out through the posterior pedicle (Fig. 26). The anterior Fig. 28. Fig. 24. flap passed over to the crest of the ilium. The hand was now placed under this flap, the fingers separated, and incisions made opposite the middle of the distal phalanx of each as guides. The hand was again removed and the pockets made, one for each finger, leaving attachments between the fingers for nourishment and better immo- bilisation of the fingers. ^ The figure is taken from a paper on Railway Injuries by Dr. Thomson, of Kentucky. Trans. Amer. Surg. Assoc, vol. ii, p. 190. CONSKin'A'I'IVE SI KGERY OF THE HAND 75 The hand was now plated in position and the upper and lower Haps united, as well as the lower border of the lower Hap to the fingers, and the upper border of the Fig. 25. upper flap to the edge of the skin of the wrist. There are several important pre- cautions to be taken in this step, namely : (1) Xot more than a quarter of an inch of subcutaneous tissue must be taken, because a thicker flap is clumsy and more difficult to unite to the skin of the hand. Fig. 26. However, if more is taken it will be absorbed in time. Some subcutaneous tissue must be attached, or the vitality of the flap is endangered. (2) There must be no 70 OPERATIONS ON THE ITPPER EXTREMITY tension on the jjedieles. (3) The edges of the skin of the hand must he luiderniined for at least a quarter of an inch, so as to allow of easy approximation. Sterile gauze was ])laced at the back of the hand, and gauze drains hehind the Fig. 27. fingers. A large dressing was placed over the hand and retained by adhesive straps. A plaster case was next applied, extending from the shoulder to the glut«o-femoral fold. At the end of three days a trap-door was (Fig. 27) cut in the case and the Fig. 28. dressings changed. Boric acid solution was the strongest antiseptic used in these dressings. The wound was dressed every third day. Second Operation. This, performed on the eighth day, consisted in dividing the inner pedicle to where the thumb protruded. Part of this pedicle was united to its CONSERVATn K SUlUiKHV OK TIIK HAND 77 former place. The flaj) was united to the thumb (Kig. 2.S). A new case was applied because of the broken condition of the old one. Dressing as before. Third Opcrnt'KW. On the sixteenth day the icruainder of the ])osterior flap was divided and the ila|) stitched to tiic radial side of hand and index finger. The flap was now nourished from the anterior pedicle and interdigital septa and the new adhesion formed. Fourth Operation. On the 1 wenty -second day the inner ])edicle was divided and stitched to the ulnar sidl^ of the i)alm and little linger. The interdigital septa were divided, and the hand thus liberated. At this time the granulating wound on the hip was curetted, ])artly closed l)y undermining the skin around it, and then grafted. Fifth Operation. On the twenty-seventh day the bridges of tlap between the index and second and between the little and ring fingers were divided and sutured to their respective edges of the finger. !^i.rth Operation. On the thirty-second day the bi-idge between the second and ring flnger was divided, and the parts sutured as before. Fig. 29. Whenever an edge of flap was united to the edge of normal skin, it was necessary to dissect back the skin, freshen the edges and bevel those of the flap below, so that good coaptation would be possible and primary union assured. Dr. Schroeder with great candour states that it was not possible in any of his cases to avoid infection absolutely, but by frequent dressings and proper drainage this did not interfere with a good result. In this case the joint opened in the index finger became anky- losed. The usefulness of the hand was very much improved, the patient, three months after the operation (Fig. 29), was able to partially flex and extend the fingers. Three other cases are given. In one, also resulting from a burn, a useful hand was obtained. The remaining two were due to injury. In one, where the hand had been caught between rollers, the greater part of the skin on the palm and dorsum were torn away and the flexor tendons freely exposed in the palm. A single flap was taken from the hip and its free edge united to the radial side of the thumb and upper and lower edge of the palm. A most satisfactory result followed. In the last case, after an attempt to save a very badly crushed hand had failed, the fingers and most of the skin on the palm and dorsum ched ; the stump was grafted from the hip. After several weeks the pedicle was lengthened, cut low down, and the flap turned up on the dorsum and sutured. The result was good, giving the patient a stump against which the thumb could be pressed. 78 OPERATIONS ON THE UPPER EXTREMITY REUNION OF SEVERED DIGITS The question wiW sometimes arise as to the advisabiUtv of attempting to reunite severed portions of thumb or fingers.' Many such successful cases have occurred, and the surgeon may well make the attempt, when the parts are cleanly severed, through a phalanx, especially the distal one, and when the patient is young and healthy ; when the cut has passed through a joint, not through a phalanx, the outlook is far less promising. The following are instances of the paits severed : The first, second, and third fingers cut off above a diagonal hne beginning in the middle phalanx of the index finger and ending in the last phalanx of the third finger near the root of the nail. The parts had been l^ing in the snow for some time and were kept for two or three hours before being applied. In other cases the part has been severed longitudinally, containing in it a portion of bone split off. The time between the injury and the treatment has varied from twenty minutes to tliree or four hours, and the severed part has been picked out of sawdust, brought up in dirty paper, whilst in a third the patient was sent back to find it in the field in which he had been reaping. When there is the least shred of soft parts left holding on the severed bit,- even a bad compound fracture of the finger with severe laceration of the soft parts may be saved. The age and condition of the patient, the time which has elapsed since the injury, the part aft'ected, i.e. whether the index finger or the thumb, must all be considered. And. in any case, the patient should be warned that, though the attempt may succeed, the parts unite, and sensation be restored, the result may be a stiff and, therefore, com- paratively useless member ; indeed, on this account, amputation may eventually be required. If it be decided to make the attempt, the part should be carefully cleansed with soap and water, antiseptics being used with caution ; it is then united exactly with a few salmon-gut or horsehair sutures, enveloped in aseptic wool, and kept in situ ^^^th carefully adjusted splints of perforated zinc. The dressings should not be disturbed for at least three days if possible. SUPERNUMERARY DIGITS (POLYDACTYLISM) This congenital deformity is sufficiently common and important to require a brief notice. The condition is usually symmetrical, and there may be one or several additional digits. The chief point of importance, from a practical point of view, is the mode of j miction of the super- numerary digits. This, consisting of two or three phalanges, may be joined by mere fibrous tissue ; in other cases there may be a complete articulation between it and the side of an adjacent metacarpal bone, or the carpus, a metacarpal bone being usually present, in addition to the phalanges, in the latter case. Lastly, the allied condition of supernumerary phalanx may be present in cases where the terminal phalanx of a thumb or finger is bifid. Treatment. This consists of amputation, as early as possible, with strict aseptic precautions, so as to secure primary union and a perfect scar in a part where a deformity is so noticeable, and also to prevent the risks of infection when a joint is opened. In each case the finger is removed by an elliptical incision, the flaps being cut so as to meet exactly ; where the union is fibrous, this is all that is required. But COXSKRVATIVP: surgery of the hand 79 where an articular surface is present, this must be exposed after dis- articulation of the finger, and sufficient of the joint chiselled or cut away with strong scissors so as to leave the surface of the bone plane and uniform ; otherwise growth will continue at this spot up to adult age, and a very unsightly deformity may be produced. When the articulation is with the carpus, additional care is required in carrying out the above steps. In the case of a bifid phalanx the treatment involves more trouble on the part of both surgeon and patient or the friends, if the result is to be satisfactory. That portion of the phalanx which is the largest, which diverges least from the straight line, and which carries the best- developed nail (if these three points coincide) is to be preserved, and the other one removed. In carrying out this step, if the phalanx be not completely bifid, it should be spilt down through its base with a chisel, bone-forceps, or strong scissors, and the part to be removed taken away. Any ligaments — i.e. the lateral on the opposite side — or struc- tures which will prevent the part left from being brought into the straight line should be divided. As soon as the wound is healed, careful move- ments of the joints and bringing the phalanx into the straight fine must be practised every few days, and a metal splint worn with a collar round the wrist, \\ith a lateral prolongation coming up along the affected finger or thumb on the side away from that to which the phalanx projects, this prolongation admitting of being bent outwards to any needful extent ; by this means the phalanx, which is at fault, can be drawn straight. But persevering daily treatment for four or six months will be required. WEBBED FINGERS (SYNDACTYLISM) (Figs. 30, 31, and 32) These should always be remedied in early childhood ; if left un- touched, the fingers may be useful, but the annoyance of the deformity will be serious. The surgeon should not yield to pressure put on him to operate in early infancy. Simple di\"ision of the web — a trifling operation — is out of the question ovsing to the inevitable recurrence of the deformity. On the other hand, especially if extensive dissections are made in raising flaps, the loss of blood ^411 be considerable, and not without risk both as to the \ntality of the flaps and of the infant itself. Xo operation should be undertaken before the child is at least three years old ; in cases where the union is very close, it is preferable to wait till the age of four. Where several fingers are united, quite a month should elapse between the operations on the first and second pairs. The treatment will depend upon the condition and extent of the web. In the slighter cases there is merely an increase downwards for some distance of the normal web ; there is then an objectionable deformity rather than any actual disability. In the more serious cases the fingers may be joined down to the terminal phalanx. The web may then be lax and free (Fig. 30). or close and thick (Fig. 32), or two fingers may be more or less completely joined by bony union of phalanges. (1) The simpler methods, \'iz. wearing a piece of thick silver wire or fine drainage tubing through a hole made through the base of the web where the cleft should begin (" ear-ring " perforation), may first 80 OPERATIONS ON THE UPPER EXTREMITY Fig. 30. Agnew's operation for webbed fingers. The flap is dorsal, large, and single. (Keen and White : American Text-hook of Surgery.) be tried. The tubing, which has the advantage of interfering less with the movements of the hand, may be attached to a band round the wrist ; the wire may be twisted in a loop round an adjacent finger. When the perforation is soundly cicatrised — i.e. in about three or four weeks — the web should be slit up, each half split, dissected up for a little way, and the edges of the two flaps thus formed united with a few points of sterilised horsehair. The greatest care must be taken to secure primary union, for otherwise granulation and cicatrisation will inevit- ably lead to contraction and displacement of the finger. The fingers should be kept apart by a layer of gauze through- out the healing. This method has the disadvantage of being tedious, and the formation of epidermis round the foreign body is liable to be incomplete. (2) If the above fail, one of the following plastic operations should be made use of : Agnew's or Norton's ^ (Figs. 30 and 31). These can only be carried out in cases where the web is ample. In Norton's operation (Fig. 31), small triangular flaps are raised on the dorsal and palmar aspects of the base of the web which is cut then through and the flaps very care- fully stitched together without tension. The object is to ensure rapid union in the upper end of the cleft, and thus no re- development of the web. Agnew's opera- tion employs a single larger flap (Fig. 30) raised from the dorsum. The flap should be thick enough to avoid risk of slough- ing, and somewhat narrow to avoid bulging. To prevent tension it should be sufiiciently long, its base being at the level of the metacarpo-phalangeal joints, and its apex, which should be rounded, almost reaching to the base of the second pha- langes. The apex is sutured to the palmar edge of the cleft, and its sides to the skin at the edge of the wound. Any re- dundant tissue between the knuckles that prevents their coming together should be cut away. The remaining web is then split and treated as above described. The line of the natural web should be carefully preserved. Fig. 31. Norton's operation for webbed fingers. The flaps are small and double. i On the Continent this operation goes by the name of Morel -Lavallee. CONSERVATIVE SURGERY OF THE HAND 81 Didot's (Fig. 32). This operation was introduced for those cases in which the web is very narrow. Two narrow longitudinal flaps are dissected up as thick as possible from the palmar and dorsal aspects of the afTected fingers by two incisions, one along the middle line of the dorsum of one finger and another along the mid-line of the palmar surface of the other, from a point opposite to the extremity of the web to the knuckle. By short transverse incisions at each end of the vertical ones (Fig. 32), the two flaps are marked out. These are most carefully raised {see below), and each flap is then folded round to cover the raw surface of the finger to which it is attached, and secured with a few interrupted sutures of fine silkworm-gut or horsehair. Didot's, like many French operations, is most ingenious and, on paper, it looks an excellent one. But, in practice, the following objec- tions will present themselves: (1) It is a severe operation, especially in little children. (2) It is not easy to raise satisfactory flaps in parts so small and with skin so little developed. Thus, if the flaps are too thick it is easy to injure the extensor tendons or digital nerves or vessels ; on the other hand, if the flaps are too thin they slough, and infection then readily occurs. (3) The flaps are nearly always insufficient to cover the denuded surfaces unless they are submitted to such tension as may lead to sloughing. Thus in part the wounds must heal by granulation, which may lead to harmful contracting scars, or by the aid of skin-grafting, which is liable to be rendered futile by the rest- lessness of the patient. (4) Consider- able difficulty will be met with in fitting neatly the quadrangular edges of the flaps at the roots of the fingers so as satisfactorily to re-establish the normal web. For the above reasons the method of operating by a triangular flap is preferable (Figs. 30 and 31) wherever the web is loose enough to render this feasible. Mr. Bidwell, in one case,^ combined the methods of a flap from the web with one from the dorsum of one finger and skin-grafting. In those rare cases where the union is bony, the choice lies between (a) lea\dng things as they are or (6) remo\dng the bone of one of the united fingers after exposing this adequately by two rectangular flaps, dorsal and palmar. Separation of the fingers is not practicable, for there is no possibility of obtaining skin flaps to cover the raw surface. Such an attempt is almost certain to result in two deformed and useless fingers, which will probably require amputation. After all operations on webbed fingers, especially the one introduced by Didot, there is more or less tendency for the fingers to become stiffly flexed or extended, according as any excess of scar has formed on the palmar oj- dorsal surface. Thus it is very common for the finger which 1 Lancet, June 29, 1895. SURGERY I 6 Fig. 32. Didot's operation for webbed fingers. (Reeves.) 82 OPERATIONS ON THE UPPER EXTREMITY has the dorsal flap, and in which the cicatrix lies along the palmar surface, to become flexed. This tendency must be met by persevering use of a splint, one similar to that mentioned at p. J^3 being applied to the dorsal or palmar surface of the finger as required. At first it must be worn day and night, and then removed for varying periods in the day to admit of active and passive movements being assiduously practised. It -^ill require to be worn at night for many months. In a few cases of this deformity a pedunculated flap taken from the dorsum will provide the most extensive and mobile skin in the position of the web. CONTRACTED PALMAR FASCIA (DUPUYTREN S CONTRACTION) AND OTHER CONTRACTIONS OF THE FINGERS (Figs. 33, 34) Dupuytren's contraction of the palmar fascia is usually met %\ith in middle-aged men. Though it often appears to be due to continued slight irritation or injury, such, for example, as is caused by the frequent use of some tool or instrument, it is undoubtedly in many cases associated with a tendency to gout. The palmar fascia is triangular in shape ; the apex is attached to the anterior annular ligament, while below it ter- minates in four processes to the four inner fingers. Each digital process consists of a central portion which joins the theca and two lateral processes which are attached to the skin of the web, the capsule of the metacarpo-phalangeal joint, and the side of the first phalanx. The contraction takes place especially in the processes going to the two inner fingers. Commencing about the transverse palmar creases, it steadily and progressively cripples the hand by drawing down the fingers, causing flexion, first at the metacarpo-phalangeal and later at the first interphalangeal joints (Fig. 33). Operation. This may be either subcutaneous, by multiple punctures, or open, the latter being effected either by multiple transverse cuts through an open longitudinal incision or by excision of the contracted fascia. The Subcutaneous Method. The best is Adams' operation, in which the contracted bands are divided by multiple punctures from the surface downwards. The skin must first be carefully prepared and cleansed. If thought desirable, local anaesthesia may be employed. Finding some spot where adhesion of the skin to the fascia has not yet taken place, the surgeon, avoiding the site of the vessels, passes a fine small tenotomy knife between the skin and fascia, and divides the band from above downwards, taking care not to dip the point too freely. If too much straightening is attempted at once, the punctures "svill gape A^idely and readily tear, especially where the skin and fascia are adherent. In cases of contraction of two fingers, a number of punctures — e.g. five to nine— may be required. It is usually easy, by operating on the pahnar bands, to rectify the contraction at the metacarpo-phalangeal joint. The straightening of the contraction between the first and second phalanges is much more difficult. The digital prolongations of the fascia may be divided by punctures in the web between the fingers, extreme care being taken to avoid the digital vessels and nerves by not depressing the point, and by keeping to the middle fine. But when the surgeon finds some difficulty in correcting this contraction thoroughly, DUFUYTREN'S CONTRACTION 83 he will act most wisely by correcting the remaining contraction gradually by the use of Adams' finger-splint with rack-and-pinion movements opposite the metacarpo-phalangeal and intorphalangeal joints.^ The splints, which should be constructed of metal to combine light- ness with rigidity, should accurately ht the palm, and the length and breadth of each linger. They are secured by broad strips of soft leather. At intervals during the clay the splint should be removed, and the hands well soaked in hot water, scrubbed in this with a nail-brush, and the patient assiduously practise placing the affected finger-tips on a table, and then making pressure on the dorsal surface of the fingers with those of the other hand. The skin should be most carefully cleansed, and Fig. 33. an aseptic dressing applied for three or four days, when the punctures will be practically healed. The splint should be worn day and night at first, carefully padded at all pressure points. Some weeks will be required to correct the interphalangeal contraction, and in advanced cases relapses can only be prevented by the persevering use of the splint. In any occupation which entails much grasping, gloves padded on the palmar surface should be worn. If the surgeon attempts to straighten completely an advanced case of phalangeal as well as of meta- carpo-phalangeal contraction, he runs the risk (1) of dividing a digital nerve, which may lead to most intolerable pain ; (2) of damaging the tendons, for these bands are often in close relation with the theca ; and (3) of injuring the vessels and thus producing slight gangrene of the finger-tips. ^ Other splints will be found figured by Mr. Adams {Lancet, 1891, vol. ii, p. 166). If the skin has been much strained or interfered with, the straightening should be deferred for a few days. 84 OPERATIONS ON THE UPPER EXTREMITY The threefold association of the palmar^ fascia with the theca, the skin of the web, and the superficial transverse ligament is, as the result of the disease, rendered more intimate than ever. To guard against a relapse the patient should, regularly and methodi- cally, practise active and passive movements of the joints, wear the splint at night for a considerable time, and if any persistent or recurrent bands threaten to be troublesome, treat these by rubbing in oleate of mercury ointment. Should the patient be the subject of gout or addicted to alcohol he should be warned and treated accordingly. Figs. 33 and 341 represent a right hand crippled by Dupuytren's contraction before and five years after operation. The man was a patient of Dr. J. E. B. Burroughs, of Lee, and was operated on in 1883, the contraction of the metacarpo-phalangeal joints being straightened at once after numerous punctures made in the manner described above, while that at the interphalangeal joints was remedied chiefly by the presevering use of Adams' splint already described. In 1890 the fingers could be completely extended, were perfectly mobile, and free from the shghtest tendency to contraction. It will be seen from Fig. 33b that some thickening, puckering, and corrugation of the palmar skin and fascia still persists, but this had now no power of producing contraction, the patient, a relieving officer, being able to write, &c., without any hin- drance whatever. But to show the importance of persevering in the after- treatment mentioned above, when, after another four years, the patient was again seen in 1894, there was some recurrence of the flexion of the interphalangeal joints. The above advice, which had been insisted upon, had been entirely neglected. And this is very often the case, owing to patients thinking that the operation, of itself, will accomplish every- thing, and that no responsibility in the after-treatment rests with them. Operation by Multiple Transverse Cuts through an Open Longitudinal Incision. This method has been advocated by Goyrand, Kocher, and in this country by Mr. Hardie, of Manchester, and Mr. Keetley. It has been recommended on the ground that mere subcutaneous division of the contracted fascia cannot be sufficient if the thickened, puckered, hardened skin is left alone, and also that intimate adhesion of the altered skin to the fascia is so general that it is difficult, if not impossible, to get the knife between the two at a sufficient number of spots for adequate straightening by the subcutaneous method. Keetley, who advocates this operation, thus describes the steps. " The limb having been elevated and an Esmarch's bandage applied, the hand and forearm, carefully sterilised, are held extended and supinated on a sterilised towel on a mall table beside the operating table, with the fingers as much extended and separated as possible. A longitudinal incision is made through the skin and into the contracted fascia. If the finger is much contracted, this incision can only be completed by degrees, as the division of the bands gradually permits the unfolding of the fingers. The extent and degree of the contracted fascia are now easily seen, and it should be divided transversely and completely in many "places until all resistance is removed, and nothing but shortening of the ligaments and structures around the joints remains. This should be left to be overcome by after- treatment. Here and there the skin itself may have to be freed by a 1 The asterisks in Fig. 34 show spots where the tenotomy knife might be introduced in contraction of the palmar fascia slip going to the ring finger. The contracted band thus isolated by the punctures gradually atrophies. DUPUYTREN'S CONTllACTION 85 touch of the knife. The skin incision is closed by silkworni-^ut sutures placed close to the edges of the wound. If the above directions are strictly followed, merely a linear cicatrix will remain, such as contrasts favourably with what has been reportcnl as the ultimate state of things aftei' excision of the conti'acted fascia." Excision of the Contracted Bands oJ Fascia, (a) Bij Rectanyular Flaps. The skin having been, for two days at least, softened by the frequent use of soft soap and hot water and the inunction of lanoline, and care- fully sterilised, a longitudinal incision is made over the contracted band from its upper to its lower limit, and then small transverse incisions are made at each end of this, so that two small rectangular flaps may be dissected up. A twofold difficulty at once presents itself : the skin is usually so adherent in places that the satisfactory making of these flaps is by no means easy, a difficulty much increased by the flexed position of the finger. A hard band of horny adherent skin may be removed by a narrow elliptical incision. The contracted fascia, when exposed, is dissected out, and the flaps united with silkworm gut or horsehair. The second difficulty is now met with owing to the con- traction and adhesion of the skin which has to be united. Where union is impossible, skin-grafting ^ ought to be employed ; any surface left to granulate means more or less recurrence of the trouble. (b) Bij a Y-shaped incisioyi (Fig. 34). The base of the V is opposite to, a little above, and overlapping the root of the affected finger ; the apex is situated in a line with the centre of the same finger, in the palm, about on a level with the transverse crease. Two diverging incisions join these points, and are carried down through the skin and fascia. The latter may be divided completely or removed entirely when the finger can be straightened. This leaves a gaping triangular wound in the palm with its apex upwards. Theoretically this should be united by careful stitching in the form of a Y. But the contracted state of the skin almost always prevents accurate stitching, and leads to some gaping of the wound, and a raw surface which may require grafting. For the severest cases Sir W. Watson Cheyne and Mr. Burghard^ re- commend a combination of the subcutaneous method and the V-shaped incision. " In very advanced cases, where the fingers are tightly bound down to the palm, removal of the fascia by dissection cannot be per- formed, because it is impossible, on account of the contraction of the fingers, to get proper access to the palm so as to make the requisite incisions. Under these circumstances the best treatment is to divide the fascia in the first instance, and to get the finger as straight as possible by this means. As a rule, however, division of the fascia will not allow the finger to come quite straight, because the skin itself is contracted, and therefore the result is incomplete. The operation by the V-shaped incision may be very usefully combined with tenotomy so as to compel the straightening of the fingers. The two operations should, however, be done at different times. The result of the tenotomy is to endanger I Skin-grafting has been somewhat hghtly recommended in these cases as too certain to complete the healing. The following cautions may be emphasised: (a) Any unhealed surface remaining after an open operation for contracted palmar fascia is far from being an ideal one for skin-grafting, like the smooth, level, regular surface of a large ulcer : (6) When the surface to be grafted is of any extent, and the hand one much em- ployed in manual labour, the grafts may not afford a permanent protection. Plastic operations are out of question in these patients, both from a local and a more general point of view. 2 Manual of Surgical Treatment, vol. i, p. 291. 86 OPERATIONS ON THE UPPER EXTREMITY the vitality of the skin at various points ; this, however, very rarely sloughs, unless too great a pressure be brought to bear upon it. Hence a sufficient time must be allowed to elapse between the tenotomy and the open operation to allow these damaged portions of skin to recover, and during this time the fingers should be kept somewhat extended on a splint ; three weeks' interval is usually enough." Before per- forming any operation the surgeon should remember that there is a considerable likelihood of subsequent cicatricial contraction. Another possible troublesome sequela is pain and tenderness in the region of the Fig. 34. scar. Total removal of the contracted fascia necessarily takes away its capacity for protecting the underlying nerves. In less severe cases, where the metacarpo-phalangeal joint is not flexed to more than a right angle, the method of multiple subcutaneous punctures should be adopted. Nowadays, with all the advantages of modern surgery, there is no excuse for the patients not coming for treatment early. In those cases, and these ought to be exceptional, where the induration is more widespread and denser, a longitudinal incision and multiple transverse section of the bands, or their total removal, should be employed. The treatment of the most severe cases has been described above. In answer to the objection that the simpler method is liable to be followed by relapses, this must be admitted, but a relapse may also follow other and more radical steps. And where relapses do follow, they are fiequently due to the patients either not being duly warned, or to their neglecting the warning that the treat- ment may require repetition, and that, in any case, it demands imperatively that much of the responsibility for success lies with them in the after-treatment. This entails patience, assiduous attention to the employment of_ splints and the needful manipulations for many months, and the giving up of alcohol. Where these essentials are attended to, relapses will be comparatively infrequent. Those who prefer the more recently advocated methods must remem- DUPUYTREN'S CONTRACTION 87 ber the following points, viz. the age and vitality of many of these patients ; the need of thorough sterilisation of the skin — not an easy matter when the contraction of the fingers renders access to all the hollows and inequalities difficult ; the oozing and possible need of a drain ; the fact that tlie puckered state of the skin always makes accurate stitching difficult, loading to a "raw surface and the need of grafting, of the objections to which mention has already been made, a need which is increased by the tendency of the sutures which it has been possible to insert to cut their way out owing to the necessary tension in places and the diminished vitality of the skin. Lastly, there is the swelling of the hand which may occur, especially in gouty patients, and which interferes greatly with the use of splints. CONGENITAL AND OTHER CONTRACTIONS AND DEFORMITIES OF THE FINGERS In addition to Dupuytren's contraction, there is a somewhat similar congenital deformity, occurring chiefly in girls, in which one tinger, usually the little one, is flexed at the first interphalangeal joint ; there may also be flexion of the second inter- phalangeal joint, but the first phalanx is hyper-extended on the metacarpal — an important difi'erence from Dupuytren's contraction. The condition may be bilateral. The mischief appears to lie in a contraction of the central slip of the prolongation of the fascia to the finger ; the fascia of the palm and the lateral shps are not affected. There is seldom any real interference with the usefulness of the hand, advice being sought on account of the deformity. Palliative treatment can only be of avail in early life, when the small size of the parts renders it difficult to carry it out. If operation be undertaken, the open method with multiple transverse incisions can be easily made use of as the skin is not affected, and the band is median, so that the digital vessels and nerves are not endangered. If the above be insufficient the lateral ligaments of the flexed joint must be divided, and tendon-lengthening may be needful ; in the most confirmed cases, where ankylosis is present, the question of excision or amputation will arise. Severe Contraction due to Injury. Here such steps as tendon-lengthening (p. 99) combined with a plastic operation may occasionally be employed with Ijenefit. Snap or Trigger Finger. In this curious condition full extension, more rarely flexion, of one finger is prevented and can only be attained with the help of the other hand, the finger being now suddenly flexed or extended with a snap like the closing of a blade of a pocket-knife. Some pain and tenderness are usually experienced near the metacarpo-phalangeal articulation. The pathology is un- certain. In some cases a thickened synovial fringe has been found, in others a small ganglion is jaresent, while a large sesamoid bone is sometimes the cause of the trouble. The articular 'surfaces may show the changes characteristic of osteo- arthritis. The treatment is to explore and if possible to remove any cause which may be found. Mallet Finger. In this deformity the terminal phalanx is slightly flexed and cannot be extended. It is usually the result of an injury which has either stretched the extensor aponeurosis, or torn the central slip from its insertion. If a splint is not successful a median longitudinal incision must be made, the extensor tendon is identified and the proximal end stitched to the periosteum. NEEDLES IN THE HAND Those who are aware of the difficulties which may accompany exploration here, and the unsatisfactory results which sometimes follow on this step, will be familiar with the need of having two skiagrams, one taken laterally and one antero-posteriorly. While on this sub- ject two hints may be given : one is that the needle fragments may be sometimes multiple here as in the foot, the other, that skiagraphy is especially useful in doubtful cases, e.g. where a patient evidently neurotic complains of a hand being numb, useless, or painful, when 88 OPERATIONS ON THE UPPER EXTREMITY there is some doubt as to the presence of the needle, or when one needle fragment has been successfully removed. With regard to the operation itself, the use of a tourniquet or Esmarch's bandage is advisable. In spite of careful localisation by X-rays, considerable difficulty may be experienced in finding the needle ; this may be due to its displacement by manipulations in the early stages of the operation, or to the small size or deep situation of the fragment. The wound should therefore be kept as free from blood as possible by gentle sponging, the greatest care being taken that the incision is made exactly over the situation of the needle. In the most difficult cases it may be desirable to make a further skiagraphic examination in the course of the operation. In some cases the electro-magnet, which is employed for extracting fragments of steel from the eye, may, if available, be used ; though occasionally successful, this often fails as the magnet, though of great power, is unable to draw the needle through muscular fibres, especially when the direction of the former is at right angles with the latter. Where the needle fragment lies very deeply in the palm, especially if a good deal of cicatricial tissue be present from previous operations, the needle may be removed from the dorsum by partial excision of a metacarpal bone. A middle-aged woman, \^ ho had been operated upon three times for the removal of a needle from the palm, was admitttd under Mr. Jacobson in October 1903; it was clear from the scars and contracted state of some of the fingers that an aseptic result had not always been secured. Mr. Shenton demonstrated the presence of a needle fragment lying deeply on the palmar aspect of the fifth metacarpal bone, a little above its base. The central portion of the metacarpal was removed, thus securing access through normal tissues. A rusty black needle fragment was at once seen embedded in the interossei. The wound, dressed at first with fomentations and kept well elevated, healed quickly, and the patient was again able to use her needle. It must always be remembered that when the needle is deeply placed, there is a danger that some important structure, such as a nerve, tendon, or artery, may be injured in the operation for its removal. Suppura- tion, too, will be attended with serious results. For these reasons, especially in elderly patients, or those whose general condition renders an ansesthetic undesirable, it may -be advisable to wait and see whether the presence of the needle causes any severe symptoms. PALMAR HEMORRHAGE There are four arterial arches concerned in the arterial supply of the hand, viz. (a) the superficial palmar arch, formed chiefly by the ulnar artery, but completed by a branch from the radial, usually the superficialis \ol;e. (6) The deep palmar arch formed by the radial and completed by the deep branch of the ulnar artery. (c) The anterior and posterior carpal arches, formed by the anterior and posterior branches of the radial and ulnar. The comes nervi mediani artery is occasionally enlarged at the exj^ense of the radial or ulnar ; it then usually joins the superficial palmar arch and takes an important part in the blood-supply of the hand. The superficial palmar arch is situated beneath the palmar fascia but is superficial to the flexor tendons and the branches of the median nerve ; it can be marked out by a line commencing just external to the pisiform bone, and then curving down- wards and outwards across the middle third of the j^alm opposite the upjier end of the cleft between the thumb and index finger (Fig. 16) The deep palmar arch is situated about half an inch above this ; it rests against the metacarpals and interossei beneath the flexor tendons. Treatment. This will vary accordingly as the case is seen early or later, and will also depend upon the septic or aseptic nature of the wound. PALMAR H.1:M0RRHAGE 89 A. Early Cases. The bleeding ' may be always temporarily controlled by pressure or by the use of a tourniquet. The woiuid will often be small, or even a mere puncture. The most desirable metliod is, aftt-r tiie skin has been cleansed as thoroughly as possible, to open uj) the wound and secure both ends of the injured vessel. This is far ])referabl(^ to ligature of the brachial, or of the ulnar (jr radial arteries, for the bleeding may come from a small branch such as the su[)erHcialis vohr* and not from one of the palmar arches. Another method is by the applica- tion of a graduated compress wliieh may be tried if the wouiul be a small ])uncture and the bleeding not severe. Tlu> bracliial having been controlled by a tourniquet and the wound cleansed, a compress — consisting of sterilised gauze or lint, cut in pieces increasing in size from a threepenny bit to half a crown — is prepared, together with strapping, sterilised i)ads and bandages. The fingers are now bandaged, the compress is placed in jjosition, covered by the sterilised pads and secured by careful bandaging. If tlie above precaution be omitted, so much and so i)aiiiful oedema of the lingers will take place as to inevitably necu-ssitate early removal of the compress ancl probable recurrence of the ha-morrhage. The arm should be kept at rest on a splint, or better still, the elbow should be fully flexed and the arm loosely bound to the side. The patient, if restless, should at first be kept under the influence of moi pliia. The compress should not be disturbed for three or four days. B. Later Cases. If pressure has been tried but has not been successful, the wound, owing to the difficulty in rendering the skin of the ])alm aseptic, is likely to be infected ; the hand will then be red, brawny, painful, and suppurating. If ha>morrhage still continues after the tension has been relieved by carefully made incisions it will be best to tie the brachial artery at once in the middle of the arm (p. 171) rather than to ligature the radial and ulnar in the lower third of the fore- arm (pp. 127, 13 )), and for these reasons : (1) Ligature of the brachial will be performed through healthy and uninflamed parts. (2) While the anastomoses round the elbow are so free and so reliable as to prevent any risk of gangrene after ligature of the main vessel, ligature of the radial and ulnar is rendered uncertain owing to (a) the anastomoses between the two palmar arches ; (6) the anastomoses between these and the carpal arches ; (c) the blood brought by the comes nervi mediani artery, which will not be stopped by ligature of the radial and ulnar ; (d) the fact that if inflammation has set in, dilatation of the arteries will have taken place. After early ligature of the injured vessel the wound may be infected, and secondary haemorrhage occur. Under these circumstances an attempt again to secure the bleeding vessel in situ is likely to fail. Ligature of the brachial will then be indicated. PALMAR ANEURYSM The rarity of this disease in arteries so small in size as those of the forearm and hand is well known. Aneurysm when present in the palm is usually the result of injury, or much more rarely it is embolic in nature and co-exists with serious disease of the heart. In a third class of case the aneurysm is an instance of localised subacute end arteritis deformans,^ and arises without any known cause. Here other arteries —e.g. the cerebral — are very probably also affected. The inner part of the super- ficial palmar arch is that chiefly affected. Operatiun. If other treatmcxit has failed, if the aneurysm continues to increase, to cause troublesome throbbing, and numbness of the fingers supplied by the ulnar nerve, it is best treated by excision after ligature of the uhiar artery above and below. The skin having been thoroughly cleansed, and an Esmarch's bandage applied above, a longitudinal incision, two or three inches long, is made over the swelling, dividing the skin, palmaris brevis, and jjalmar fascia. Any tendons and the ulnar nerve are carefully drawn aside. The ulnar artery is then tied with steriHsed silk or catgut above and below the swelling. The sac is next snipped away with scissors, and, if needful, the deep branch of the ulnar artery is tied also. The 1 The wound sometimes does not bleed when examined. If there is a history of much bleeding and if the depth of the wound make it probable that an artery is injured, pressure should he applied. 2 An instructive case, treated successfully by incision of the sac with interesting remarks on the pathology and treatment of this disease, is recorded by Dr. J. Criffiths, of Cambridge, Brit. Med. Journ., 1897, vol. ii, p. 646. 90 OPERATIONS ON THE UPPER EXTREMITY palmar fascia should be united -with a few buried sutures of fine sterilised catgut, and the skin incision closed with sterilised salmon-gut. jMovements of the thumb and index finger should be carefully commenced in two or three days, but the other fingers should be kept quiet for the first week. The wound should have healed in ten days. While the above course is certainly the best, cases which have been recorded ^ show that ligature of the ulnar, or of the ulnar and radial, will be suifieient in palmar aneurysm, if, for any reason, the surgeon prefer to adopt this course. COMPOUND PALMAR GANGLION TUBERCULOUS TENO-SYNOVITIS Tuberculous teno-syuovitis occurs in two forms : (1) AVhere the distended sheath contains numerous " rice-grain " or " melon-seed " bodies ; (2) the f ungating form, in which masses of tuberculous granula- tion tissue exist in and project from the lining membrane. Some cases where there is a chronic serous effusion into the tendon-sheath are also tuberculous in origin. Tuberculous disease may affect any tendon- sheath, but one of the most frequent and important sites for this disease is the sheath of the flexor tendons or palmar bursa. Practical Points. (1) There is the risk of spreading infection if the wound be not kept carefully aseptic. (2) Recurrence is very frequent, from the fact that it is difficult to remove all the " melon-seed " bodies which are often pre- sent in great abundance, or all the diseased synovial membrane. (3) A compound palmar ganglion is very often tuberculous. In these cases the disease is very likely eventually to extend to the carpus. The arrangement of the syno\dal sheaths of the fingers is shown in Fig. 35. Treatment. A radical operation is strongly advised for compound palmar ganglion owing to the frequency with which this disease is tuberculous, and its consequent dangers from its surroundings. But as, in a few cases, this disease may be of a chronic inflammatory nature, and as the surgeon may not always be able to avail himself of the skilled assist- ance, &c., which is an absolute sine qua non for the radical operation, a simpler operation will be first described. It is not recommended, and any one employing it must remember that if he fails to cure the disease, he will have rendered subsequent needful steps much more difficult. A. The parts ha\nng been rendered sterile, an incision should be made an inch above the anterior annular ligament, avoiding the median nerve, and going down into the ganglion, the opening ^ into which is not to be a mere button-hole, but must be kept free and dilated. The edges of the free opening into the ganglion being held apart by tissue forceps, all the " melon-seed " bodies must be removed, partly by pressure, partly by the use of the curette, which should explore all the ^ A. Caddy, of Calcutta {Lancet, 1896, vol. ii. p. 603). The aneurysm was traumatic, and the patient 33. The radial and ulnar were tied. W. Robertson, of Glasgow {Brit. Med. Joiirn., 1897. vol. ii. p. 1637). Here there had been no wound, but the palm had been repeatedly knocked in starting some engine-gear. The patient was 18. The ulnar artery alone was tied. Fig. 3.5. COMPOUND PALMAR GANGLION 91 cavities into which these ganglia are sometimes divided. The question of providing a second opening below the annular ligament will now arise. When the ganglion is large, and when the " melon-seed " bodies are numerous, a second op(Mnng should certainly be made. This may be done by passing a director or dressing- forceps from the upper opening under the annular ligament, and cutting down upon it through the palmar fascia, care being taken to avoid the superficial arch. This opening having been enlarged with the help of the dressing- forceps, the curette is again applied, if needful, and when, either by this means or by rubbing between the openings a strip of sterilised gauze, all the " melon-seed " bodies are detached and removed, the cavity is washed out with a sterile saline solution and then, by pressure, and the applica- tion of sterilised pads, dried as thoroughly as possible. A small rubber drainage tube may be inserted for a few days between the upper two of the interrupted silkworm-gut sutures which close the wound above the wrist. The hand and forearm may be conveniently put up with the fingers flexed, as on a Carr's splint. Passive move ments of the fingers should be started at the end of a week. B. A more radical operation should be performed in practically every case, owing to the probable tuberculous nature of the trouble and the risk of the infection extending to the carpus. It should cer- tainly be performed when there is reason to suspect tuberculous mischief, or when the disease recurs. The ganglion having been opened by the steps given above, but with much freer incisions, its walls will certainly be found to be thick and velvety, perhaps showing vascular fringes over the tendons. In such cases each of the tendons must be separately hooked up and cleaned with curved, blunt-pointed scissors and dissecting forceps, the diseased tissue being removed in as large continuous pieces as possible. To eradicate the whole of the tuberculous synovial mem- brane it will be needful to divide the anterior annular ligament, the position of the median nerve being first carefully noted. The four cases given below, in which this step was taken, show that no weakening of the hand need be feared. The incision must be boldly made from about one and a half inches above the annular ligament down through this structure to a point just above the level of the superficial palmar arch. Otherwise there is danger that, by insufficient exposure of the parts, persistence of the tuberculous mischief, and, ultimately disease of the carpus, may ensue. When by the use of a blunt hook, dissecting forceps, and blunt-pointed scissors, each individual tendon has been cleaned as thoroughly as possible, the surgeon examines for the presence of bone disease, flushes out the cavity with hot sterile saline solution, followed by rubbing in of sterilised iodoform emulsion. During the operation every bleeding-point must be secured and ligatured. The use of forci-pressure is less advisable owing to the risk of damage to the tendons ; general oozing is checked by the hot saline solution. The annular ligament is then united with buried sutures of catgut and the dressings are, when the wound has been closed, applied so as to exert a uniform pressure. Two more points need reference. First, as to the use of a tourniquet. This is not of material importance. The after oozing, always free, will be especially so if this, or an Esmarch's bandage, be 1 If on cutting into the ganglion its wall is found to be thick, velvety ]^and vascular this operation is certain to fail. 92 OPERATIONS OX THE UPPER EXTREMITY employed. Drainage should be pro\'ided by inserting a small tube between two of the silk:«-orm-gut sutures which are left untied at the upper end of the wound. The tube may be removed and the wound closed after two or three days. Another and more important point is one which has not received adequate attention, and that is the condition of the sheath of the flexor longus pollicis. There are usually two synovial sheaths beneath the annular hgament, one for the flexor tendons of the fingers and the median nerve, the other for the long flexor of the thumb. The latter, which may communicate with the former, extends continuously from above the annular ligament to the base of the ungual phalanx of the thumb. It is not always involved in tuberculous syno\-itis of the palmar bursa. Thus in two of the cases mentioned below it had escaped. In two. fulness in the thenar eminence and thickening along the tendon below gave evidence of more extensive tuberculosis. In order to avoid di\-iding the short muscles of the thumb, the .sheath was laid open along the phalanges, the thickened tuberculous membrane there was removed, and then, by means of a curette and strips of sterilised gauze soaked in iodoform emulsion, passed by means of sinus-forceps from the opening over the thumb below to that above the annular hgament, the diseased synovial tissue was curetted and rubbed away as far as possible from that part of the sheath which lies beneath the muscles of the thenar eminence. As soon as the wounds were healed collodion dressings were employed, and over these, uniform pressure with strapping, apphed especially firmly over the thumb. The cure was complete when the patients left the hospital, and remained so {vide infra) during the six months which had elapsed since the oper- ation. After this operation passive movements of the fingers must be begun as early as possible to guard against matting together of the tendons. The constitutional and general treatment of tuberculosis must also be carefully carried out. In the following four cases Mr. Jacobson di\^ded the anterior annular hgament. " The first, in 1896, was a woman, set. 53. who earned her living by working at fancy embroidery. Dr. Holland \\ right, whose patient the woman was. sent her to me in June 1904 to show the result. This was perfect;. The patient had followed her employment all the time, but there was some e\'idence of phthLsis in the left lung. The second case was a woman, set. i'l. Though very numerous ' melon-seed ' bodies and much thickening of the synoA-ial membrane was present, this was the only case in which tubercle bacilli could not be found. When I last saw this patient, one and a half years after the operation, the hand was as good as its fellow. The third and fourth patients were sent to me by Dr. Jones, of Alton, almost coincidently, in 1903. In both the sheath of the flexor longus pollicis was markedly involved. Both were young patients, one a grocer's assistant ; the other, a barmaid, had been operated upon before by a single incision above the wrist. This fact, the disease persisting, greatly increased the difficulty of the operation. In answer to my inquiries, the man wrote to me as follows about six months after the operation : ' My hand is quite strong, much stronger than when I first felt anything of it. The top joint of the thumb is still stiff, and I can't close the hand quite as well as the other. Otherwise it feels perfectly well.' With regard to the fourth case, that of the barmaid, Dr. Jones \\Tote about six months after the operation : ' As far as I can see. the result is as perfect as UNION OF DIVIDED TENDONS 93 possible. 8he has regained all movements of the fingers, the grip of the hand is a little weaker than on the sound side.' '■ The above cases prove that, with skilled assistance, there need be no hesitation about division of the annular ligament. With regard to my treatment of the flexor sheath of the thumb, six months is insufficient to prove anything. At all events, the example is worth following. If the method prove incomplete, I should not hesitate to divide the muscle and lay open the whole of the sheath. A sound hand, at the expense of a less mobile thumb, would certainly be preferable to persistent tuberculosis, matted tendons, and invaded wrist- joint with sinuses, and secondary tuberculosis in the lungs or elsewhere. Should tuber- culous teno-synovitis occur in the extensor sheaths at the back of the ■wrist it must be treated on the same lines, i.e. the sheath must be thoroughly opened up, the diseased synovial membrane clipped or scraped away, any pockets thoroughly curetted, and any bony focus completely scraped out." Treatment of a simple ganglion. These small cy.sts, which most commonly occur ill connection with the tendon sheaths at the back of the \VTi.st, are variously regarded as due to local tenO'-synoWtis, colloid degeneration of the synovial mem- brane, or hernial jjrotrusions of the tendon sheath, or in some cases from the .synovial membrane of the carpal joints. Should simpler methods, such as the application of iodine, pressure, or incision with the injection of a few drops of pure carbolic fail, the ganglion should be excised. OPERATIONS FOR UNION OF DIVIDED TENDONS. TENORRAPHY. TENOPLASTY As in the case of divided nerves, the union of divided tendons may be primary or secondary, according as the surgeon sees the case at once or after an interval. This injury is especially frequent and of great importance in the tendons of the hand and v\Tist. Preliminary consideratio7is. (1) The diagnosis usually presents no difficulties. There wall be entire loss of the movement produced by the injured tendon. Loss of power may result from injury to a motor nerve, but in this case there will probably be some anaesthesia, and electrical stimulation of the muscle wd\ produce the lost movement. (2) When a tendon is di\'ided there will certainly be some retraction of the proximal end owing to the tonic contraction of the muscle. Mr. A. H. Tubbv ^ points out that in the case of the extensor tendons of the fingers, there wall be but little retraction if they are divided at the back of the hand or fingers owing to the connection between the various tendons, their aponeurotic expansions, and their close attachment to their sheaths. If the extensors of the thumb are di\aded at the back of the wrist there is but little retraction ; if, however, they are divided at the back of the metacarpal the upper end may retract as much as three inches. In the case of the flexor tendons there is but slight retraction, owing to the presence of the vinculse if they are divided over the phalanges ; there is also but little separation if the injury occurs in the palm, but if they are divided above the wrist great retraction of the upper end is to be expected. (3) It is necessary to insist upon the importance of immediate suture. If the injury to the tendon has at first been overlooked the difficulty in finding the separated ends and bringing them together is much increased owing to obliteration of the sheath and matting of the 1 Deformities, 1912, p. 769. 94 OPERATIONS ON THE UPPER EXTREMITY tendon to surrounding structures. Here, too, it may be pointed out that adhesions of the flexor tendons to each other or to a cicatrix will certainly prevent full extension of the fingers. (4) In all these opera- tions careful aseptic precautions must be taken. A tendon has a poor blood-supply and, if the wound becomes infected, sloughing is very likely to occur. For the sake of convenience, operations for the union of divided tendons may be classed under the following heads : A. Cases where both ends can be found and where they can be easily adjusted. If the injury is recent a longitudinal incision enlarging the original wound will usually be best, but in some cases — e.g. where the injury is old-standing and the tendons are matted together — a flap may be preferable. Any bruised, torn, sloughy, or scarred tendon tissue is removed as cleanly and charily as possible with a sharp knife or scissors. There is no difficulty in finding the distal or fixed end of the tendon. Should the proximal end have retracted, it may be sought for by one of the methods described on p. 97. The best msterial for sutures is fine catgut, which wiU resist absorption for twenty days ; sterilised silk may also be employed, while Cheyne and Burghard' recommend the use of very fine fishing gut. Small non- cutting curved needles should be used ; needles with, a cutting edge are very likely to tear through the damaged tendon. Methods of inserting the sutures. (1) When the tendon is round, and either of medium or large size, the suture may be passed from before backwards through one tendon end, and then from behind forwards through the other, and the ends are knotted on the superficial surface of the tendon. Large tendons may be secured with two lateral or with one central and two lateral sutures, smaller tendons with one median suture only. As the suture is tightened the ends must be kept in exact apposition, and not allowed to override one another. In this method and in the others which follow, care must be taken not 1.0 insert the sutures too near to the tendon ends. There is a tendency for the sutures to separate and cut through the parallel fasciculi ; this will certainly happen if there is any tension or if muscular contraction throws any strain on the stitches. This splitting is very likely to take place in the thin flat extensor tendons. (2) Under these circumstances, where the tendon is flat, there is a strong tendency for the suture to cut its way out if inserted in the ordinary manner ; one of the following methods, viz. Wolfler's, Le Fort's, Le Dentu's, which are made plain in Figs. 36 and 37, will be found preferable. (3) Where the tendon is round and small, too small for the methods of Wolfler or Le Dentu, and where, owing to the size of the tendon and the tension, a suture inserted in the ordinary way will cut out, Schwartz's method may be tried (Fig. 37). A circular ligature is tightly tied round each tendon end a short distance from the cut surface ; two longitudinal sutures are then passed above and below these Hgatures, and thus prevented from slipping, serve to draw the ends together. An objection to this method is that the circular, ligatures endanger the nutrition of the tendon ends. (4) Cheyne and Burghard ^ advise the following method, which avoids the above drawback to Schwartz's, while it meets the tendency of Loc. infra ciL, p. 228. ^ Manual of Surgical Treatment, vol. ii. p. 9.3. TTNION OF DIVIDED TENDONS 95 Fig. 36. — Wolfler's transverse tendon-suturo {Wien. Med. Woch., 1888, 5. 1). When the ends touch, the inventor calls oidimiiily applied interrupted sutures to cut out too quickly : " The best plan is to pass the needle across from front to back through the whole thickness of the tendon quite to one edge of it and close to the line of division, and then to tic the thread over the small piece of tendon included in the loop. Although the piece of tendon below the ligature may possibly die, a secure hold is thus ob- tained, which may be pulled on firmly without fear of the thread cutting its way out. The same procedure should be adopted also on the opposite side of the tendon, and both the upper and lower ends should be prepared in this way, care being taken that the stitches are inserted at exactly corresponding points in the two ends, so that the tendon is not twisted when they are tied together. The ends of the cor- responding threads on either side of the (divi- sion are then tied sufficiently closely to bring hV^method " direct transverse the two cut surfaces into apposition. It is well tendon" suture, and gives it to put in one or two stitches in the centre to ^L^rdTcanlrbobS^ghuo" remforce the lateral ones ; these will prevent gether, and the threads are tied the cut surfaces from being displaced laterally and left to form guides for the or curled up, and as they do not bear any strain, '^'"'^°Sng bridge^"' '°"' they may be inserted in the usual manner." When the divided tendons have been united and all haemorrhage and oozing have been checked, the wound is carefully sutured. If the wound when first seen is dirty, or if after-collection of blood or serum is thought possible, a small drainage tube should be inserted. The dressings should be applied in sufficient quantity and uniformly so as to exert even pres- sure. If possible they should remain unchanged for seven or ten days. The limb must be ar- ranged on a splint in such a position that no undue tension falls upon the united tendons, while at the same time the com- fort of the patient is attended to. Moulded splints of poro-plastic or gutta-percha are best, or a perforated zinc trough, which is readily cut, fairly easily bent and moulded to any degree of flexion, and which can be boiled, will be found useful in the common cases of tendons injured about the wrist where the elbow, wrist, and fingers must be kept flexed. If wooden splints be employed, a Carr's splint is comfortable, but must be reinforced by an angular spfint to maintain flexion of the elbow. Wooden splints are, however, much less efficient, in that they fail to secure the needed amount of flexion, A. B. Fig. 37. A. Le Dentu's method of tendon-suture. B. That of Wolfler. C. E. Schwartz's method. (Le Dentu and Delbet, Traite. de Chir., t. iii, p. 825.) 96 OPERATIONS OX THE UPPER EXTREMITY or the power of modifying this later on. The patients comfort will be greatly promoted by remo\ing the splint every two or three days and altering the angles slightly. Restlessness, while recovering from the anfesthetic, must be prevented, for contraction of the muscle may cause the sutures to tear through and the ends of the tendon to again separate ; if the sutures do not hold, the parts will tend to heal in one contracted mass. Most careful attention will be needed afterwards in the employ- ment of warily begun, and perseveringly continued, passive and active movements. In commencing movements the surgeon has. on one hand, to prevent the formation of adhesions ; on the other, he must remember the risk of breaking down the recently formed union. The date must vary with each case, but, as a rule, in the case of the tendons of the fingers, passive movement may be begmi. very gently so as not to strain the union, about the sixth day. and gradually increased. From the fourteenth to the twenty-first day will usually be early enough for the commencement of active movements. Soft adhesions will certainly have formed, but if the sutures have been so placed as to secure a firm hold, and if the wound has run an aseptic course, there is little risk of the union being broken down. In cases of secondary tendon-suture, as in that of nerves, the result may be disappointing for some months ; but if the tension was not extreme, and if the wound heals by primary- union, the final result will probably be satisfactory, if the patient does his best to help the surgeon. This opportunity may be taken to point out that, in the treatment of incised wound of the hand or foot, the condition of the tendons should be cleared up as well as that of the vessels. Too often attention is directed solely to arresting the urgent haemorrhage, especially if the situation of the womid does not exactly correspond to the course of a tendon. The wound heals quickly, and then attention is drawn to the I0.SS of power. The following is a good instance : In August, 1888, H. P., aet. 31, was seen with constant flexion of, and in- ability to extend, the last two phalanges of the thumb. A few months before he had been treated for .severe hsemorrhage from an incised wound of the dorsum over the first phalanx and metacarpal of the right thumb. Bj' dissection the extertsor secundi intemodii was fomid to have been divided, the upper end coming into Anew on following up the sheath. The extensor brevis had been only partially divided for three-quarters of its width. When trimmed the two ends of the extensor secimdi were separated by an interval of an inch on complete extension of the thumb. By the use of a stout suture, and by pushing down the upper end of the tendon, the ends were brought to within a quarter of an inch of one another ; two fine sutures then brought the ends into good but not exact apposition. On hyper-extending the thumb the V- shaped notch in the partially divided extensor primi was obliterated, so no sutures were used here, the edges of the notch being merely refreshed. A splint was applied on the palmar aspect, so as to keep the thumb hj^^er-extended. When seen two months later, the piatient had recovered complete power of exten.sion. B. Cases where only one end can be found. The distal or fixed end of the tendon can nearly always be found. The difficulty of finding the upper retracted end of one of the flexor tendons may often be extreme. Should it not come into \-iew on sHtting up the sheath for a short distance one of the following methods may be tried : (a) The muscular belly may be pressed down by manipulation with the fingers, or an Esmarch's bandage may be appHed commencing at the elbow and passing down wards towards the wrist, (b) M. Felizet ad\ises, if 'sHtting up the sheath and methodically pressing down the muscular belly are insufficient, UNION OF DIVIDED TENDONS 97 Fig. 38. Buttonhole method of tendon-anastomosis. Method of MM. Tillaux and Duplay. (Duplay and Reclus, Traite de Chir., t. i, p. 825.) that the upper end may be made to emerge into view, and further disturbance of the parts avoided, by extending the adjacent fingers. By this step, what M. Felizet terms the Uttlc fibro-serous vincula, which tie together adjoining tendons, are drawn upon and pull down the upper end of the severed tendon into view, (c) When the slitting up of the sheath would have to be very extensive, and might involve danger to important structures, Cheyne and Burghard advise that a second incision be made over the tendon well above the wound, and the sheath opened ; from this incision the tendon is pushed down by means of sinus forceps until the divided end appears in the original wound, {d) In cases where difficulty is experienced in finding the distal end, e.g. in secondary operations for divided tendons at the wrist where the proximal end is likely to be fixed by adhesions, the same writers advise as follows : " A better plan than di- viding the aimular liga- ment is to cut into the palm and expose the tendon well on the dis- tal side of the division ; then, by pushing a probe up the sheath, the point at which ad- hesion has taken place may be found, and an attempt made by for- cing the probe upwards through the adhesions, to make it protrude into the wound, and form a guide along which the tissues can be turned aside until the end is reached." (e) The only alternative to these methods is to make a prolonged dissection upwards, dividing the sheath, the annular ligament, and the muscles, but taking the greatest care not to damage vessels or nerves, until the proximal end is found and freed. If, after careful search, it is still impossible to find the upper end, the lower end may be attached to a neighbouring tendon by tendon- anastomosis. This may be eft'ected by one of the three follo^^^ng methods : (a) Bv fixing the severed end in a button-hoJe made by splitting an adjacent tendon longitudinally (Fig. 38). (h) Anastomosis by bifurca- tion or splitting of an adjacent tendon. Schwartz describes a case where the proximal ends of two of the extensors of the thumb divided at the back of the metacarpal could not be found. The tendon of the extensor carpi radialis longior was split longitudinally ; the outer division was separated below and sutured between the peripheral ends of the divided extensors of the thumb (Fig. 39). The following case^ is a good example of this method, and of one means of employing sutures so as to prevent tension : An oblique cut with a bread- knife divided the common extensor of the index and middle finger, and the extensor indicis, the central end of the latter retracting so far that it could not be reached, unless by slitting up its sheath. The ends of the common extensor were united by fine silk sutures. The peripheral end of the extensor indicis was attached to both ends of the sutured tendon from the extensor communis to the index finger. The strongly stretched extensor tendons of the second and third fingers were now fixed (to prevent retraction by muscular action) by sutiu:es past 2 cm. higher up, through skin and tendon sheath, and tied over a strip of gauze. 1 Fillenbaum, Wien. Med. Wocli., Nos. 29 and 30, 1885. SURGERY I 7 98 OPERATIONS ON THE UPPER EXTREMITY These were removed on the fifth day. Passive moveraeut was begun on the sixteenth day. Six months later the man had perfect use of his lingers. The back of the hand is the most favourable situation for the anastomosis of tendons, as they are here united by fibrous expansions. Thus a neighbouring tendon can be relied upon to render active the peripheral end of another tendon whose central end cannot be found. Furthermore, it is on the back of the hand, and especially near the knuckles, that operations on tendons give the best results. Retraction is less here than else- where, owing to the presence of connecting bands and expansions to the joint capsules ; there is less bleeding ; the skin is thinner, and its greater mobility renders less harm- ful the formation of any adhesions. But while tendon anastomosis is especially applic- able to the extensors, the following case, in w^hich Mr. F. T. PauP joined the tendon of the flexor longus pollicis to the index tendon of the flexor profundus, shows that it may also be employed in the case of the flexors. A boy, fet. 7, had sustained a severe cut across the ball of the right thumb. There was no power over the last joint, and consequently no power of holding anything — e.g. a pen in the usual way. An incision over the flexor longus revealed the distal end of the tendon in good condition and firmly attached to the scar. The central end was sought for, but though the incision was ])rolonged an inch above the annular ligament could not be found. Under these circumstances it was decided to form Fig. 39. Tendon-anastomosis an anastomosis between the terminal end of the by splitting or bifurcation of an cut flexor and the side of the index tendon of the adjacent one. Method of M. E. flexor profundus ; a step which, if successful, would Schwartz. (Dentu and Delbet.) give the patient power of flexing the thumb and fore- finger together, and thus of holding articles between them. The free end of the thumb tendon was inserted into a notch made in the side of the index tendon, where it was fixed by two or three sutures. A year later it was found that not only had the boy the combined power of grasp hoped for, but that, under training by a skilled pianist, he was obtaining independent movement of the thunjb and forefinger. The fact that, while the boy had only one muscle between the two digits, he could yet fle.x them sei)arately, was entirely due to the training of the extensors. Thus, if told to bend the thumb alone, he would fix the forefinger by its extensor, and then flex the thumb, or the reverse. C. Cases where both ends can be found, but it is impossible to adjust them. This difficulty is usually met with in some cases of secondary tendon suture, or after the removal of a growth which has become adherent to a tendon. The following methods are available : (1) Tendon Lengthening, (a) Method of Trnka {Fig. 44). This may be tried in the case of large tendons. The longitudinal incision must not be carried too near the end of the tendon, and to prevent the dis- placed slip becoming detached by any tension that it may be called upon to bear it should be secured above as well as below by several fine sutures (Fig. 44a). ^ Liverpool Med. Chir.Journ., 1895, p. 500. UNION OF DlVinEO TKNDONS 99 Fi(i.40. Tendon- lengthening hy Czerny's method. ( D e n t u an d Delbet.) (b) Method of Czermi (Fif^. 41)). CziMiiy, in a case in which one of the extensors of the tliunil) had been diviih'd, filled up the gap by sphtting the ptM-ij)li(M'al end to the i'e(juii'ed extent and reversing it, suturing the lower end of the dis])Iaced slip to the divided central end. If this method be employed, a circular suture should be inserted at the angle where the slip is turned down so as to prevent its being torn away. Should this happen, the separated portion of the tendon is almost certain to slough. A transverse incision is made between one or two inches above the free end of the proximal part of the tendon, according to the size of the gap to be filled. The incision only goes across half of the tendon, and from this point the latter is split vertically downwards as far as a point from a (juarter to half an inch from the cut end. The flap is then turned down, care being taken that it is not detached, and to meet any future tension at the angle sutures are passed and securely tied as described above. If necessary a similar flap may be turned up from the distal portion of the tendon. Under these circumstances the two flaps should be cut long enough to overlap, so that sutures can be placed between their contiguous sides. Here, as in all cases when newly united tendons are submitted to some tension, the parts must be kept fully relaxed for a sufficient time, active and passive movements begun very gently, and increased very gradually. Where many tendons — e.(j. the flexors of the wrist — have been lengthened, it may be wise to defer active movement for a fortnight. In the method of Hibbs (Fig. 45) a longitudinal slip is turned down as in Czerny's method ; further lengthening is then obtained by splitting this slip in a similar fashion, the transverse incision being made on the opposite side of the tendon to the first, and the longitudinal incision extending upwards towards the first transverse cut (Fig. 45). The angles require careful strengthening by sutures. (c) The tendon may be lengthened by some method requiring a second transverse division of the tendon. Some other method should, if possible, be adopted, for there is a strong tendency for the separated portion to slough. When the tendon is thick and rounded, Anderson's method may be em- ployed. The gap that remains between the two ends of the tendon hav- ing been carefully measured, each tendon is split accurately in the middle line, care being taken not to bring the split too near to the end of the tendon. At the two ends of the above incision section of the opposite halves of the tendon is made, as in Fig. 41. (d) Tendon lengthening by zig-zag incisions (Fig. 42). Poncet has shown that this method may be successfully employed in cases where, owing to the tension, the sutures threaten to cut through. In the first case, that of a boy whose tendo achillis had just been severed, s^ -4 4- .^s^' Fit;. 41. One method of tendon-lengthening, a. Tendon split longitudinally, b. Section completed by incisions at ends of fissure, c. Divided tendon elongated and sutured. (Anderson.) 100 OPERATIONS ON THE UPPER EXTREMITY zag M. Poncet. in order to diminish the tension so as to allow the ends to come together made, on the upper portion of the tendon, two cuts in zigzag fashion, each passing a little more than half across the width of the tendon. Marked elongation of the tendon followed, and the ends were then easily sutured without tension. The boy was allowed to walk on the twenty-eigh.th day, and left the hospital about seven weeks after the injury, walking being almost perfect. While this method is especially applicable to the tendo achillis owing to its size. M. Poncet has also used it in the case of the extensor indicis. The incisions should always pass through at least half the width of the ten- don ; there is no risk of the tendon sloughing if all pre- cautions are taken to avoid infection of the wound. (e) Tendon lengthening hij means of osteotomy. M. Poncet has also made use of the following ingenious method for uniting a severed tendo achillis (Fig. 43) : Forty days after the injury (by an axe) the wound was healed, but the ends of the tendon were 3 cm. apart, and the lameness was very disabling. A U-shaped flap having been turned up- wards from the back of the heel, a slice of the os calcis. con- taining the insertionof the tendon, was detached vertically by a saw ; when quite loose it was glided upwards, and the lower part of it fixed to the upper part of the sawn surface with an ivory peg. The ends of the tendon could now be brought into close apposition without undue tension. The result was perfect. (2) Distance sutures, (a) Distance sutures alone. In some cases, where the ends of the tendons could not be Fig. 42. Tendon- adjusted, the widely separated lengthening by zig- ends have been joined by suture loops which have appeared to diminish muscular tension, and to help in directing the process of repair. Cat-gut and fine silver wire have been employed, but mercurialised silk {see footnote, p. 106) is recommended by Mr. Tubby as the most satisfactory material. Distance sutures seem to have been employed in this country as long ago as 1899. by Mr. Gost- ling. of Worcester.^ in a case of injury to the ex- tensors of the thumb. Eleven weeks before, while the j^atient was pruning, his knife inflicted a wound, the scar of Avhich, an inch in length, was found an inch above the ba.se of the metacarpal of the left thumb. Just below this scar the di.stal ends of the ex- teiasor primi internodii and extensor ossis metacarpi poUicis could be easily felt, but the proximal ends could only be indistinctly made out, five inches off. on the back of the forearm. The left hand was seriously crippled, the thumb being flexed and adducted into the palm. An incision exposed the distal ends at once, but the synovicil sheath was blocked for three-quarters of an inch bj^ scar tissue. This was cut through and the sheath slit up until the proximal ends of the tendons w^ere found. All four ends were smoothly rounded off. and no adhesions had formed. As the ends were five inches apart it was impossible to bring them nearer together than three-quarters of an inch. The ^ Lancet, vol. ii, 1890, p.,767. incisions. (Poncet.) Fig. 43. Suture of tendo achillis by partial detachment and sliding upward of the OS calcis. Poncet's method. (Duplay and Reclus.) TENDON GRAFTING 101 ends having been pared, the corresponding ends were nniled hy two catgut sutures. The wound healed l)v primary union, and six montiis later all the movements of the tiuiml> were perfect. M. (iliick. who has employed the method of distance sutures with marked success in several cases, used it in one instance not for filling up a gap in a tendon, but for re- placing an end which was lost.^ A boy had the tendons of the exterusor indicis and the extensor communis divided as the result of an injury. The central ends were tied witli loops of silk which were carried to their points of insertion and fixed by means of a steel needle. The first trial failed, the sutures tearing out. A second ojieration succeeded. When the needle was removed, at t he end of four weeks, both t he middle and terminal phalanges could be extended. In another case in which the two ends of tiie flexor tendons of the middle finger were widely separated after an injury, M. Gliick^ was able to remedy a gap of 10 cm. by the substitution of threads of silk and catgut. Healing by first intention and perfect restora- tion of movement followed. It was thought that in this case a gradual substitution of the catgut by connective tissue took place. In other cases the foreign body employed remains long encysted in a sheath of connective tissue. In all these operations strict asepsis is, of course, essential. (3) Tendon-grafting. Here a portion of another tendon, from the same patient, in cases where there has been an extensive injury, as in a partially crushed hand, or a tendon from an animal is made use of. Mr. Mayo Robson^" successfully grafted four and a half inches of a flexor tendon from a finger too much smashed to save, on to the dorsum of the hand, so as to form a new extensor for the index finger, the tendon of which had been completely torn away. The proximal end was stitched to the belly of the extensor communis, where the missing tendon had been originally at- tached, the distal end being fixed to the small portion left near its insertion into the phalanx. The case, which is an excellent instance of conservative surgery, ended in recovery with a most useful hand. During extension of the index the new tendon could be felt to move under the skin. Grafts from tendons of animals are extremely likely to slough or to be absorbed. Even if no suppuration occur the grafts, in all prob- ability, only act as conductors for new^ fibrillse as in the case of distance sutures. Dr. Rochet, of Lyons, has described a case in which he successfully practised a method of tendon-grafting, which he called autochthonous, the graft being taken from one of the divided tendons themselves (Fig. -16). This method is especially applicable to the flexor tendons of the fingers. 1 Semaim Mediccde, 1892, p. 198. " ^^oc. supra cit. 3 Clin. Soc. Trans., vol. xxii, p. 291. Fig. 45. Method of Hibbs. 102 OPERATIONS ON THE UPPER EXTREMITY The patient had, two months before, suffered division of the flexor tendons at the root of liis right index finger. The two lower phalanges were constantly extended, all power of flexion being lost. At the operation an interval of 6 cm. was found between the divided ends which by no means could be reduced to less than 2 cm. To fill this gap an incision was made over the lower ])art of the middle phalanx and the base of the last, just where the flexor jirofundus emerges from between the two slips of the sublimis. Dr. Rochet divided the former, and then, returning to his first wound, drew the piece of the flexor pi'of undus, which was now cut above and l)elow, ujiwards to All the gap, the attachments of the ten- don to the sheath yielding readily. The lower end of this tendon-slip was then sutured to the distal end of the flexor sublimis, and its u])])er end to the proximal ends of the flexor sublimis and pi'ofundus — directly to the former ten- don, and latterly to the later. Lastly, the small slip of the flexor profundus, which had been left attached to the last phalanx, was sutured to the two slips of the flexor sublimis a little above its in- sertion into the phalanx. On the fif- teenth day some power of flexion was already present. Eventually the second phalanx could be flexed as freely as that of the other hand. Flexion of the third phalanx was more limited, this not pass- ing beyond a very obtuse angle. Dr. Rochet observes that it would be possible to carry out this method by taking the graft from the ])roximal por- tion of the divided tendon without in- terfering with its insertion or making a fresh wound. M. Desquin has devised another method of tendon -grafting, by which the use of a flexor tendon was restored. A carpenter, a^t. 25, had the right middle finger in permanent extension, owing to the severance of the flexor tendons by broken glass thirteen months before. A free incision having been made along the course of the tendons in the finger and in the palm, an interval of 4-5 em. was found between the divided ends of the super- ficial tendon, while it was impossible to find the deep tendon. By strong traction on the central end of the superficial tendon, it could be brought into contact with and sutured to the jihalangeal end. This could only be done by strongly flexing the finger, and it would have been impossible to unite the superficial parts over the strongly flexed tendon. Returning to the wrist, therefore, th(> operator divided the tendon with a small piece of muscle adhering. The flnger was then extended and the tendon just divided stitched to that for the index finger, so that the flexor for the latter, on its contraction acted ujion both fingers. The result was perfect. Resection of bone in aid of tendon-suture. It will suffice merely to allude to this method, which can only rarely be justifiable. K. Lobker^ seems to have been the first to make use of it. In a case of long-standing division of the tendons above the wrist, portions of the radius and ulnar were resected. The result was only a partial success, and the bones took three months to unite firmly. Mr. R. P. Rowlands has used this method most successfully.- TENDON SHORTENING This may be occasionally called for in some cases of acquired talipes calcaneus, where the tendo achillis is elongated. As these cases are 1 Centr.f. Chir., 1884, No. 50. 2 Lancet, Oct. 21, 1905. Fig. 40. Autochthonous tendon-grafting. (Rochet.) To the right is seen the gap between the tendons found on exploration; to the left the manner in which it was filled up. TKNDON SHORTENING 103 usiuilly due to inliintilc paralysis a careful examination of the electrical reaction of th(> calf muscles should be made before the operation. When these muscles arc com])letely paralysed and have undergone fatty de- generation, shortening ot the tendo achillis is useless. Conversely, if the electrical examination shows that tiiere is some healthy muscle ti.ssue left, it is well to postpone tiie shortening of the tendon till as much good as possible has oeen obtained by a systematic course of electrical treat- ment, combined with massage of the calf muscles. In suitable cases the tendo achillis may be shortened by one of the following methods : (1) Willets method. "^ A Y-shaped incision, some two inches in length, is made over the lower end of the tendo achillis down to the tendon. At the lower or vertical point of the incision the dissection is continued until the tendon is fully exposed over its superficial and lateral surfaces for the space of one inch in length, its deep connections being left undisturbed. The tendon is now cut across at the point of junction of the obliipie portion of the wound with the vertical. Next the proximal portion of the tendon is raised, with its superficial con- nections to the integument undisturbed, to the extent of fully three- quarters of an inch, by dissecting along its upper surface, i.e. by re- versing the dissection made upon the distal segment. A wedge-shaped slice of the tendon is now cut o£E from both segments, that from the proximal being removed from the deep surface, whilst from the distal it is taken from the superficial ; in both instances the face of the wedge- shaped portion removed being at the point where the tendon has been divided. The heel being now pressed upwards, the proximal portion, including both skin and tendon, is drawn down and placed over the distal, thus bringing the prepared cut surfaces of the tendon into apposi- tion. In this position they are held by an assistant whilst four sutures, two on either side, are passed deeply through the integument, then through both portions of the tendon, and again out through the integument, and fastened. When the operation is completed, the united edges of the w^ound assume a V-shaped appearance, owing to the angle of the proximal portion being now attached to the terminal point of the distal portion of the original incision." (2) Z-shaped method. This is described in the oper- ations on the lower extremity. (3) outer's method of tendon shortening without in- terrupting its continuity.- When the tendon is large, he removes wdth a very small knife, the central part. A window having been thus made, the upper and lower ends are brought together with sutures, and the lateral bands, folding upon either side, contribute to the joining of the two ends. Where the tendon is narrow, instead of making a window, M. Oilier adopts the plan shown in Fig. -17. In either case sutures of fine sterilised silk should strengthen the spot where the folded portions join the main tendon. Fig. 47. TENDON-TRANSPLANTATION, MORE ESPECIALLY IN RELATION TO ITS EMPLOYMENT IN INFANTILE PARALYSIS It will be convenient to study here, owing to their association with operations on tendons, the surgical treatment of infantile paralysis, 1 St. Bartholomew'' s Hospital Reports, vol. xvi. p. 309. - Traite des Resection, vol. ii, p. 473. 104 OPERATIONS ON THE UPPER EXTREMITY spastic paralysis, and the so-called ischsemic paralysis, though most of these concern the lower extremity. Arthrodesis, or the artificial stiffen- ing of frail joints, which has often to be combined with transplanta- tion of tendons in infantile paralysis, will be considered in the surgery of the low^er extremity (q.v.). The object of tendon-transplantation is to reinforce a paralysed muscle by attaching to its tendon one or more tendons of adjacent healthy muscles. This mode of treatment deserves most careful consideration owing to the great frequency of infantile paralysis, especially in our large towns ; the lifelong crippling which it entails, including, not infrequently, it should be remembered, amputation in early adult life on account of established trophic ulcers ; the expense involved by mechanical treatment, extending, as this usually does, over a lifetime ; the limited amount of good w^hich other operations — e.g. tenotomy — usually effect ; and the fact that transplantation of tendons, of itself not a severe operation, can be employed early in life, when the muscles on which additional work is placed have not yet reached their full development, and when at the same time the paralysed muscles have not yet had time to undergo those secondary changes which are so baffling to the surgeon. On the other hand, it is necesi^aiy to point out the discredit which will fall upon this method if the conditions which surround it, owing to the pathology of the disease which may call for it, are forgotten, if too much is expected of it, if operations be performed indiscriminately, if no definite plan is formulated, based on very careful previous examination, before any transplantation is undertaken, and if the need of unremitting after-attention for long periods be lost sight of. As long ago as 1882 Nicoladoni ^ recorded a case of paralytic tahpes calcaneus in which he reinforced the tendo achillis with the two peronei, with a good result. Drobnik, of Posen, published in 1892 ^ the first series of cases, sixteen in all. Dr. Milliken^ and Dr. E. H. Bradford,^ Surgeon to the Children's Hospital at Boston,* were amongst the pioneers in this work in America. In this country, first Mr. R. J. Jones, of Liverpool, and, later, Mr. A. H. Tubby, have brought this method of treatment of a very disheartening disease prominently before the pro- fession in the Medical Amiual for 1889 and the Liverpool Medico- Chirurgical Revieiv 1899, p. 270, and more recently in their " Surgery of Paralyses," 1903. The credit of whatever time proves to be of real value in the account that follows must be given to these writers especially. PRELIMINARY POINTS IN TENDON-TRANSPLANTATION ^ " Before it is decided to perform the operation the case must be carefully studied, and a definite plan of procedure formulated. The electrical reactions of the muscles should be pre\aously ascertained, and an attempt made to estimate the strength of those which it is intended to transplant. In the case of the foot all secondary conditions, such for instance as contraction of the plantar fascia should be remedied. For mechanical reasons it is advisable to select the reinforcing tendon from a muscle whose line of action is as nearly as possible parallel with that of the muscle to be reinforced. For instance, in a case of paralytic valgus it may be better to graft a strip of the tendo achillis into the tibialis po.sticus rather than to bring the tendon of the peroneus longus across the front of the ankle, and into the tibialis posticus. It is also miportant to remember that muscles which before the operation appear to be hopelessly paralysed, exhibit after the operation signs of returning strength. The operation is rarely called for when onty one muscle is jiaralysed, nor should it be 1 Arch. j. Hin. rhir., Bd. xxvii, S. G60. - Zeit.f. Chir., Bd. xliii, S. 473. 3 New York Med. Record, Nov. 28, 1896. 4 Ann. of Surg., Aug. 1897. ^ Tubby and Jones, p. 159. TENDON-TRANSPLANTATION 105 Fig. 48. The pero- neus longus tendon has been drawn through and fixed on to the back of the tendo achillis. The ends of the pero- neus tendon are sewn on to the back of the tendo achillis at d and E, having been first drawn through the tendon at c. (Tubby and Jones.) done when nearly all the muscles round a joint are implicated. Tlic latter cases aro suitable only for artliroil(>His {(/.v., operations on the lower extremity), and, indeed, there is a fear that an indiscriminate use of transplantation may lead to unsatisfactory results, and so bring the operation into undeserved discredit. A great point is the choice of cases." The selected muscle should belong, if possible, to the same group as the paralysed one, because it is nearest, and restoration of voluntary function is thus more quickly and perfectly secured. " The reinforcing tendon should be carried as directly as possible to the paralysed muscle, and not bent round at an angle, a manreuvre which has the effect of considerably lessening the transfer of power. For instance, if the peroucus brevis were used to reinforce the extensor communis digitorum, the former should be attached to the latter above the ankle, and not below and in front of the ex- ternal malleolus. When an opponent of a paralysed muscle is selected, it gives emphasis to this principle, namely, that by selecting one of the opponents of a paralysed muscle we not only reinforce that weak muscle, but we lessen the an- tagonism which exists between the two groups. And by trans- ferring, for example, the insertion of the peroneus longus in a case of paralytic talipes valgus from the outer to the inner border of the foot, we effect an equality between the forces acting upon the two borders." Mr. Tubby ^ mentions the following methods of tendon-transplantation : A. Intermediate Methods. (1) The tendon of a healthy muscle is completely cut across near its peripheral extremity, and its central end is inserted into the paralysed tendon (Figs. 48 and 49). (2) The central end of the divided healthy tendon is attached to a strip from the distal part of the paralysed tendon. (3) The healthy and the paralysed tendons are divided, the central end of the active one is joined to the distal end of the paralysed, and the proximal end of the paralysed is joined to the distal end of the active. This is the " complete in- terchange " method. (4) The paralysed tendon is cut across, and its distal end is sutured to that of a healthy muscle. (5) A strip is taken from the central part of a healthy tendon, and is attached directly to the undivided paralysed tendon (Figs. 51 and 52). (6) A strip from the central part of the healthy tendon is joined to a strip from the distal part of the paralysed tendon. This method gives better results than others, because the continuity of the healthy tendon is not destroyed completely, and its action is fully conserved. Moreover, as the continuity of the paralysed tendon is not interrupted, if some recovery takes place later in the apparently paralysed muscle, or if any power remains in it, aid is given to the reinforcing strip from the healthy tendon. B. The Immediate Method. Here the healthy tendon is divided and is then directly attached to the periosteum. This method has been strongly advocated by Lange, of Munich, who ascribes many of the failures in tendon-grafting to subsequent stretching of the paralysed and degenerated ten- don.2 Where the distance between the sound tendon and its new insertion is too great, this surgeon employs artificial tendons of silk (Fig. 50). He reports fifty-six cases. In only two was the result unsatisfactory. In a case of paralysis of the quadriceps extensor, where attempts to correct the de- formity by suture of the sartorius had failed, Lange brought the semi-tendinosus and biceps forward under the skin, after freeing them from their insertions. The ends were now found to be so far above the patella that it was impossible to suture ^ Deformities, vol. ii, p. 626. 2 Munch. Med. Woch., April 1900, Jan. 7, 1902, and Med. Record, vol. v, No. 3, pp. 143-145. Fig. 49. Tendon- grafting for relief of paralji;ic talipes cal- caneus by insertion of the peroneus longus tendon a into the tendo achillis at h. At c is seen the distal end of the peroneus longus. (Tubby and Jones.) 106 OPERATIONS ON THE UPPER EXTREMITY Biceps Semilcndinosus. Fig. 50. Langc's method of artificially elongating the trans- planted hamstring tendons by silk sutures, so as to effect a junction with the tubercle of the tibia. (Tubby and Jones, after Liinge). them to the ligameutum patellae. A serviceable silk tendon was provided by the passage of a number of silk threads through the tendinous ends of the trans- jilanted muscles above, and the jieri- osteum of the tubercle of the tibia below, giving eventually excellent power of extension. Several of the artificial tendons were eight inches long. When, some months after the operation, the transplanted muscles began to act, and render the silk cords constantly tight, these steadily increased in thickness. It is probable that the increase in size was due to the formation of fibrous tissue around the silk. Of this method Mr. Tubby says : " There is no doubt that the immediate method of I^ange marks a great advance over the older methods and has rapidly displaced them." Before the operation all secondary deformities, such as contraction of fascia% must be remedied. The importance of electrically testing the muscles has already been emphasised. Care must be taken to select such tendons as will improve function and diminish deformity. Mr. Tubby insists on the necessity of a clear con- . - ception of the relative import- ance of the functions of the part. He also points out that the operation should be em- ployed in the stationary stage of infantile paralysis when if is quite certain that the trouble is otherwise irremediable. Technique of the Operation. Needless to say the most careful precautions must be taken to avoid sepsis. "In many cases a single incision will suffice, but it sometimes happens that, to avoid a single large incision, two smaller ones are made, e.g. when the ])croneus longus is transferred to the inner border of the foot. In this case one incision is made over the front of the fibula, and a second over the scaphoid.^ By burrowing through the subcutaneous tissues of the dorsum of the foot with a director, a channel is made for the passage of the tendon to the scaphoid. It is curious to remark that no adhesion of the transplanted tendon takes place to the subcutaneous tissue doubtless from the endothelium on its surface : hence we learn the necessity of handling the tendons very carefully." As regards the actual method to be adopted Mr. Tubby re- marks : " If we use the intermediate method, it is generally conceded that the best results have been obtained by one of two procedures. Either joining a strip of the reinforcing tendon to one taken from the paralysed one, or, better still, laying the strips side by side and firmly uniting them. Undoubtedly, however, the most reliable results are reached by Lilnge's direct periosteal implantation." 2 Great care must be taken to avoid any twisting of the tendon or bending it at an angle. Mr. Tubby advises that sterilisable electrodes should be at hand in case it should be thought necessary to ascertain the condition of the muscles. This may also be determined by inspection. "Thus a healthy muscle is dark red, and its tendon divided at ?>. (Tubby is glistening white ; a paralysed muscle and tendon are yellow- 'i"d Jones.) white, a partially paralysed muscle is mottled, red and yellow, ^ Needless incisions for exploration should be avoided. These cases, long the subjects of trophic lesions, are not ideal ones for securing primary union. Further, any incisions required should not be too long ; the scars are undoubtedly liable to become keloid, a result which may interfere with the after-treatment, and the pressure of boots. 2 When Lange's method is employed, the silk for artificial tendons should be prepared as follows : " The skein of silk is undone and soaked for half an hour in ether, and then for a few minutes in alcohol. It is then boiled for one hour and placed for a week in a solution of 1 in 1000 biniodide of mercury. It is finally wound on glass reels and always kept in this solution." Fig. 51. Operation for relief of paralytic talipes equino-val- gus. The inner part of the gastrocnemius andtendo achillis is split off at u,(i. and TENDON-TRANSPLANTATION 107 and the tendoii is wliifo. Tho last-named muscles will respond partly to stimuli, and cannot be regarded as entirely useless. After -trentmcnt. "The j)ar(s are kept absolutely at rest in the new position for at least six weeks, in ])laster of Paris. The greatest danger of relapse is when this is taken olf, so that suitable su])])orts should be einployi-d both by night and day to limit the movements. And here no fixed rules can be given; experience alone is useful. Move- ments must be limited at first, and then very gradually in- creased. The nutrition of the nuisele of the transplanted \ tendon should be maintained at its highest i)oint by very careful massage, and by weak electric currents, and efforts arc made to re-educate the transplanted nuisde and tendon to their new function." Details of tlie various operations will be found in the description of the operative treatment of the different forms of talipes in vol. ii. Infantile Spastic Paralysis, or Cerebral Paralysis of Chil- dren.^ The two authors from whom the above quotations have been made group their cas(»s into (1) infantile hemiplegia ; (2) cerebral diplegia ; (3) s[)astic paralysis. In cerebral tliplegia, while rigidity and paralysis are associated, rigidity is the more striking feature ; in the hemiplegic form paralysis preponderates, the rigidity being secondary to it. Again, in the hemiplegic form, the arm is more affected than the leg, but this is not so with the diplegic form. The following facts are of chief interest to the surgeon : (a) The upper limb, when affected, is more seriously implicated than the lower. (b) The lesion of the upper limb is more permanent, (c) The power of dorsi-tlexion of the hand and the simultaneous extension of the fingers is lost, (d) The movements are performed without precision, spas- modically and slowly. (e) The power of the thumb is often lost. The disabilities of the lower limb are generally : (a) Contraction Fig. 52. The second stage of the operation for the relief of para- lytic talipes equino- valgus. The inner half of the gastroc- nemius and tendo achillis a is brought forward and united either to the tibialis posticus b, or the peri- osteum of the sca- phoid. The third stage consists in division of Fig. 53. Tendo-transplan- tation for the relief of talipes valgus. The pero- nsus brevis, a, is divided and inserted into the tibialis anticus, c, at e. At d is seen the distal end of the peroneus brevis, and b marks the peroneus longus. (Tubby and Jones.) the outer half of the tendo achillis in order to relieve the equinus. (Tubby and Jones.) Clinically this group of the knee, (b) Extension of the foot. {('.) Internal rotation of the femur, with adduction, (d) Rigidity. The cerebral diplegic form is by far the most serious, as we have to deal here with both arms and legs. may be divided into : (a) Cases with and without severe mental complications, (b) Complete and partial dis- ability of the hands, (c) Complete and partial disability of the limbs, (rf) Cases associated with athetotic move- ments. A. The classes of cases which are and are not adapted to treatment. " A suitable case for treatment is a child or young adult of fair intellectual development, who has had no fits for tliree or four years. Such a case may be brought with the following conditions : The feet are in a state of talipes equinus or equino-varus. The knees are flexed owing to the tightly contracted hamstrings, and they knock together on account of the ad- ^ Though the lesions of this disease also are chiefly met with in the lower extremities, they are dealt with here for convenience' sake. For a full description of the deformities due to this hitherto most unpromising disease, readers are referred to Messrs. Tubby and Jones's Surgery of Paralyses, and to Mr. Tubby's Deformities (1912) from which this account is taken. 108 OPERATIONS ON THE UPPER EXTREMITY duction of the thighs. The thiglis are flexed and inverted, and the tensor fascia; femoris. sartorius. and ilio-tibial band are rigidly contracted. B. The classes of cases which are entirely unsuited for treatment ar? the idiotic, th? microcephalic and the violently irritable diplegic who is .'subject to fits, active athetotic movements and convulsions, and the patient who has no control over the sphincters. Another cla.ss of case which is not hopeful for treatment is where the affection of the hands is of such a character as to promise but slight hope of their assistance to the lower limbs dm-ing walking with crutches. That is to say, if the paralysis is complete, or if spasm of the hand and arm never relaxes, treatment is of little avail. It is important to recognise the length of treatment required. Active treatment may be required for many months, and it is therefore unwise to undertake a case in the hospital for a month or two, and then to send it to a miserable home, where neglect will be the inevitable consequence. Even after active treatment has ceased, massage, skilfully directed exercises, with careful and thorough education of the muscles in acquiring new movements, must be carried out for some years. It is therefore necessan,' to secure the co-operation of intelligent parents, anxious to do all they can for their cliild and w illing to face all the trouble involved in careful training. The principles upon which operative treatment is ad- vised are as follows: (1) A constant Ij- over-stretched para- lysed muscle tends to become progressivelj- weak and degenerate. By tenotomy they are placed in a state of rest and may then recover. (2) Excessive deep reflexes are characteristic of thir. disease ; it is therefore of the greatest importance, if possible, to limit tliis excitabiUty. The tension of a muscle is reflexly dependent upon the tension of its tendon. If the tendon of a tightly con- tracted muscle is divided, the stimuli wliich it sends to the cord, and which are thence reflected to the muscles, abate. The vicious circle is thus broken, and the muscle is no longer tonically contracted. Thus, in spastic talipes equinus. division of the tendo Fig. 54. Transplantation achiUis will enable the pointed condition of the foot to be of the sartorius into the remedied, and prevent over-stretching of the paretic ex- patella at a to reinforce tensors which are in this way placed in a state of rest and a paralysed quadriceps, therefore in a position of recover^'. Again by division of The distal part of the the tendo achillis, the reflex excitability of the calf muscles divided sartorius is seen has been largely abohshed ; and not' only so, but the at 6. (Tubby and Jones.) authors believe that the removal of this excessive reflex excitability of the cord permits of that quiescence of the nerve centres so essential to the welfare of these children. Treatment. This falls into the following divisions : A. Operative and B. post- operative. (1) Treatment of the upper extremities ; (2) Treatment in the case of the lower extremities. (1) Treatment in the case of the upper extremities. The most pronounced deformities here are flexion of the elbow, pronation of the forearm, and flexion of the wrist and fingers. The operative procedures consist of tenotomy, tendon trans- plantation, and lengthening of tendons. In all cases it is best to commence bj- relieving the spasm of the flexor tendons at the wrist, remembering that in spastic conditions there is danger of over-correction. Mr. Tubby recommends (a) lengthen- ing the tendons of the flexor sublimis and profundus at the wrist by the Z-method. (h) In order to overcome spasm of the caqial flexors, transplantation of the flexor carpi radiahs and the flexor carpi ulnaris to the dorsal surface of the bases of the second and fifth metacarpals, as originally suggested by ]\Ir. R. Jones. When the tendons are not long enough, Lange"s method of prolonging them by strands of silk may be employed. Great care must be taken to avoid matting of tendons or much stiffness may result. To relieve the flexion of the elbow and ex- cessive pronation of the forearm Mr. Tubby describes an operation for converting the pronator radii teres into a supinator by transplanting its tendon behind the radius, through an incision in the interosseous membrane, to the outer side of the radius.^ The after-treatment consists in educating and training the limb in its new 1 This operation is described by Mr. Tubby in the Brit. Med. .Journ., Sept. 7, 1901, and with several important modifications, in Deformities (1912), vol. ii, p. 729. TENDON-TRANSPLANTATION 109 position. Passive movements are at first limited, so as not to stretch the bands of union unduly, and after the sixth week they are more extensive. At the latter date active movements are begun. The principles which should guide them are as foUo.v: (a) The movements should bo pra'tisod slowly without excitement. (6) They sliould bo made interesting to the patient, (c) Those movements wliicli are op[)osed to the direction of the deff)rMiity should predomi- nate, (d) Those presenting the greatest difficulty should be chiefly jjractised. (2) Treatment in the ca^c of the lower extremities. The following series of operations on the hip. knee, and ankle may be required, and aro per- formed, if necessary, in stages. Open operation is always indicated. The adductors of the thigh are first dealt with. The adductor longus is exposed through a longi- tudinal incision and three-quarters of an inch of its tendon is excised. The limb is abducted and the adductor brevis and the gracilis are treated in the same way. If needful, the horizontal ])art of the adductor magnus and the pec- tineus are divided ; in fact, every tissue which limits free abduction; the sartorius, tensor fasciEe femoris, and ilio- tibial band are divided in the same way. The knee is then dealt with by longitudinal incisions, one on either side usually sufficing. By burrowing under the subcutaneous tissue, and retracting the skin, the various bands of fascia can be reached and divided as well as the hamstrings. Finally the tendo achillis is elongated by the Z-method (q.v.) and the patient is then secured comfortably in Jones's abduction frame with the Icnees straight and the feet at right angles. At the end of three months the splint is taken off dm-ing the day and the movements are regularly practised. A Uttle later, when the patient has been taught to stand unsupported, walking is begun with crutches. At first the nurse must take great care that the limbs are not approximated. The limbs must be kept abducted at night, and massage of the muscles, with active and passive movements of the different joints and adduction of the Yig. 55. Muscle-trans- limbs must be assiduously practised. In from twelve to plantation for the relief twenty-four months, with careful supervision and after- of paralysed quadriceps treatment, and with the intelligent co-operation of the by reinforcement of the parents, the child should be able to walk a considerable paralysed muscle from distance, aided by sticks, and this with perfectly straight the biceps and sartorius. limbs, and toes and heels on the ground. Later on. At a a ^IJP i^ brought many cases will manage to walk with'one stick only, and forward] from tjhe others will be able to dispense with all kinds of artificial biceps; at & theproxi- ., ^ mal part of the sar- The conclusions of Messrs. Tubby and Jones have been ^^rd and the muscular given at length because of the pains which they have taken gjjpg „ ^nd h are in- to develop the different operations and the authority with serted into the patella which they speak upon orthopaedic subjects. But it is right at e. The distal por- to state that there is another side to this question, and tions of the biceps and that other opinions are less favourable. In this country sartorius are shown at neither Mr. Keetlev nor Mr. Jackson Clarke speaks highly d and c. If the sar- of the result in their books on Orthopcedic Surgery. And torius bo paralysed, the it must be remembered that both are men of large ex- seraitendmosus may be perience and well-known fairness. From America, where every fresh operation is at once tested largely and with much zest, we have warnings not to expect too much from tendon -transplantation m infantile paralysis. Thus Dr. Hibbs, speaking at a meeting of the New York Academy of Medicine, from an experience of 150 cases operated on at the New York Orthopjedic Hospital said : " Where sufficient time is allowed to elapse, the ultimate compared with the immediate results are as a rule very disappointing. In itself tendon-transplantation practically never fulfils expectation, and is only a help to the use of apparatus. It is not an independent orthopaedic measure ; it does not prevent deformity, but may be used as an adjunct to facilitate the use of apparatus, and thus enable the orthopaedic surgeon to use any possible bit of force which the patient can exert. The operation undoubtedly deserves a place in the armamentarium of the orthopaedic used instead. (Tubby and Jones.) 110 OPERATIONS ON THE UPPER EXTREMITY surgeon, but has nothing like the marvellous effect which is sometimes claimed for it." 1 Later opinions are, however, more favourable. Thus Dr. R. W. Lovett, of Boston (Sixteenth International Congress of Medicine, section 7, p. 12), says, " In some instances the results are brilliant, in some the extent and character of the paralysis prevent us from obtaining as good functional results as we would desire. We know of no case in our series made worse by operation'. Under these conditions we now regard the operation in suitably selected cases as one strongly to be recom- mended to patients and in the great majorty of such cases as one followed by most satisfactory results." The method must therefore be still regarded as sub judice. All will allow that the results of treatment of infantile paralysis are amongst the least creditable to us. If tendon-transplantation does no more it may at least do good by attracting, with its glamour of a new opera- tion, more attention to a neglected subject. Whether the results claimed by some are verified in the future depends not so much on perfection of technique — already largely arrived at — as on a wise selection of cases, more careful attention to after-treatment, in which the patient and friends must share a larger responsibility, and, above all, to medical men ceasing to look upon these cases as ones in which nothing can be done and allowing them to drift on until, early childhood past, the mischief is advanced and confirmed, and not only the tendons — to which too much attention has been directed — but the ligaments, joints, bones, fasciae, and skin are all concerned. Finally the literature of this subject, which has rapidly increased, would gain greatly in value if those reporting cases of operation would do so in more detail and with greater accuracy, and also would give us the later as well as the earlier results, telling us especially how far tendon-transplantation does away with that worst of all sequelae of infantile paralysis, viz. the trophic ulceration, which is so liable to set in in late adolescence and early adult life, and which may call for amputation of the thigh. 1 Med. News, April 12, 1902. CHAPTER V OPERATIONS ON THE WRIST I. EXCISION OF THE WRIST-JOINT This operation is not often performed. Extensive tuberculous disease, with abscesses and sinuses, is practically the only indication. The conditions needful for success and the reasons for it often failing may first be considered. (1) Whether the tuberculous disease begins in the synovial membrane or in the bones it extends rapidly, not only to the wrist-joint, but to the two rows of carpal bones and the bases of the metacarpals, along the complicated synovial membranes,^ which bring all these bones into contiguity with each other. The disease thus extensive, is also most obstinate, and is often further complicated by other tuberculous lesions, and. in adults especially, by a tendency to phthisis. Thus partial operations are useless and often worse than useless. Lord Lister ^ was the first to insist on the importance, and to show the possibility, of remo\dng every trace of the disease, including the ends of the radius and ulna, the two rows of carpal bones, and the bases of the meta- carpals (Fig. 58). (2) From the close relation of the flexor and extensor tendons in front and behind these complicated joints, and from the numerous grooves on the bones, it is most difficult to extirpate the disease without dis- turbing the tendons. The tendon-sheaths too may be extensively invaded by the disease. However stiff the wrist may be left, flexion and extension of the fingers are absolutely needful for the operation to be a success ; hence it is imperative that, throughout the prolonged operation, the tendons should be disturbed as little as possible, a direction very difficult to follow, since the sheaths are frequently tuberculous, and the necessary manipulations during the operation may easily lead to the tendons sloughing, and thus to a useless " fin-like " hand. (3) Passive movement of the fingers should be begun as early as ^ The arrangement of these, usually five in number, must be remembered, and their close proximity to each other. («) The membrana sacciformis of the inferior radio- ulnar joint, which also lines the upper surface of the triangular fibro-cartilage. (6) That of the wrist-joint proper, passing from the lower end of the radius and the inter-articular fibro-cartilage above to the bones of the first row below, (c) The common synovial membrane of the carpus, the most complex of all, extending transversely between the bones of the two rows and sending upwards two vertical prolongations between the scaphoid and the semi-lunar and the semi-lunar and cuneiform, and downwards three prolongations between the four bones of the second row usualh', but not always communi- cating with the inner four carpo-metacarpal joints, (d) A separate membrane for the joint between the pisiform and the cuneiform, (e) Another separate one between the trapezium and the first metacarpal. Fig. 56 shows a variety of this arrangement in which seven sj-novial sacs are present. 2 Lancet, 1865, vol. i, p. 308. Ill 112 OPERATIONS ON THE UPPER EXTREMITY possible, and most perseveringly maintained. Owdng to the unsatis- factory character which this operation inherited by the very poor results to which it attained before the days of aseptic surgery, and owing to the unsatisfactory conditions, both general and local, with which the surgeon is called upon to deal — the estab- lished tuberculous trouble, often not iso- lated in the wrist- joint, the joint itself and tendons, it may be, riddled with sinuses, and the fingers swollen and stiff- — excision of the wrist has not found the favour with Eng- lish surgeons which it perhaps deserves. In spite of the above disadvantages and difficulties, it is much to be desired that, as no less than the saving of hand and fingers is at stake, this operation should, mth the advantages of modern surgery, be persevered with, and that all cases, whatever the result, be fully published. Two methods only will be described. Excision of the wrist is not a common operation ; it must be a difficult one ; and the operating surgeon will do well to make himself famiUar with, and to practise, one method. The two methods given below bear the names of surgeons who are authorities on the subject — (1) Lord Lister's, introduced to the profession as long ago as 1865 ; (2) that of the late M. Oilier, whose name stands second to none as an authority on excision of joints, and w^ho has done more than any other surgeon to place excision of the wrist on a sound basis. The second method may be recommended as the less complicated of the two. In young children, o'wdng to the weakness of the ligamentous and other fibrous single structures, the single longitudinal dorsal incision of van Langenbeck or Boeckel — for they are practically the same^ — ^may suffice. (1) Lister's Operation (Figs. 57, 58). In this method two incisions are required, one on the radial side of the dorsum, the other on the imier side of the wrist. Before the operation the fingers are forcibly moved so as to break down any adhesions. An Esmarch's bandage or tourniquet should be employed. The radial incision, angular in direction, is then made, as in Fig. 57. This incision is plamied so as to avoid the radial artery and also the tendons of the extensor secundi internodii and extensor indicis. It commences above at the middle of the dorsal aspect of the radius on a level with the styloid process. Thence it is at first directed towards the inner side of the metacarpo-phalangeal joint of the thumb, running parallel in this course to the extensor secundi internodii ; but on reaching the line of the Fig. 56. The bones and the seven synovial sacs which enterinto joints about the wrist. The seventh, that between the cuneiform and pisiform, is not shown. (MacCormac.) EXCISION OF THE WRIST 11.3 radial Imrdcr of (he. srcoiid metacarpal hone i( is carried downwards loii<;itudinally for lialf its Ictij^tli, the radial artery iK-iiifj; thus avoided, as it lies a littK^ further out. The tendon of the extensor carj)! radialis lougior is next detached, together with that of the extensor brevior, while tiio extensor secundi iuternodii, with the radial artery, is thrust somewhat outwards. The? next step is the sciparation of the trapezium from tlic rest of the oarpus by cutting forceps applied in a line with the longitudinal part of the incision, great care being taken of the radial artery. The removal of tho trapezium is left till the rest of the (sarpus has been taken away, when it can be dissected out without much diflliculty, whereas its intimate relations with the artery and neighbouring parts would cause much trouble at an earlier stage. The hand being bent back to relax the extensors, the ulnar incision should next bo made very free by entering the knife at least two inches above the end of Fig. 57. a, Radial artery. b, Extensor secundi internodiipollicis. c, Extensor indicis. D, Extensor communis, e, Extensor minimi _, ^o t> i ™ „j ; „;^,-„„ digiti. F, Extensor primi intcrnodii. g. Ex- ^ig. 58 Parts removed m excision tensor ossis metacarpi. h, Extensor carpi of the wrist. (Lister.) radialis longior. i, Extensor carpi radialis brevior. k. Extensor carpi ulnaris. L L, Line of radial i ncision. ( Lister. ) the uhia immediately anterior to the bone, and carrying it down between the bone and the flexor carpi ulnaris, and on in a straight line as far as the middle of the tifth metacarpal bone at its palmar aspect. The dorsal lip of the incision is then raised, and the tendon of the extensor carpi ulnar is cut at its insertion, and its tendon dissected up from its'groove in the ulna, care being taken not to isolate it from the integuments, which would endanger its vitality. The linger extensors are then sepa- rated from the carpus, and the dorsal and internal lateral ligaments of the wrist- joint divided, but the connections of the tendons with the radius are purposely left un- disturbed. Attention is now directed to the palmar side of the incision. The anterior surface of the ulna is cleared by cutting towards],the bone so as to avoid the artery and nerve, the articulation of the pisiform bone opened, if that has not abeady been done in making the incision, and the flexor tendons separated from the carpus, the hand being depressed to relax them. While this is being done, the knife is arrested by the unciform process, which is clipped through at it base with bone- forceps. Care is taken to avoid carrying the knife further down the hand than the bases of the metacarpal bones, for this, besides inflicting unnecessary injury, would involve risk of cutting the deep palmar arch. The anterior ligament of the wrist- joint is also divided, after which the junction between carpus and metacarpus is severed with cutting forceps, and the carpus is extracted from the uhiar incision with sequestrum-forceps, any ligamentous connections being divided with the knife. The hand being now forcibly everted, the articular ends of the radius and uhia will protrude at the ulnar incision. If they appear sound, or very superficially effacted, the articular surfaces only are removed. The ulna is divided obliquely SURGERY I 8 114 OPERATIONS ON THE UPPER EXTREMITY with a small saw, so as to take away the cartilage-covered rounded part over which the radius sweeps, while the base of the styloid jirocess is retained. The ulna and radius are thus left of the same length, which greatly promotes the symmetry and steadiness of the hand, the angular interval between the bones being soon filled uj) with fresh ossific deposit. A thin slice is then sawn off the radius parallel with the articular surface. For this it is scarcely necessary to disturb the tendons in their grooves on the back, and thus the extensor secundi inteniodii may never appear at all. This may seem a refinement, but the freedom with which the thumb and fingers can be extended, even within a day or two of the operation, when this point is attended to, shows that it is important. The articular facet on the ulnar side of the bone is then clipped away with forceps applied longitudinally. If the bones prove to be deeply carious, the forceps or gouge must be used with the greatest freedom. The metacarpal bones are next dealt with on the same principle. If they seem sound, the articular surfaces only are clipped off, the lateral facets being removed by longitudinal application of the bonc-forcei:)s. The trapezium is next seized with forceps and dissected out without cutting the tendon of the flexor carpi radialis, which is firmly bound do\\'n in the groove on the palmar aspect ; the knife being also kept close to the bone so as to avoid the radial. The thumb being then pushed up by an assistant, the articular end of its metacarpal bone is removed. Though this articulates by a separate joint, it may be affected, and the symmetry of the hand is promoted by reducing it to the same level as the other metacarjoals. Lastly, the articular surface of the pisiform is clipped off, the rest being left if sound, as it gives insertion to the flexor carpi uhiaris and attachment to the anterior annular ligament. But if there is any suspicion as to its soundness, it should be dissected out altogether ; and the same rule applies to the process of the unciform. The only tendons di\aded are the extensors of the carpus, for the flexor carpi radialis is inserted into the second metacarpal below its base, and so escapes. Only one or two small vessels require ligature. Free drainage must be given. The hand and forearm are put up on a special splint with a cork support for the hand, which helps to secure the principal object in the after-treatment — viz. frequent movements of the fingers — while the wrist is kept fixed during consolidation. Passive movement of the fingers, whether the inflammation has subsided or not, is begun on the second day and continued daily. Each joint should be flexed and extended to the full extent possible in health, the metacarpal bone being held quite steady to avoid disturbing the A^Tist. By this means the suppleness gained by breaking down the adhesions at the time of the operation {see p. 113) is maintained. Pronation and supination, flexion and extension, abduction and adduction, must be gradually encouraged as the new ^\Tist acquires firmness. When the hand has acquired sufficient strength, freer play for the fingers should be allowed by cutting off all the splint beyond the knuckles. Even after the hand is healed, a leather support should be worn for some time, accurately moulded to the front of the limb, reaching from the middle of the forearm to the knuckles, and sufficiently turned up at the ulnar side. This is retained in situ by lacing over the back of the forearm. (2) Ollier's Operation^ (Fig. 59). No surgeon speaks ^\ith greater weight on excision of the wrist than the late celebrated surgeon of Lyons : none have had so much operative experience, and no one worked so hard in order to bring the operation into better favour, and to insist on the necessity of attention to minuteness of detail both during the ^ M. oilier claimed that by his method, which must be, as far as possible, subperiosteal, not one attachment of the tendons need be lost. By other methods the attachments of the extensors of the carpus, those of the flexor carpi ulnaris and radialis, and perhaps that of the supinator longus, arc, he maintains, usually sacrificed. EXCISION OF illK WHIST 115 perforniaiico of the operation and in the al'tei-treatnient. Finally^ M. Olher not only had uniivalh'd experience i)i the excision of this joint/ but he lias repeatedly, either liiinself oi' hy his pupils, placed his results before the profession. - M. Oilier, having tried sevei'al dilTerent incisions, recommends the following. At first sight the number (three) ap- pears complicated, but it will be remembered that the third — that over the radial styloid process — is merely for drainage. With a view to simplify as much as possible what must in any case be a very com- plicated operation, a single dorso -radial inci- sion, the chief or meta- carpo-radio- dorsal one of Oilier, may be employed.'^ From respect and in justice to that excellent surgeon, his operation is given in detail. Much of it refers to advanced cases of disease. It should be the object of all con- cerned to antedate this stage. The parts having b been made evascular by an Esmarch's bandage, and all adhesions broken down, the hand is sup- ported, extended, and pronated by a sand pillow. First stage Fig. 59. The tendons concerned in excision of the wrist. A a', b b', c c', The three incisions usually emijloyed by M. Oilier, d, the incision of Boeckel, sometimes described as Langenbeck's, the two being practically identical. Incision R- Radius, u, Ulna. 1 and 2, Radial extensors of the nf Sh'r) nnrJ TinnrnP-nt^ carpus. 3. Extensor ossis metacarpi pollicis. 4, Extensor OJ i^Kin ana lAgameniS. primiinternodii. 5, Extensor secundi internodii. 6, Ex- tnsor communis. 7, Extensor indicis. 8, Extensor minimi digiti. 9, Extensor carpi ulnaris (Oilier.) The surgeon, comfort- ably seated, makes the first and chief incision, metacarpo - radio - dorsal, starting from a point in the centre of a line drawn between the two styloid processes, and running down- wards, at first vertically and then somewhat obliquely outwards ^ Traite des Res^zdious, 1888, t. ii, p. 448 ; Resections des grandes Articulations, 18S5. 2 M. Oilier himself, loc. supra cit. Congres Franc, de Chir., 1894, p. 872 ; and Resections des grandes Articulations, 1895. M. Gangolphe, " Turaeur blanche du Poignct," Tr. de Chir., 1896, t. iii, p. 595; Dr. Mondan, " La Tuberculose du Poignet," Rev. de Chir., 1896, p. 186. * This method of excision by a single dorso- radial incision was first employed by Boeckel and Langenbeck. Kocher (Text Book of Operative Surgery, 1911) describes a mode of excision through a single dorso-ulnar incision, extending from the middle of tlie fifth metacarpal upwards over the middle of the wrist joint, and from thence along the middle of the back of the forearm. 116 OPERATIONS ON THE UPPER EXTREMITY along the outer side of the extensor indicis, and ending below over the second metacarpal bone at the junction of its upper two and lower thirds. A subcutaneous branch of the radial nerve having been, if possible, avoided, the incision is carried down to the perios- teum and dorsal ligaments, great care being taken not to injure the extensor indicis and the extensor carpi radialis brevior. The extensor indicis is first recognised, but its sheath should not be opened as the incision is deepened. It should be drawn aside with a blunt hook so as to expose the tendon of the extensor carpi radialis brevior, the insertion of which it conceals. The periosteum over the base of the third metacarpal is next incised so as to admit of the detachment of the last-mentioned extensor, together with its periosteal sheath, which constitute the radial lip of the deeper part of the wound. The incision is then prolonged upwards along the forearm according to the amount of bone to be removed, and over the annular ligament outside the parti- tion common to the extensor indicis and communis. A little higher up the incision passes between the extensor indicis and the extensor secundi internodii, these tendons being drawn respectively inwards and out- wards. In the highest part of the incision the periosteum over the lower end of the radius should be divided. This incision should be four inches or more in length, so as to avoid needless bruising of the soft parts, and to give adequate access to the disease. The ulnar incision is next made, starting about one inch above the styloid process of the ulna, and ending below over the base of the fifth metacarpal bone, the incision being kept rather towards the palmar surface so as to leave the tendon of the extensor carpi ulnaris above in the dorsal lip of the wound. The incision should be made carefully so as not to injure a filament of the ulnar nerve which crosses it, and thus not compromise the sensibility of the little finger. The incision is deepened down to the cuneiform and unciform. A third incision, for drainage only, is made about an inch long over the styloid process of the radius. It should be made now, before the landmarks have disappeared. Second stage. Removal of the Bones. This is facilitated by division of the posterior annular ligament, which allows of easy separation of the tendons. The radio-carpal joint having been opened, the periosteal and ligamentous connections of the carpus are gradually divided, and, the carpus having been made to project more and more above, the flexor tendons are safely detached and held aside in front. It does not matter which of the carpal bones is taken first, whether those that lie beneath the radio-dorsal or the ulnar incisions ; as soon as one is removed the extraction of the others becomes easier. The great aim of the surgeon is to remove each diseased bone completely. Being very friable they are easily crushed, and any diseased part that is left adherent is liable to cause a focus of infection and tedious suppuration. Each bone should be turned out of its periosteal and ligamentous adhesions with a periosteal elevator or gently seized with small forceps and any adhesions carefully divided. The pisiform usually, and often the trapezium, may be left, and the unciform if sound. Otherwise, if difficulty be met with in shelling out this bone, the process may be cut through, the bone itself turned out, and the process subsequently taken away. The lower ends of the radius and ulna are now examined, each from the incision over them, and dealt with according to the amount of disease present. Thus in some cases erasion with a sharp spoon or EXCISION OF THE WRIST 117 gouge may be sufficient. In others the ends may be removed, a small saw being so used as to form a new articular end. The styloid processes shouKl always be left, if possible ; and even when all the articular cavity of the radius nnist go, some of the expaiuled end of the bone should be left so as to furnish a soHd support for the hand. The periosteum all round each bone, and lateral ligaments, should be carefully retained when healthy. In young subjects the operator must be careful not to leave a caseating se(iuestruni in the epiphysial line above a section of bone which is apparently healthy. The same remarks apply to the treatment of the four inner metacarpals, which alone are usually diseased. The bases of any of these which require removal must be most carefully shelled out of their fibrous coverings, or the tendons and deeper palmar arch may be damaged. If more than gouging is required, the section is better made with a fine saw than with cutting forceps. Question of Preservin to rely upon the patients for any lielp in active mobiUsation of the joint, calls for free removal of bone. (2) Complications. These are most likely to present themselves in the shape of disease of other bones and joints, for such a complication as phthisis will probably call for amputation. Caries of the meta- carpal or metatarsal bones is not of itself a contra-indication. If a diseased spine is present, the question of excision will depend on whether the vertebral caries is old, or recent, or active. If old, is the elbow a source of much irritation ? Two large joints are rarely diseased at the same time. Mr. Holmes ^ has recorded a case ^^. of a boy, aged 5, where he excised, with v^ ^» excellent results, both elbow-joints — only a few weeks intervening between the two operations. Mr. Clement Lucas - relates a case in which disease of the left elbow came on about two years after excision of the right joint, and was also success- fully operated on. Since 1886 Mr. Jacob- son has excised the elbow- joint with good results in four children, in whom some years before he had successfully excised a knee-joint. And in one of the four he had, later on, to remove a tuberculous tarsus by a Symes amputation. When this child was seen a year later all three operations were sound. The new elbow- joint was a very useful one. (3) Question of the Value of Preserv- ing the Periosteum. While the perios- teum may be easily preserved in cases where it is swollen and loose, its preser- vation is in others a matter of very great difficulty, rendering the operation much more laborious and prolonged, and it is extremely doubtful if it is of any ad- vantage in this joint, where the ordinary operation gives such excellent results. ^ Some cases — e.g. primary excision for injury — are unsuited to this method, as the unaltered periosteum is most difficult to remove from the irregular bone ends. In tuberculous disease it is often un- desirable on account of the risk of leaving mischief behind. Subperiosteal resection is said to lead to less haemorrhage, less dis- turbance of the capsule and attachments of muscles, mth greater lateral steadiness and completeness of the new joint. While the last two are ^ Clin. Soc. Trans., vol. i, p. 143. 2 Brit. Med. Journ., 1881, vol. ii, p. 897. ' In the case of excision of the shoulder-joint (p. 222)^ the conditions are very different. Fig. 76. Right elbow after ex- cision of the joint by the usual posterior incision. (Farabeuf.) 1 and 4, Gut edges of the outer ex- pansion of the triceps tendon. 2, Ulna. 3, Humerus. 5, An- coneus, covered by 6. Outer expansion of triceps. 7, Supi- nator longus and radial extensors of the carpus. To the right the bones removed during the opera- tion are seen. The humerus has been sawn through at a point some- what higher than usual. It will also be noticed that care has been taken not to unduly expose the shaft of the ulna. 150 OPERATIONS ON THE UPPER EXTREMITY '^^^v=^.*'^ undoubted, this step may bring about impaired movement/ and the surgeon should only trouble to preserve the periosteum, while clearing the lower end of the humerus of its important muscular attachments, especially in cases where an unusually- large amount of bone has to be removed. If the periosteum is kept, the removal of the bone will be additionally needed. Operation. The single vertical incision at the back gives such excellent results that this operation will alone be fully described ; the method by two lateral and a single bayonet-shaped incisions which have the preference by high authorities ^^'ill be given later. As in all difficult and not very common operations, the surgeon will act most wisely by practising one operation. An Esmarchs bandage having been applied as high as possible over the upper arm, which is first well elevated, or the whole limb being rendered evascular as far as the above point by the use of two bandages, the limb is flexed and carried over the front of the trunk, so as to present it fairly to the surgeon, who usually stands on the opposite side of the body. The surgeon, then, noting the relative position of the condyles and the course of the ulnar nerve, makes a straight incision of sufficient length (about four inches in the adult) with its centre at the tip of the olecranon, a little internal to the centre of the back of the joint, and parallel with the ulnar nerve. This incision should begin above or below as is most convenient, and go down to the bone throughout its whole extent, splitting the triceps, muscle and tendon and incising the capsule. Partly with the point of the knife, partly with a rugine or elevator- (Fig. 80). the surgeon then raises, as far as possible in one piece and without tearing or jagging, the outer half of the triceps, which, vnih its expansion into the deep fascia of the forearm over the anconeus (Figs. 75 and 76 ) — this latter muscle being drawn up at the same time — is peeled up as thickly as possibly from its insertion into the ulna. It is on the preservation of this expansion that the regaining of active extension will depend. Resection-knives and elevators of the French pattern (Fig. 80) are the best. ^ A case is given {Langenbeck, Arch., vol. viii, p. 136) in which, after subperiosteal resection, the condyles had been very perfectly reproduced, and the olecranon had been reformed to even an inconvenient extent, for it was so long and curved as somewhat to limit extension. This method should usually be rejected in children, and also in cases of ankylosis, for fear of a recurrence. The candid Prof. Oilier, with all his experience wrote {loc. supra cit.. p. 218), *• Aussi, apres une resection sous-periostee, est-ce la roideur qui est plus a craindre que la trop grande laxite." - Unless the tissues are softened by mflammation any " blunt dissectors " are useless. Any periosteal elevator, e.g. the one showTi in Fig. 80, should have a distinct but not sharp edge. If the knife be used each cut should be short, and, as it is made, the edge must ever be kept turned towards the bone. / Fig. 77. To show the level to which tlie bones are to be cleared, and the way in which the thumb-nail is kept between the knife and the soft parts. EXCISION OF TIIK KLHOW 151 The (It'cpiM- parts oti tlie outer ^ side of tlie joint are then separated from the bones with the elevator until tlu; external condyle, and the head of the radius are completely exposed. The left thumb, all the time sunk deeply into the wound, pushes the flap of soft parts, as it is detached towards and over the external condyle. It is, finally, displaced over this, as the joint is flexed strongly. Next, the parts on the inner side should be detached from the imier condyle and inner border of the olecranon, great care being taken, by the following precautions, to keep intact the ulnar nerve : («) By keeping the knife or rugine parallel with the nerve and close to the bone ; here and on the outer side alike the instru- ment should follow closely the different bony irregularities around the joint, (b) By the use of the thumb which displaces the soft parts as they are separated by the knife. By these means the soft parts will be satisfactorily cleared from the bones ; retractors well applied will be found most useful, as the process of peeUng off the soft parts is some- what fatiguing to the thumb. This is especially the case in excision for accidents or on the dead body, and it is in these only that the nerve may be seen, though indistinctly. Where the parts have been long inflamed, they peel off much more readily, and the nerve is buried in the swelling. It is well to remember that the nerve may be injured at three places: (1) Above, in the inner head of the triceps; (2) be- hind the internal condyle ; (3) below, under the extensor carpi ulnaris. The clearing of the soft parts off the bony prominences will be much facilitated by keeping the joint extended as much as possible, and the soft parts thus relaxed. Each lateral ligament, if this has not been already done, is raised, together with the periosteum and the group of flexors or extensors respectively, freed from their bony attachments and pushed over them, and there retained with retractors. The joint is now strongly flexed, and the capsule opened just above the olecranon. The bone ends are then turned out and prepared for the saw by passing the knife down to the bone, along the lines of intended section, the soft parts being well retracted beyond these lines. In turning out the bone ends it is easy, in patients where the parts are delicate or softened by inflammation, to strip off a needless amount of periosteum, e.g. on the anterior aspect of the shaft of the humerus. Site of bone section.- The ulna should be sawn (from behind forwards with a small Butcher's saw set firmly), so as to remove the greater and lesser sigmoid cavities with the olecranon. The radius is removed at the same time just below its head, above the biceps. Before this is done, the assistant, who is holding the forearm, should thrust the ends of the bones prominently but carefully {vide supra) into the wound. The section of the humerus requires careful attention. An insufficient amount is usually removed here, and limitation of subsequent movement thereby invited. It is generally considered sufficient to remove all the articular cartilage, the section being made to pass through the lower part of the coronoid and olecranon fossae, and below the level of the epitrochlea on the inner, and through the epicondyle on the outer side. This is not ^ For the sake of practice, it is well to take the outer side first, before clearing the inner with the ulnar nerve in proximity to it. 2 Refer also on this point to Fig. 76. Fig. 78. To show the application of the saw. The dotted line across the humerus passes above the articular cartilage, but is not high enough (vide infra). 152 OPERATIONS ON THE UPPER EXTREMITY enough.^ The saw should pass at a higher level, i.e. above the level of the epicondyle, and through the highest part of the epitrochlea, removing quite the lower two-thirds of this process. This is the very lowest level at which the surgeon should hold his hand if he desires to obtain good movement.- And before he is satisfied on this point he should place the fingers of the affected limb not only on the opposite shoulder and the mouth (as is often done), but on the shoulder of the same side, and behind the back to the angle of the opposite scapula. Unless these movements are perfectly free, he should take another thin slice off the humerus, removing the whole of the epi- trochlea. This step may seem a needless shortening of the limb, and likely to lead to a flail- joint. Such, however, is not the case. As long as the elbow- joint is freely movable, shortening of the bones matters very little. If atten- tion has been paid to the advice given at p. 151, and the soft parts separated very carefully and, as far as possible, subperiosteally from the epicondyle and the epitrochlea, the joint will become sufficiently steady laterally as well as freely movable although these bony prominences have been widely removed. Another test which the surgeon should always apply before considering the section of the bones completed is the interval between the sawn ends. Professor Annandale considers that an inch and a half should inter- veiie between them when the bones are extended. This will be none too much in adults, especially in cases where, owng to the condition of the parts, recurrent inflammation is certain. Here two or even two and a half inches separation is desirable.^ In all cases (and this is especially so in those of ankylosis ^ where a recurrence of the trouble is to be dreaded) more bone must be removed from the humerus than ^ If only half an inch of humerus be removed, together with the head of the radius and the olecranon process — the la>tter perhaps oblic^uely — ankylosis is certain. 2 M. Oilier (Traite des Besections. t. ii, p. 203) usually makes the section at a much higher pomt than most surgeons. He first states that the section of the humerus may be made at different levels: (1) That which removes the articular surface only, the sub- epitrochlear ; (2) That which passes just above through the substance of the epitrochlea, the intratrochlear ; (3) That which passes just above the epitrochlea, the supra- epitrochlear ; (4) That passing through the shaft. He then goes on to say : " The section most frequently made — that which is indicated in the majority of cases of chronic joint- disease, whether in young or old subjects — is the section above the ej)! trochlea," i.e. number (3). 3 Mr. Whitehead (Brit. Med. Journ., 1872, vol. ii, p. 554) records the case of an adult in which two and a half inches of the shaft of the humerus had to be removed after sawing off the condyles. The patient was the subject of tertiary syphilis, and the opera- tion was performed three years after an injury to the elbow. The joint is stated to have been completely disorganised. Nine months she was able to follow her occujiation as charwoman with full use of the joint. * In cases of bony ankylosis, it is well, before attempting to make sections of the bones, either to break down the union forcibly (care being taken not to fracture the possibly atrophied bones above and below, or to separate any of the epiphyses) ; or, bettei', to divide the ankylosis, with a saw, chisel, or osteotome. EXCISION OF THE ELBOW 153 from those of the forearm, where the section is Hmited by the attach- ment of important muscles. The extent of bone to be removed having been detailed, it is well to remember the advice of Professor Kocher^ to make the sawn section curved. It is especially important to do so with the olecranon, as this step goes a long way towards preventing partial dislocation of the forearm forwards and also gives good leverage for the triceps. Mr. Holmes has pointed out, long ago, that if, after renio\'ing as much bone as is ^\^se, disease is still felt upon the anterior surface, it is not necessary to make further sections so as to get beyond it ; thorough curetting will be sufficient, and will save any further inter- ference with the attachment of muscles. Cheyne and Burghard- give the following advice here, which is one recommendation of the method of two lateral incisions : " The finger can be made to pass from one incision to the other between the capsule and the superficial structures, amongst which will be the brachial artery. '• By passing the finger across from one incision to the other and shifting the soft parts upwards and downwards, the entire front part of the capsule can be separated, and may be cut across at its attach- ments to the bones and removed whole." While the bones are sawn, the olecranon and trochlea of the humerus may be steadied in the grip of a lion-forceps, the soft parts being well retracted. =* Any soft, caseous patches in the bone ends are now gauged, any possible sequestra removed. In bad cases the bones are liable to be fatty, with Uttle natural marrow ; such, however, are not necessarily irrecoverable. If the bone above the levels of section appear roughened, and the site of periostitis, this need not be touched ; all will probably subside when the cause of irritation is removed. Any sinuses or suppurating pockets should next be laid open, with due regard to the ulnar nerve, and their contents scraped out with sharp spoons. The extensive wound should then be thoroughly irrigated with sterilised sahne solution (temp. 120 ° Fahr.). A drainage tube should always be inserted, as considerable oozing is certain to take place. If infected pockets or sinuses have been opened and scraped a few sutures may be used and additional drainage secured by packing these with sterilised gauze soaked in iodoform emulsion.'* Very varied forms of splint have been advised.^ Some surgeons, to keep the bones apart, from the first put the limb upon some form of right-angled splint ; others, fearing a flail-like condition of the joint, prefer to begin with the arm and forearm on a straight splint, or on one with an obtuse angle (about 135 degrees) some form of hinged angular splint, alloAving the degree of flexion of the elbow to be altered at each dressing, should be used. Cases may be put up from the first on a metal angular splint, using some such cheap form as that 1 Text-book of Operative Surgery, Stiles's translation, third English Edition, p. 317. 2 Manual oj Surgical Treatment, vol. iii. p. 248. 3 Mr. Heath thinks {loc. supra cif.) that *' the uhiar nerve is in more danger of being cut with the saw when the ulna is divided than when the section of the humerus is made, it being more difficult to clear the former bone." i Farabeuf {Man. Opcr., p. 710) points out that if, owing to long-existing disease of the elbow, the shoulder, wrist, or fingers are stiff, oj^portunity should now be taken to break down adhesions. ^ By some surgeons a splint is here dispensed with. The use of one which is light and simple is strongly advised (vide supra), especially in children, as during the first two weeks, where a splint has been dispensed with, the bone ends have been known to project from the wound. 154 OPERATIONS ON THE UPPER EXTREMITY described in the Brit. Med. Journ., 1877, vol. i, p. 774, in which the anterior metal bar supports the limb, while it leaves the wound and its vicinity well exposed and is easily kept clean, both parts being readily boiled in a steriliser ; moreover, the movable handpiece readily admits of some early passive pronation and supination. The only Fig. 79. E.smarch's wire splint for excision of left elbow. The supine position of the hand, which it is important to preserve, is well maintained in this splint. Plaster of Paris bandages may be used. The splint should be bent to an acute angle. (MacCormac.) objection to this splint is that it does not give quite enough support to the limb. Volkmann's (based on that of Nathan Smith for the lower extremity), Esmarch's (Fig. 79), and Olher's, all of wire and easily bent, are better in this respect, and all admit of the limb being slung — a great relief to many patients during the first week or so, this position also readily showing whether any discharge has made its way through the dressing. Plaster of Paris bandages should not be employed to fix the splint owing to their cramping effect upon the muscles. Passive movement of the fingers and wrist should be begun on the second or third day. The joint itself should be moved as soon (but very gently and slightly) as all irritation has subsided — about seventh Fig. 80. A, Farabeuf's rugine. B, Ollier's periosteal elevator. to tenth day — this date varying according to the size of the gap left between the sawn bones, the probable condition of the tissues as to inflammatory exudation, &c. In children an anaesthetic may have to be given several times. The angle of the splint should be altered or the limb put up straight for a few days, and then again flexed. Later on weight-extension should be used, by securing a bag of shot, which EXCISION OF THE ELBOW 155 is ULlded to I loi inlay to day. A better method, especially with children, because it is gradual and gentle, and one that can be made interesting to them, is the old-fashioned one of weight and pulley. The patient is seated with the elbow resting near the edge of a table. To a pulley overhead a rope carrying a weight is attached. The patient grasps the free end of the rope with the hand on the sound side, while with the other he holds the rope a little above the weight. The rope is now pulled upon with the hand on the sound side ; this flexes the joint, and when the pull is relaxed the limb is extended. This should be practised assiduouslv until half an hour a time two or three times a day is attained. To be of use this method nuist be begun early. The elbow must be kept firmly on the table, or the movements will be made at the shoulder- joint. Later, the sound limb may be fastened up, so that the child must use the excised joint. But when these aids have to be resorted to, the result will often be imperfect. The surgeon should put himself on the safe side by ensuring, originally, a sufficient gap between the bone ends when he uses the saw. The best test of the future usefulness of the limb is that the first passive movements are free and almost painless. The getting of children to use the joint is often most difficult, as friends are usually too foolish to see that the surgeon's directions are carried out daily, because they cause a little brief, but most necessary, suffering. Parents are far too ready to think that because an operation has been performed, and the wound nearly, if not quite, healed, no more is necessary.^ Li commencing pronation and supination early the ulna should be steadied while the hand and radius are very carefully moved. The first attempts at passive movement should be exceedingly gentle, and too much should not be attempted at first. When the parts are sufficiently firm, usually at the end of two weeks, the splint may be left off and a sling substituted. Falls must be carefully avoided, and no liberties taken with the new union, i.e. by a patient attempting to do too much wdth the limb, as in lifting. Later on, when an increasing range of movements may be allowed, resort to a gymnasium vdW be very beneficial.- Finally, it is alwavs to be remembered that a twelvemonth must elapse before the full benefits of the operation — \\z. a complete combination of mobility and stability — are gained.^ If, at the end of four weeks, movement is so free that a flail- joint seems Hkely, the limb should be again immobilised for another month, either on the splint or by plaster of Paris bandages. Should flail-Hke union still threaten the patient should wear moulded leather supports for the arm and the forearm, the two portions being connected by two jointed metal bars which permit of flexion and extension at the elbow, but prevent all lateral mobility. Tests of success. In about four months from the operation the patient should be able to move the new joint freely and efficiently, to dress and feed himself easily, and to lift fairly heavy weights. But it ^ Pronation and supination in a child are often only apparent, the forearm and arm being rotated together from the shoulder. 2 In some cases the regaining of only a limited amount of movement is unavoidable, e.q. where an injury to the elbow-joint requiring e.Kcision co-exists with a fracture of the humerus necessitating absolute rest of the limb. Here the bone ends must be removed very freely. » See a paper by Mr. T. Wingate Todd (Ann. Surg., 1913, vol. Ivii, p. 430) on " The End Results of Excision of the Elbow for Tuberculosis." 156 OPERATIONS ON THE UPPER EXTREMITY will be nine months or a year before the joint is thoroughly firm and strong. Repeated excision. Mr. Jacobson has tried this in three cases, two of them instances of obstinate tuberculous disease ; in each a very useful, but much shortened, limb resulted. In the third, partial excision had been performed at a provincial hospital for an injury to the lower epiphysis of the humerus in a boy of fourteen. Great pains had been taken, but the limb was almost completely stift' and at an obtuse angle. After re-excising the joint completely, a useful angle was secured admitting of the hand being brought to the mouth, placed behind the back, &c., so that the boy could feed and dress himself. The movements of the joint ultimately remained much restricted owing to the absolute apathy and indifference of the patient. While opening up the old wound and again separating the bone ends gives excellent access to the remaining disease, this step wdll be but seldom required if the rule is followed, after excision of such joints, to give ether repeatedly as soon as there is evidence of persistent disease, and slit up any sinuses or undermined tissues, thoroughly use sharp spoons, and, if needful, pack in, for a few hours, strips of iodoform gauze wrung out of an emulsion of glycerine and iodoform or sulphur. {See the remarks made on this subject under " Excision of the Wrist and Knee.") Where, in cases of failed excision, the tuberculous mischief has burrowed out amongst the muscles, where osteitis and osteo-myelitis are also present, amputation is to be pre- ferred, especially if the general condition of the patient is not satisfactory. Other methods. Excision by a single posterior incision has been describe:! in detail because this method gives the best results in the largest number of cases, and is best suited to the majority of operators who will not perform this operation very frequently, and who should, therefore, strive to perfect themselves in one method. The above method is very simple ; it affords, if freely made and efficiently aided by retractors, ample exposure of the joint ; its limited interference with the triceps does not prevent the regain of complete extension. Therefore other methods will be very briefly given. M. Oilier, while admitting that the single posterior incision allows of the fulfilment of the essential conditions of the subperiosteal method, considered it inferior to his method because it affords less facility for the different steps of the operation, gives less room, and is, besides, inferior as regards the after-treatment. A final and especial objection given is that this incision cannot serve as an exploratory one when the surgeon is uncertain whether he will perform a complete or partial resection. These objections are, however, not serious ones, and, with regard to the last, paitial excisions are not to be recommended. Ollier's Method by a Bayonet-shaped Incision. This method, though generally preferred by the well-known Lyons surgeon, was introduced by him especially for cases in which ankylosis, which could not be broken down, was present in an extended position. An incision, vertical at first, made above, over the external supra-condyloid ridge, sinking between the triceps and supinator longus from a point two and a half inches above the level of the joint to the top of the external condyle, and passing vertically down over this ; the incision then passes obliquely across the olecranon between the outer head of the triceps and anconeus, and below descends, vertically again, upon the posterior border of the ulna for two inches. Through this, the main incision, the external condyle, head of radius, and olecranon are dealt with. To expose the inner condyle, make sure of the ulnar nerve, and to detach the EXCISION OF THE ELBOW 157 soft parts and lateral ligament, a second small incision, about two inches long, is made internal to the ulnar nerve and parallel with the inner border of the humerus. The incision is at first a superKcial one. As it is carefully deepened, the above- mentioned intermuscular i)lanes are identified, and along these planes the bones and joint are reached, by division of the periosteum and capsule. The operation is completed on the lines already given. The following are objections to the above method. In the first ])lace, ankylosis in the extended position is a rare condition. Further, the central or oblique part of the incision must surely divide the very important outer expansion of the triceps. Finally, while the main incision exposes fully the parts above the external condyle, the small internal one, wliile introducing a complication, would be inadequate, with most operators, for the sepaialion of parrs on the inner side of the wound. Kocher's Modification oi Ollier's Incision.' With the elbow flexed to about 1 50 degrees.an angular incision is begun at the external supra -condylar ridge one and a half to two inchesa bove the line of the joint,and is carried downwards, practically j)arallel to the axis of the humerus, i.e. vertically downwards to the head of the radius, and from thence along the outer border of the anconeus to the posterior border of the ulna, three inches below the tip of the olecranon ; finally, the incision termin-.ites by curving inwards over the inner surface of the ulna. This incision falls in the interval between those muscles supplied by the musculo-spiral and those supplied by the posterior interosseous. Subsequent muscular atrophy is thus avoided. The external lateral Ugament with the attachments of the extensor ten- dons and the capsule attached to the external condyle, are separated by a raspa- tory. The forearm can now be completely dislocated inwards. If complete resection is desired, the internal lateral ligament is separated along with the muscles from the border of the ulna and the internal condyle, and the ends of the bones are removed. Method by Two Lateral Incisions. Both Oilier and Heuter have employed this method largely, especially advocating it in cases of ankj'Josis. It is also sti'ongly re- commended by ChejTie and Burghard ^ both for excision and erasion of the elbow- joint. It is described in the account of the latter / f |^ operation on p. 161. Treatment of Gunshot Wounds of the Elbow-joint. The structure of the joint renders it impossible for the capsule to be injured without injury to bone. As in the case of gunshot wounds of other bones and joints, the experiences of the South African War differ considerably from those of previous campaigns, both as regards the nature of the injury, the treatment, and the prognosis. With modern high velocity projectiles a simple perforation of the joint may occur, or there may be exten- sive comminution involving the articular surfaces with severe lacera- tion of adjacent soft parts. The latter are by far the more serious injuries, especially as, in the majority of instances, they are septic. ^ Optrative Surgery, third Eng. Ed. by Stiles and Paul, p. 314. 2 Man. of Surg. Treat., pt. iv, vol. iii, p. 246. Fig. 81. Kocher's incision for excision of the elbow. 158 OPERATIONS ON THE UPPER EXTREMITY Lt.-Col. Hickson ^ collected fortj'-nine cases of gunshot injurj' of the elbow-joint, thirteen of which Avere of the nature of pure perforations, the remaining thirty-six being either comminutions or fissured fractures extending into the articulation. Of the first grouji nine were aseptic, and of the latter only three. Only one case terminated fatally, and there amputation was performed for gangrene, which appears to have been caused, or at any rate contributed to, by the application of a plaster of Paris casing. Treatment. '• In the aseptic and in the less serious septic cases the treatment was directed to keeping the wound as free from infection as possible and placing the limb on suitable splints. The total number of comminuted fractures which recovered \\-ithout recourse to oj^erative measures was only eight. The remainder were subjected to operative interference of some sort : thus, in seventeen, fragments of the various bones were removed, of which number fifteen were septic, one aseptic, and one doubtful. Incision for the evacuation of pus, without further measures being required, was performed, and was followed by recovery in one case. Excision of the elbow-joint has been reported in seven cases, but in two of these amputation was subsequently carried out on account of necrosis and suj^puration. Amputation of the arm was required in seven cases, in two of which an unsuccessful excision had previously been performed, and one died." Mr. G. H. Makins^ does not mention any cases in which excision of the elbow- joint was performed. He ^^Tites : " Injuries to this joint ^ came second in frequency in my experience to those of the knee. Thej- were, in fact, comparatively common especially in conjunction with fractures of the various bony prominences sur- rounding the articulation. Fractures of the lower end of the humerus were of worse prognostic signiiicance than those of the ulna, on account of the greater tendency to splintering of the bone. I saw several cases of pure perforation of the olecranon without any signs of implication of the elbow-joint. Several cases of suppuration which came under my notice did well. I saw one of them, six months after the injury, with perfect movement." Partial Excision. The value of this operation has been disputed. In cases of disease it should not be employed as, in addition to the probability of ankylosis, it is likely that the parts affected will be im- perfectly removed. It should also be rejected for the treatment of ankylosis at an unsatisfactory angle, for excision of the lower end of the humerus alone will not permit of pronation or supination afterwards, as the radius and ulna are firmly united at their upper ends. In excision for injury it might be permissible to leave the bones of the forearm untouched when it had been needful to remove the ends of the humerus very freely. The importance of securing free mobility must always be borne in mind. The same conditions, which, after an injury to the elbow- joint, may interfere with a good result from forcible movement, will also interfere with success after partial excision. Thus osteoid masses may be formed by stripped-up periosteum, a torn part of the capsule may be displaced between the joint surfaces, the articular surfaces or the radial^ olecranon or coronoid fossae may become filled with fibrous tissue, or ankylosis develop at the superior radio-ulnar joint. Some of the above — e.g. the formation of osteoid deposits — will be especially marked in young patients. Partial excision thus risks a result of incomplete value, i.e. a joint of limited mobility, though one. perhaps, with a useful angle. The only cases in which partial excision of the elbow-joint for injury is to be recommended are : (1) Cases where it is necessary to excise a large amount of bone from the humerus. (2) Excision of a fractured epicondyle or epitrochlea, or fracture of the head of the radius. Removal ^ Bepf. on Surgical Cases in the South African War. 2 Surg. Experiences in South Africa, 1899-1900, p. 23(3. ' Apparently all the injuries were from bullet and not shell. EXCISION OF THE ELBOW 159 of this process will be specially indicated when it is made out, at once or later on, to be the cause of limited movement in the joint, or when it is the cause of pressure upon the ulnar nerve. (3) Some gunshot injuries {vide supra). Excision of the Superior Radio-ulnar Joint. Indications. Thisopera- sion may be, very occasionally, made us(^ of, with every precaution, in old cases of dislocation of the head of the radius, where reduction has not been effected owing to the amount of swelling, &c., and where the movements of the forearm are much hampered, especially in a young and healthy adult. Operation. An incision about two inches long is made over the projecting head of the bone behind or through the posterior part of the supinator longus. The soft parts having been separated with a blunt dissector and held aside with retractors, the neck of the radius is carefully divided with a fine saw or cutting bone-forceps. Sufficient bone must be removed here or from the external condyle to leave a gap that will avoid the risk of fresh ankylosis. The musculo-spiral nerve lies to the inner side, and great care nmst be taken not to interfere with this or the biceps tendon. The forearm should be put through its movements {see p. 152) freely but carefully, while the patient is under the anaesthetic, so as to break down adhesions. Any needful drainage should be provided, and every care taken, by not interfering with the soft parts more than is absolutely needful, and by keeping the wound aseptic, to secure primary union, and thus avoid the risk of stiffness again occurring. After a few days a sling may be substituted for a splint, and, ten to fourteen days later {see p. 155), passive movements made use of daily, with the aid of an ansesthetic if needful. In October 1894 Mr. Jacobson excised the head of the radius in the following obscure and instructive case : In the previous August the lad, aged 12, had fallen from a ladder on to his feet,' partly on his right elbow, not on the hand. Much swelling of the joint had followed, with subsequent stiffness, rendering the limb very useless. The forearm was fixed in a position midway between pronation and supination, and flexed at a right angle. No flexion was possible beyond this. Passive extension possible to about 120 degrees. Pronation and supination, passive and active, quite abolished. A pro- minence — ? the head of the radius — to be felt below the external condyle, but not admitting of rotation : there was no crepitus. A diagnosis of dislocation of the head of the radius was made, though against it were the history of direct violence and the absence of any rotation in the swelling. On exploration of the injury by a free lateral incision, it turned out to be one' of those rare cases of fracture through the neck of the radius. Just below the external condyle the head of the radius was found separated from the shaft by a fracture through the upper part of the neck, and lying with its articular surface turned directly outwards. On removal of this there was distinct improvement in pronation, but little in supination. Flexion was now possible to 40 degrees, and extension to almost the complete range, but only on forcible movement. As the movements were stiU incomijlete, and certainly would not be retained, I removed the capiteUum of the humerus from the same incision with a narrow osteotome. The forearm could now be put through its full range of movements. The wound healed under an aseptic clot, and the patient, on leav- ing the hospital five weeks later, had recovered almost complete active movements of the joint, though the whole limb was still weak. Three months later he could " do everything nearly as before the accident, and he could also carry considerable weights." Unfavourable Results and Sequelae of Elbow- joint Excision. (1) Per- sistence of tuberculous disease. This is especially likely when, previous 160 OPERATIONS ON THE UPPER EXTREMITY to the operation, the capsule has been perforated and disease has burrowed out amongst the origins of the flexors or extensors. (2) Caries and chronic osteo-myelitis. These are not unlikely to supervene when the reparative power is poor and the wound becomes infected. (3) Ankylosis. This is not uncommon in children, owing to the great tendency of inflammatory products to organise quickly in early life. Furthermore, there is the difficulty of getting them to use the joint or submit to passive movement ; all they will do is to move their arm and forearm from the shoulder-joint. But thorough persevering treatment will secure a sound, though stiff, joint, with a very useful hand. (4) A flail-like joint. A limb may remain weak for some time, owing to the muscles not taking on firm attachments. Friction and galvanism should be used perseveringly. If there is too much separation between the ends, the patient should wear a well-moulded support ; the use of the hand and fingers will thus be retained and, if the patient is young, gradual and great improvement will very likely take place in the elbow. Re-excision and wiring may be tried in some cases with healthy patients. Most of the flail- joints follow the extensive removal of the lower end of the humerus, especially in cases of injury. In such cases the perios- teum of the condyles and the muscular attachments should be as little interfered with as possible. Flail- joints are of two kinds : (1) Active flail-joints, in which the muscles are strong and exercise control. These may be very useful, especially when aided by a support to the elbow. (2) Passive flail-joints, where the muscles are wasted, and the hand only can be used by the employment of a supporting splint. (5) Infection of the wound. (6) A useless limb, owing to the muscles being utterly wasted from long disease and disuse. > (7) Injury to the ulnar nerve, with its resulting interference with motion, sensation, and nutrition. A few days after the excision the nerve should be found by a second incision below and in front, traced upwards and the divided ends united. (8) An adherent scar. ERASION OF THE ELBOW-JOINT This operation has not been extensively practised, partly on account of the good results given by a carefully performed excision and partly because this joint does not lend itself to free exposure by so simple an incision as in the case of the knee-joint. Erasion is especially indicated in children, but in the elbow, as in other joints, it can only be perfectly satisfactory if performed in suitable, i.e. early, cases. Where the bones themselves are not diseased, erasion will give better results than excision, but tuberculous disease of the joints, and among them the elbow, does not always come before the surgeon in its early stage. Mr. Glutton, at a meeting of the Medico-Chirurgical Society ^ advo- cated early erasion of the elbow-joint in place of late excision. He exposed the joint by dividing the olecranon. Nine cases were thus treated. Of these the first two had ankylosed joints, but very service- able limbs. Six cases resulted in more or less movement in the joint, 1 Brit. Med. Journ., Dec. 16, 1893. ERASION OF TlIK KL1?0W 101 with cessation of the disease. The niiitli and hist case was subsofjuently excised. After erasion there is always a tendency to fibrous ankylosis between the ends of the bones which are left. Now this is not a matter of nuich importance in the lower extremity where a firm support, as little shortened as possible, is the chief point to be attained. In the case of the elbow-joint, on the other hand, complete removal of the disease and free mobility should be our aim. The latter certainly — and the former also with the majority of operators — will be best attained by excision with free removal of the ends of the bones. Next to thorough exposure and complete removal of the disease, a freely movable joint is what we reipiire here and, if this be attained, it matters very little if the liml) is shortened. Operation. The following account is taken fiom the " Manual of Surgical Treatjuent," vol. iii, p. 246, by Cheyne and Burghard. It will be noticed that these writers speak guardedly of the amount of move- ment which may be expected afterwards. " Arthrectomy in children is an extremely satisfactory operation, which generally leaves a certain amount of movement, although the restoration of function is not com- plete. The operation is best performed through two long lateral incisions, one on either side of the joint. On the inner side the incision should reach from just below the point at which the ulnar nerve pierces the internal intermuscular septum downwards to about two or three inches below the level of the joint. On the outer side, the incision may extend slightly higher up the arm, but must not reach as low down on the forearm for fear of injuring the posterior interosseous nerve just opposite the neck of the radius. It is as well to make the incisions as free as possible because plenty of room is required to enable the surgeon to see clearly what he is doing. The incisions are carried down to the condyles of the humerus, and the removal of the synovial membrane from the back of the joint is proceeded with. The capsule can usually be readily defined especially upon the outer side, and the skin and subcutaneous tissues are raised from it by a blunt dissector. The whole of the capsule over the radio-ulnar and radio-humeral articulations is thus gradually separated as far as the edge of the olecranon. The triceps is also raised from the capsule as far as the middle line of the joint, when a similar procedure is adopted on the inner side, care being taken to raise the ulnar nerve from its groove behind the internal condyle along with the soft parts and not to injure it. The fingers can then be made to meet across between the triceps and the capsule, and thus the whole of the upper part of the synovial membrane is easily separated and can be divided by a knife just at its reflection on to the bone, and peeled carefully downwards ; it is also divided on each side in the line of the incisions, and is cut away below at its attachments to the ole- cranon, and to the radius and ulna. The entire posterior portion of the synovial membrane is thus removed, and the next step is to deal with the anterior portion. In order to do this satisfactorily it is generally advisable partially to detach the tendinous origins of the muscles from the condyles of the humerus, beginning over the outer one. The periosteum is incised and stripped forwards together with the muscles ; these structures are pulled forcibly forwards, an assistant holds the limb flexed to a right angle, and the anterior surface of the capsule is defined and separated by a blunt dissector and the fingers. Special care must be taken not to damage the posterior interosseous nerve SURGERY I II 162 OPERATIONS ON THE UPPER EXTREMITY in the lower part of the incision. The structures on the inner side are then dealt with in a similar manner, the periosteum and the tendinous origins of the muscles being separated from the internal epicondyle and the capsule defined and separated from them. The finger can soon be made to pass across from one incision to the other between the capsule and the superficial structures, amongst which will be the brachial artery. The entire front portion of the capsule can now be separated and may be cut across at its attachment to the bones and can be removed whole. The lateral ligaments are divided in doing this, and the ends of the bones can then be easily protruded through the wound ; the olecranon is first pushed through whichever incision it can be made to project from more easily — generally the outer — and the synovial membrane of the radio-ulnar articulation is completely removed. The orbicular ligament will also require careful inspection, for it is often diseased. After all the synovial membrane has been removed from its attachment to the bone, and after any portions of cartilage or bone that are affected have been shaved ofF with a knife or freely gouged out, the humerus is protruded through one of the wounds — generally the inner — and examined. Special attention must be paid to the olecranon and coronoid fossae, and the articular surface must be treated in a manner similar to that adopted for the bones of the forearm. After the disease has been thoroughly removed, the bones are replaced, the wounds stitched up without a drainage tube, the usual antiseptic dressings applied, and the limb placed upon an intornal angular splint." " After-treatment. The splints should be retained for three or four weeks, after which the arm should be kept in a shng for another two or three weeks, and the patient encouraged to move it freely. There is no particular advantage in performing passive movement. The only form of passive movement that is really desirable is rotation of the hand, and this may be practised diligently, both actively and passively." OPERATION FOR FRACTURE OF THE OLECRANON A. Simple fractures. Operation should be the rule, a few days after the injury, unless contra-indicated by the want of any separation between the fragments, by some constitutional condition or by the age of the patient. In the first case the diagnosis may be only possible after a radiographic examination. Otherwise firm bony union is very im- probable owing to (a) the wide separation of the fragments brought about by the triceps ; (b) the interposition of torn portions of the aponeurosis of this muscle between the fragments ; and (r) tilting to the upper fragment. The subsequent fibrous union leads to considerable deficiency in the power of extension of the joint and consequently of serious disability. It is especially indicated when both olecranon processes have been fractured, or when a patient, in addition to a fracture of one olecranon has a fracture anywhere in the other upper extremity, thus rendering him very helpless. B. Coni'pound fractures. Here the operation is distinctly indicated. The free incision required will relieve the tension of the ecchymosed soft parts, it will aid the neefled asepsis, it will admit of the removal of any detached fragments, it will enable the surgeon to empty the joint of clot, which, even if it do not suppurate, will persist tediously and impair future movements. FRACTURE OF THE OLECRANON 163 C. //( some old-standing fractures, originally treated by sj)lints, where treatment is sought on account of the resulting weakness. It may here be mentioned that, when for any reason, operation is not performed, no time should be wasted by attempts, usually futile, to draw down the upper fragment with strapping. The case should be assiduously treated from the first with we]l-a])])lied massage. If this be intelligently carried out, the w^asting of the triceps and other muscles does not take place, the effused products are c^uickly absorbed, and the adhesions in and about the joint are prevented. The splint is left off after a few' days, the patient then carries his arm in a sling and begins to use it cautiously. The result is excellent with far less irksomeness to the patient, and trouble on the part of the surgeon. Operation. The parts having been most carefully cleaned, the surgeon raises a convex flap, including the skin, subcutaneous tissue and the olecranon bursa. The incision begins a little above the level of the fracture, about one inch to one side of it, and is then carried downwards and curved across the back of the elbow about one inch below the lower extent of the olecranon, and then finally carried up upon the opposite side to a point opposite to where it began. The convexity of the flap is thus directed downwards ; care must be taken that it is of even thickness throughout. The line of fracture is then made out,^ any torn edges of fascia which may lie between the fragments are turned aside and trimmed clean, but not removed ; the joint is fully flexed, and any clots picked out or washed away with sterile saline solution. To carry out the wiring, a small incision is made vertically down to the ulna, a full half-inch below the line of fracture. The cut edges of the periosteum are at once seized with small clip forceps, to mark the spot and to obviate one difficulty in passing the wire. The bone is then drilled obliquely with a drill of suitable size, the point emerging on the articular surface just behind the articular cartilage. A second small vertical incision is then made with the same precautions through the periosteum of the upper fragment, and its edges seized with forceps. The drill is then again intro- duced obliquely so as to make a passage for the wire exactly opposite to the first. The greatest care must be taken in drilling these holes that they exactly correspond on the fractured surfaces, other\vise exact apposi- tion w'ill not be secured. Sterilised silver ware is then insinuated through the openings in the fragments, and the forceps which act as guides are not removed until this is done. Full flexion of the joint facilitates the passage of the wdre. The joint is now finally washed out with hot sterilised saline solution, the forearm is extended, and an assistant brings the fragments accurately together by pressure with a piece of sterilised gauze in each hand. The surgeon, grasping the ends of the wire in strong forceps, straightens them, and keeping his hands low makes a small, neat twist of about four half turns. The ends, cut short, are then hammered down into the periosteum and bone. The ends should be completely buried by suturing over them with catgut any fascia or periosteum that is to hand. Any lateral gaps in the capsule are closed in the same way. The skin is then sutured and, as a rule, no drainage is required. An ample dressing should be applied, but no ^ This may be in one of three places : (a) The tip of the olecranon may be broken off; (b) fracture may occur at the narrowest part of the sigmoid cavity ; (c) the process may be detached at its junction with the shaft of the ulna. SURGERY I ll' 164 OPERATIONS ON THE UPPER EXTREMITY splint is necessary. Passive movements should be commenced in about a week, and massage as soon as the stitches have been removed. The patient may be allowed to move the joint himself at the end of a fortnight, but free use should not be permitted for five or six weeks. In old-standing cases the operation will be upon similar lines, but owing to adhesions having formed between the upper fragment and the olecranon fossa of the humerus, and owing to the great separation brought about by the action of the triceps, great difficulty may be ex- perienced in drawing the frag- ments together. This may be overcome by lengthening the triceps. The method of effecting this is indicated in Fig. 82. Mr. Walton^ suggests as an mipro\enient a method similar to that advocated by Lord Lister for old-stand- iiig fractures of the patella." Fractures of the Condyles of the Humerus. These injuries, which always involve the articular surface, are, unless the fiagments are accurately replaced, very hkely to be followed by serious disability Either condyle may be frac- tuied or there may be a T-shaped fiactuie, in which the lower extremity of the humerus is separated while a vertical line of fracture extends from the trans- verse line to the articular surface. The tip of the epicondyle may also alone be fractured, in which case the joint is not opened. A thorough and careful radio- graphic examination is essential for the diagnosis of these injuries, and also to guide the surgeon in the treatment to be adopted. An attempt may at first be made to manipulate the fragments into position, the patient being anaesthetised. The arm should then be put up in the fully flexed position. A second Fig. 82. Method of lengthening the triceps in the operation for wiring long-standing cases of frac- ture of the olecranon. The larger figure shows the long flap re- quired for exposure of the triceps, and the serrated division of the muscle described in the text. The smaller figure shows the method of approximating the serrations above and below, and how the muscle is elongated. The apices of the serrations arc made blunt in order to secure a larger surface for union. (Cheyne and Burghard. ) radiographic examination should always be made and if the position is not satisfactory, open operation, if not contra-indicated by age, or by some constitutional condition, should certainly be advised. It must be remembered that in an important joint, such as the elbow, a very trifling irregularity of the articular surface may cause much limitation of movement, and also that callus ^ Fractures and Separated Epiphyscf!, 1910, p. 155. 2 See Operations for Fracture of the Patella. FRACTURE OF THF OLECRANON 165 or osteoid masses foinied by stripped-np ])eriosteum may subsequently seriously interfere with the inobility of the joint. Operation. The fracture nuist be freely exposed either by a lon<; vertical median incision over the back of the joint, or by a lateral incision along the supra-condylar ridges of the humerus. The former incision is best for dealing with a T-shaped fracture, while in separation of one condyle a lateral incision may be employed. Two lateral incisions may be made if necessary, when the soft parts may be separated from the capsule in front and behind (as described for Erasion, see p. 101). Care must be taken to avoid injury to the ulnar or musculo-spiral nerves. In this way a free exposure of the fracture and of the joint may be obtained. With either incision, after the soft parts have been reflected, the joint is opened and all blood clot washed away with sterile saline solution. The fragments are now manipulated into good position and secured by a screw or by a small Lane's plate. Li the case of a T-shaped fracture the two small fragments should first be accurately fitted together, while the lower extremity should be fixed to the shaft by means of a small plate. One of Lane's three-limbed plates may be employed for this purpose. The rent in the capsule is then closed by a few catgut sutures and the wound closed. An internal angular splint should be applied, care being taken that the vessels in front of the elbow are not constricted by too tight bandaging. Cautious passive movements may be started in a week, while gentle massage should be commencedas soon as the stitches have been removed. Separation of the Lower Epiphysis of the Humerus. In certain cases, where reduction of the deformity is impossible or in some old- standing cases where the mobility of the joint is seriously affected, operation may be called for. It is carried out on the lines described above. The epiphysis is exposed through one of the above-described incisions, manipulated into position, and secured by a plate, wire, or staple. The after-treatment is also similar. Sir A. Lane advises removal of the plate as soon as union has occurred in all cases of mechanical fixa- tion of epiphyses ; otherwise interference with growth, leading to subsequent deformity, is likely to occur. Dr. G. E. Davies, of Philadelphia, advises osteotomy of the humerus for cubitus varus, the deformity which may follow a fracture of the internal condyle not corrected at the time of the accident. He looks upon this as the most common of fractures about the elbow-joint. Technique. An incision is made over the internal condyle and prolonged up- wards, and the bone exposed by careful dissection. The brachial artery and the median nerve he to the outer side and in front of the ulnar nerve to the inner side and behind this incision. The edges of the wound having been well retracted, a narrow osteotome is introduced and the bone divided, but not completely. The remainder is then fractured or bent until the desired position is attained. The Hmb is kept extended in plaster of Paris for six weeks ; after the removal of this, massage and movement restore the mobihty of the joint in two weeks. Three cases are given with successful results.^ Arthrotomy. Opening the elbow- joint may be called for in the following conditions: (1) For drainage in cases of acute suppurative arthritis. This may be the result of a punctured wound or be pysemic in origin. (2) For the removal of loose bodies. These are usually small pieces chipped from the articular surface, the result of injury. In the 1 Ann. of Surg., January 1899. SURGERY I 1 1 166 OPERATIONS OX THE UPPER EXTREMITY former case drainage may be effected by two incisions, one on each side of the olecranon. The proximity of the uhiar nerve must be remem- bered when making the inner incision. Frequent free irrigation with sterile saline solution should be carried out, or immersion of the elbow in an arm-bath containing hot boracic lotion or saline solution may be tried. The elbow should be flexed to a right angle and the forearm kept midway between full pronation and supination. Passive movements should be commenced early, as ankylosis is very likely to follow. Not infrequently however in pysemic cases, especially in children, surprisingly good movement is obtained. For the removal of loose bodies an incision on the outer side, over the head of the radius, is recommended. A fragment detached from the articular surface of this bone is one of the commonest loose bodies in the elbow-joint. VENESECTION Indications. Though not very frequently performed, there are a number of conditions in which this operation is strongly indicated. Generally speaking, these are characterised by a rapid, weak, often irregular pulse of low tension, a labouring and dilated right ventricle, and backward pressure along the systemic veins. Dr. Beddard says : " In extreme cases of cardiac dilatation venesection may be an almost necessary preliminary to enable the overstretched muscle to respond to digitalis, strychnine, and other cardiac stimulants." The following are the chief indications : (1) In some cases of chronic bronchitis, especially when an acute attack exaggerates the chronic trouble leading to rapidly increasing cyanosis and cardiac failure from over-distension of the right side of the heart. ^ (2) In some cases of injury to the lung and pleura and of traumatic pneumonia. Captain F. J. Porter. R.A.M.C., relates a case- which illustrates the truth of the above remarks : " A lieutenant was shot through the chest in a Boer ambush. He was picked up four hours later in a critical condition, o^\-ing to dyspnoea from a large effusion of blood into the right pleura. Twenty-four hours later, while the patient was being taken across countn,- to Heilbron. the lividity became so great and the pulse failed so much that ten ounces of verj' dark blood were taken from the median basihc vein. The patient immediately turned on his wounded side and went to sleep. Next morning he was quite rational. Fifty miles were trekked in twenty-eight and a half hours. The recovery was uninterrupted." In cases of acute lobar pneumonia, owing to the tendency to cardiac failure, venesection will be very seldom indicated and should only be done after consultation with a physician. (3) In severe cases of cardiac valvular disease, when the heart is so dilated and engorged that the right ventricle can with difficulty contract upon its contents. (4) In some severe epileptic attacks, especially the status epilepticus, a moderate venesection is of service. In severe ursemic con\Tilsions the fits may be arrested in this way. though care must be taken not to draw off too much blood. It has also been employed with advantage in the treatment of puerperal eclampsia.-^ ^ Very interesting papers (with casos) will be found by Dr. Pye Smith {Med. Chir. Trans., vol. Ixxiv, p. 14), Dr. Qfile and Sir S. Wilks (Lancet, vol. i. 1891, pp. 1029, 1139). 2 Brit. Med. Journ., vol. i, 1901, p. 9.54. 2 Dr. Thomas [Brit. Med, Journ,, 1898, vol. i, p. 400). VENESECTION 107 (5) 111 aiioiirysiiis, ospecially thoracic. Only a small amount of l)loo(l should he withdrawn, though the treatment may, if necessary, he repeated. Venesection here undoubtedly relieves certain very troublesome symptoms, viz. dyspnoea and pain. Operation, liie skin having been cleansed, the patient being usually in a sitting ])osition, and a bandage tied round the middle of the arm with sufHcient tightness to retard the venous circulation without arresting that in the arteries,^ the surgeon selects the median cephalic or the median basilic, whichever is more prominent.- Steadying this vein by placing his left thumb upon it just below the point of intended puncture and with his right hand resting steadily upon its ulnar margin, he opens the vein with a small, sharp scalpel, scrupulously clean, making with, a gentle sweep of his wrist a small incision, and not a mere puncture, into the vein. The anterior wall of this being divided, the joint, without penetrating any deeper, is thrust onwards, first increasing the slit in the vein, and then being cut vertically, care being taken to make the skin wound larger than that in the vein. The thumb is now raised and the stream directed into the measuring vessel.^ While the blood is escaping the limb should be kept in the same position, lest, by the skin slipping over the wound in the vein, the blood should be prevented from escaping freely and thus make its way into the cellular tissue. The required amount of blood having been withdrawn, a sterilised thumb is placed on the wound w^hile the bandage is removed. A small pad of aseptic gauze is then placed on the puncture, and secured with a bandage applied in the figure of 8. This pad may be removed in about forty- eight hours, and for a day or two the patient should use a sling. Difficulties during and complications after Venesection. (1) Difficulty in finding a vein. This may be due to their small size, the feebleness of the circulation, or the abundance of fat. If a vein cannot be made sufficiently distinct by hanging down the limb, putting it in warm water, flexing and extending the wrist and fingers, and chafing the limb, one should be opened on the back of the hand, or blood withdrawn from the external jugular or internal saphena at the ankle. (2) In other cases, where the patient is much emaciated, owing to the absence of steadying fat the mobility of a vein may enable it to avoid puncture, unless a very sharp instrument be used and the vein well steadied. (3) When the vein has been opened, sufficient blood may not escape owing to : (a) The opening may be a mere puncture, (6) The skin opening may be insufficient in size, or not parallel in position to that in the vein. These impediments are removed by a freer use of the knife, carefully made, or by bringing the wound in the vein parallel with that in the skin, (c) A pellet of fat may block the opening in the vein. This should be snipped away, (d) The patient may faint, (e) A thrombus may form. This will disappear when the venous current becomes more active. (/) The bandage may be tied too tightly round the arm. (4) Wound of the brachial or some other artery, e.g. an abnormal ^ The surgeon makes use of the pulsation in the arteries to tell the relation of the brachial, or one of its branches given oflE abnormally high up and running superficially to the veins at the bend of the elbow. 2 If the patient is nervous, or if the veins are small, he should be told to hold a walking- stick or book. This steadies his arm, distracts his thoughts, and, by producing muscular contraction, supports and fills the veins. ^ Not a drop of blood should be allowed to go on the bed or the patient's linen. 168 OPERATIONS ON THE UPPER EXTREMITY ulnar. TJiis can always be avoided by a careful use of the scalpel, and by noting beforehand the existence of any pulsation. The force of the jet and the mixture of bright with dark blood will tell of this accident. Pressure should be carefully applied and maintained, and blood taken from the opposite arm if required. (5) Escape of blood into the cellular tissue. This will lead to ecchymosis, and perhaps formation of a thrombus, which may be absorbed, but which also may suppurate. (6) Phlebitis or inflammation of the lymphatics. These may be caused by the use of infected instruments. Every precaution must be taken to secure asepsis, as any failure is likely to lead to the following two most grave results. (7) Cellulitis and septicaemia. (8) Intense pain in the limb, with gradual flexion of the elbow-joint. This is due to puncture of the external or internal cutaneous nerves, which are con- nected through the brachial plexus with the motor nerves to the brachialis anticus and biceps, which flex the elbow-joint. The injured nerve should be divided, subcutaneously if possible, or the scar excised. LIGATURE OF THE BRACHIAL ARTERY AT THE BEND OF THE ELBOW (Figs. 64 and 83) This operation, common enough fifty years ago owing to the frequency of venesection and the facility with which the brachial artery was wounded, will be briefly described here. Indications. (1) Wound of the artery, especially after venesection or tenotomy of the biceps tendon (here a ligature above and below the wound will be required), or a punctured wound from any other cause. (2) Traumatic aneurysm, whether arterio- venous or not, occurring after accidents such as the above. The late campaign in South Africa saw a great increase in the occurrence of arterio-venous aneurysms from the passage of high velocity bullets of a small calibre through adjacent arteries and veins. This subject will be referred to at p 190 in the account of ligature of the axillary artery, the vessel of the upper extremity in which, according to Mr. G. H. Makins, operative interference is most likely to be useful. Guide. The inner side of the biceps tendon. Relations. hi Front Skin ; fasciae ; bicipital fascia; median basilic vein. Branches of internal and external cutaneous nerve. Outside Inside Biceps tendon. Brachial artery Median nerve Vena comes. at bend of elbow Vena comes. Behind Brachialis anticus. Operation ^Figs. 64 and 83). The hmb being steadied, with the elbow slightly flexed, the site of the biceps tendon should be defined, and also that of any large veins, by making pressure a little above the proposed site of the ligature. An incision about two and a half inches long is then made, a little to the inner side of the biceps tendon, through the superficial fascia, carefully, so as to avoid the median basilic vein and its companion, the internal cutaneous nerve. If these are seen, they must be drawn inwards. The deep fascia is then divided, but this LIGATURE OF THE BRACHIAL ARTERY 169 and the semi-lunar fascia of the biceps, which strengthens it, should be interfered with as little as possible. The artery, with its vena; comites, lies directly underneath. The needle should be passed, after the veins are separated and the artery cleaned, from within outwards, so as to avoid the median nerve, which lies more deeply and to the inner side.^ In the case of traumatic aneurysm, arterio-venous or not, resisting other treatment, a proximal ligature placed as near as possible above the sac, or the old operation of placing double ligatures,- will be preferable to the Hunterian one, which runs the risk of overlooking the possibility of a rather higher division than usual of the brachial into radial and TENDON OF BICEPS I BRACHJAL MEDIAN N. MED. BASILIC K MED. CEPHALIC W. Fio. 83. Ligature of the brachial artery at the bend of the elbow. ulnar. If much haemorrhage is expected, the brachial should be com- pressed about the middle of the arm with an Esmarch's bandage or a tourniquet. The median basilic vein will, in many cases of arterio-venous ^ If it be needful to prolong the incision downwards so as to secure the upper end of the radial or ulnar, the bicipital fascia must be divided more freely, and the median basilic vein secured if it cannot be drawn to one side. 2 On this and all other arterio-venous aneurysms the advice of Mr. Makins, p. 190, should be studied. It will be seen that he prefers trial of a proximal ligature first. If a local operation is found to be needful, ligatures will be required above and below the communication with the vein in the case of aneurysmal varix, and above and below the sac if the surgeon is dealing with a varicose aneurysm. It may be better (the artery being commanded above) to open the sac, and thus find the apertures into the artery by the aid of a small bougie. As Mr. Holmes {Syst. of Sunj., vol. iii, p. 92) points out, the other plan of attempting to find and tie the artery without opening the sac presents these difficulties, viz. that the artery is surrounded by dilated and closely packed veins, and that below the sac it is of small size. Every precaution should be taken to spare the main vein. If haemorrhage from it, uncontrollable by pressure, be present, a lateral ligature should be attempted. Only, if it be absolutely unavoidable, should the vein be tied above and below. 170 OPERATIONS ON THE UPPER EXTREMITY aneurysm, be found much dilated by the entrance of arterial blood. Occasionally it has been obliterated. In ordinary traumatic aneurysm the sac should be cut away with scissors after the artery above and below has been secured. This operation at the bend of the elbow should always be performed with the utmost carefulness at the time, and pains taken with the after- treatment, so as to ensure the minimum of disturbance and the smallest amount of cicatrix, and thus to interfere as little as possible with the movements of the elbow-joint. CHAPTER VIII OPERATIONS ON THE ARM LIGATURE OF BRACHIAL ARTERY (Figs. 84, 85 and 86) This is performed {a) in the middle of the arm and, much more rarely, (h) at the bend of the elbow, the operation last described. (a) In the middle oJ the Arm (Fig. 85). Indicatiuns. (1) Chiefly wounds of the palmar arch, resisting pressure {see p. 89). (2) Wound of the artery itself by a penknife, bayonet, bullet, &c. (3) Gunshot wound of the elbow, leading to secondary haemorrhage resisting other treatment. (4) Angeioma of hand. In March 1891 Mr. Jacobson tied first the brachial, and, five months later, the radial and ulnar arteries for a congenital angeioma with much erectile tissue affecting all the fingers and the palm of the hand in a girl aged 18. By the first Fig. 84. Incision for Hgature of the brachial artery. operation the vascularity was quickly reduced ; the second, aided by catgut setons, was followed by very marked skrinking, and, ultimately, a complete cure. A full account of the case with the result ten years after the operation, is given in the Guy's Hospital Reports, vol. Ivi. (5) Wound of one of the arteries of the forearm, followed by severe haemorrhage, a sloughy condition of the parts preventing ligature of the vessel above and below the wound. In the year 1882 a patient came under the care of Mr. Jacobson for secondary hannorrhage from a wound of the forearm, infiicted by the bursting of a gun in rook-shooting. The parts were much swollen and sloughy : the ulnar artery in its middle third, from which the hamiorrhage was coming, was greenish in colour, and apparently not in a condition to hold a ligature. A good recovery, with no further haemorrhage, took place after ligature of the brachial in the middle of the arm. In 1885 it was found necessary again to tie this artery, for ha?morrhage occurring repeatedly a few days after a suppurating palmar bursa had been opened in the usual way, above and below the anterior annular ligament. The patient recovered with a weakened limb. (6) Traumatic and spontaneous aneurysm. In traumatic aneurysm, 171 172 OPERATIONS ON THE UPPER EXTREMITY whether of the brachial or the arteries of the forearm, the old operation is preferable to the Hunterian, as the sac is often imperfect {see also remarks on p. 173 on ••Abnormalities of the Brachial Artery"). Dr. H. Bousquet records ^ a case of traumatic aneurysm ^ of the forearm, dating to a gunshot injury, cured by excision of the sac. A labourer, while poaching, received a charge of No. 6 shot, which, entering in the lower third of the forearm, passed obliquely upwards almost as high as the elbow. The wound healed up in about six weeks. Evidence of an aneurysm became manifest thirteen days after the injury, but operative treatment was refused. Six months after the accident, an Esmarch's bandage having been apphed, an incision was made over the swelling, which was now of a pyriform shape, and reached from the middle of the arm to the lower third of the forearm. The brachial arterv having been tied as low down as possible, the aneurysm was separated from the Fig. 85. Ligature of the brachial artery in the middle of the arm. adjacent structures. In spite of much care, its walls, which were very thin, gave way at several spots. Its interior was iilled with passive clot. Its lower extremity was embedded in the cicatrix of the wound. The aneun'sm probably sprang from the arteries of the forearm near their origin, jx'rhaps also from the brachial. The removal of the aneurysm left a large cavity, of which the floor was formed by the interosseous membrane, and the sides by muscles of the forearm. Several vessels were tied before and after the removal of the Esmarch's bandage. As it was im- possible to bring so large a wound together, it was plugged with iodoform gauze. The patient recovered with a useful limb. With regard to spontaneous aneurysms, it is well known that these are very rare in the upper extremity, and usually associated with cardiac disease. When this complication is present, ligature will only be thought of when the aneurysm is rapidly increasing, or causing painful pressure upon a nerve. Local anaesthesia mav be useful here. 1 Congres Fran, de Chir.. 1895. p. 741. - The aneurysm is also described as arterio- venous, but no evidence of this is given. The account of the vessels affected is practically nil, LIGATURE OF THE BRACHIAL ARTERY 173 Line. From the junction of the middle and anterior thirds of the axilla, along the inner edge of the coraco-brachialis and biceps, to the middle of the elbow-triangle. This line is of especial importance, when, owing to the swelling, &c., the edge of the biceps is difficult to make out. Guide. The above line and the inner edge of the biceps. Relations in arm. In Front Skin ; fasciae ; branches of internal and external cutaneous nerves. Median nerve ^ (about the centre of the arm). Outside Inside Coraco-brachialis (above). Biceps. Brachial artery Ulnar nerve. Internal cutaneous nerve. Vena comes. in arm. Vena comes. Basilic vein superficial to deep fascia in lower half, beneath it above, usually. Behind Triceps (middle and inner heads) ; coraco- brachialis ; brachialis anticus. Musculo-spiral nerve and superior profunda artery (above). Collateral circulation. («) If the ligature be placed above origin of the superior profunda, the vessels chiefly concerned will.be : Above Below The subscapular ^^^^ rj,^^ -^^^ profunda. Ihe circumflex (6) If the ligature be placed below origin of the superior profunda : Above Below The radial recurrent. ^, • r 1 i.! The posterior ulnar recurrent. The superior profunda with ^j^^ interosseous recurrent. The anastomotica magna, (c) If the ligature be placed below the inferior profunda : Above Beloiv The radial recurrent. ^, . . T The anterior and posterior The superior profunda ^,^^^ ^^j^^^^ recurrents. The inferior profunda ^j^^ interosseous recurrent. The anastomotica magna. Abnormalities. These are so far from infrequent that the surgeon must be prepared for the following : (1) The artery being in front of the nerve. (2) A high division of the artery. According to Quain, in one out of every five cases there were two arteries instead of one in some part, or in the whole, of the arm. The point of bifurcation is thus described by Gray : " It is most frequent in the upper part, less so in the lower part, and least so in the middle, the most usual point for the apphcation of a ligature ; under any of these circumstances, two large 1 The median nerve is to the outer side of the artery at its commencement, crosses it Buperficially about the middle of the arm and is to the inner side in the lower third. 174 OPERATIONS ON THE UPPER EXTREMITY arteries would be found in the arm instead of one. The most frequent (in three out of four) of these pecuharities is the high origin of the radial. That artery often arises from the inner side of the brachial, and runs parallel with the main trunk to the elbow, where it crosses it. lying beneath the fascia ; or it ma}^ perforate the fascia, and pass over the artery immediately beneath the integument." ^ (3) The artery may be partially covered by a muscular slip given off from the pectoralis major, biceps, coraco-brachialis, or brachialis anticus. (4) Instead of following its usual course along the brachial anticus, the brachial artery may accompany the median nerve, behind an epicondylic process or liga- ment, as in many carnivora. (5) It may also give off a vas aberrans or a median artery, and any of its ordinary branches may be absent. The vas aberrans usually ends in the radial, sometimes in the radial recurrent and rarely in the ulnar artery (Cunningham). Operation (Fig. 85). The arm being extended and abducted from the side, with the elbow-joint flexed and supported - by an assistant, the surgeon, sitting between the limb and the trunk, ^ makes an incision three inches in length along the inner border of the biceps, beginning from below or above as is most convenient, going through the skin and fascise. and exposing just the innermost fibres of the muscle.^ This is then drawn outwards with a retractor, the median nerve next found and drawn inwards or outwards with an aneurysm-needle. and the artery defined and sufficiently cleaned, when the ligature is passed from the nerve. In doing this the basilic vein and the venae comites, which increase in size as they ascend, must be carefully avoided. It may be here pointed out that the brachial artery is by no means so easy a Vessel to tie as might be supposed from its superficial position. This is especially the case when the artery is concealed by the median nerve at the point where it is sought, and when its beat is feeble and the vessel itself small and but little distended after repeated haemorrhage lower down.^ AMPUTATIONS OF THE ARM (Figs. 87-90) Indications. Amongst these are : (!) Accidents, e.g. compound fractures, machinery accidents. &c., which do not admit of any part of the forearm being saved or of amputa- tion at the elbow. (2) New growths involving the forearm and not admitting of extirpa- tion. (3) Disease of the elbow- joint not admitting of excision, or in which this operation has failed {see pp. 156, 160). (4) Gunshot injuries of the upper part of the forearm, elbow, and arm not admitting of conservative treatment or excision. 1 The possibility of this superficial position of the radial or ulnar should alwaj^s be remembered when venesection, or Ugature of the brachial, at the elbow is about to be performed. 2 Mr. Heath has pointed out (Oper. Surg., p. 18) that if the arm, when at right angles to the bod v. be allowed to rest upon the table the triceps is pushed up, and displacing the parts, may bring into view the inferior profunda and the ulnar nerve instead of the brachial and the median nerve. 3 This is a much more comfortable position than standing on the outer side and looking over. * Authorities differ as to this step. The operator is strongly advised to avail himself of this guide. If it can be done carefully, and" the wound kept aseptic afterwards, it can do no harm. The fibres of the muscle aire a distinct help, and (as stated above) ligature of this arterv is not so easy a one as it would appear. 1 This^was so marked in the latter of the two cases mentioned at p. 171, that, when the vessel was exposed, several bystanders felt certain that it was not the brachial, but one of its branches. INFERIOR THYROID A:- THrROID AXIS A. SUPRASC/^PULAR A. ACROWO-THORACIC A ANTERIOR CIRCUMFLEX A. POSTERIOR CIRCUMFLEX A SUPERIOR PROFUNDA A. t- POSTERIOR ^SCAPULAR A. DORS A LIS SCAPULAE A. DESCENDING ARTICULAR BRANCHES OF SUPERIOR PROFUNDA A ^-k POSTERIOR 1 INTEROSSEOUS I RECURRENT A. > RADIAL RECURRENT A POSTER. INTER P ECU PRE I OP \ \.fPt\ OSSEOUS >' I f liW lENT A. ) \ I f\ \\\ ANASrOMOTICA MAGNA A. --{posterior branches of XANASTOHOriCy^ MAGNA ^. \ {ANTERIOR BRANCHES OF "^ \ANASrOMOTICA MAGNA /4 . ^ *9 POSTERIOR ULNAR. RECURRENT A. ANTERIOR ULNAR RECURRENT A. POSTERIOR ULNAR RECURRENT A. Fig. 86. Anastomosing branches of subclavian, axillary and brachial arteries. 176 OPERATIONS ON THE UPPER EXTREMITY Amongst the special conditions which will have to be considered here are the size and character of the projectile, the gravity of the laceration of the soft parts, the amount of longitudinal splintering of the bones, the extent of lesions to the vessels and nerves and the degree to which conservative measures can be adopted in the absence of hospital facilities or of easy transportation. If the surroundings of the surgeon and patient admit of it, attempts will, nowadays, be made to suture the nerve ends, especially when only one or two of the chief trunks are involved. Reference has already been made to the infrequency of severe gunshot injuries to the elbow- joint in the South African War. It is noteworthy here that Mr. Makins writes i^ " I am unable to say what was the proportional number of shell wounds among the men hit, but I can say with some confidence that it was not as great as 10 per cent. I should be inclined to place it as low as 5 per cent. Again. I cannot fix The proportionate occurrence of wounds from bullets of large calibre, such as the Martini Henry, but this was certainly not large. I think if lU per cent, is deducted to repiesent the number of hits from either of these forms of projectiles, that we may fairly assume the remaining 90 per cent, of the wounds to have been produced by bullets of small calibre." With regard to treatment of wounded jo'nts Mr. Makins states (p. 235) that this was generally simple. " The old difficulties of deciding on partial as against complete excision or amputation was never met with by us. We had merely to do our first dressing with care, fix the joint for a short period, and be careful to commence passive movement as soon as the joints were properly healed, to obtain in the great majority of cases perfect results. If suppuration occurred, the choice between incision and amputation had to be con- siclered. In the early stages this choice depended entirely on the nature of the injury to the bones. If this were slight, incision was the best course to adopt. I saw several cases so treated which did well, although convalescence was often pro- longed, and only a small amount of movement was regained. Amputation was sometimes indicated in cases of severe bone-splintering when the shafts were impli- cated, but as a rule only performed after an ineffectual trial to cut short general infection of the septic:emic type by incision. I should add that, on the whole, suppuration of the joints was uncommon, except in the case o' injuries far exceeding the average in primary severity."^ (5) In some cases of acute septic infection of the forearm, when septicaemia or toxic absorption threatens the patient's life. So inestimable is the value, even when only partial, of the hand, and so good are the results of conservative treatment and secondary amputation, that the tissues must be almost disorganised for the surgeon to think of primary amputation here. The following case illustrates the power of recovery after very extensive injury to soft parts : A man, set. 22, was admitted into Guy's Hospital in November 1911 with a large transverse gash just below the right elbow-joint, caused by a fall through a glass window. The severe haemorrhage was checked by a tourniquet applied at once by a policeman, but on arrival at the hospital he was almost pulseless. The whole of the soft structures were divided down to the bones, the elbow- joint being opened and the head of the radius exposed on the outer side. All the superficial flexors of the forearm were divided just below the internal condyl •, and also the supinator longus and the tendon of the biceps. The radial and ulnar arteries were divided at their commencement and also the common interosseous. The median, radial, and posterior interosseous nerves were severed, the latter, just at its passage through the supinator brevis. The tendon of the bicejis and the muscles were sutured, though it was impossible to identify the various muscular bellies. The 1 Surgicnl Experiences in South Africa, 1899-1900, p. 11. - In the present war the proportion of shell wounds is certainly much greater than in the South African War. Owing to the conditions of trench warfare, too, infection and supiJuration are almost certain to occur. AMPUTATION OF TIIK AKM 177 nuMlian iiiul radial nerves wore also identified and sutured, hut oonsideral)le diffi- cuity was experienced in identifying the ])()steri()r interosseous as it was liere giving ofT a number of imiscular branches. The injincd arteries were hgatured. Kxcept for the sloughing of a large lacerated area of skin on the forearm below the elbow, the wound healed well. The function of the median and radial -nerves was recovered and there was good movement, and sensation in the fingers, but owing to the scarrhig in front of the forearm, though this was minimised as far as possibh^ by skin- grafting, full extension of the elbow was impossible. Owing to the ])ersistence of paralysis of the extensors the posterior interosseous nerve was subsequently exposed, dissected free from the scar tissue and sutured. A. B. Fig. 87. A. Amputation through shoulder joint by deltoid flap. Amputation through arm by long anterior and short posterior flaps. B. Amputation through arm by the circulai- method. Spence's method of amputating at the shoulder. A compound fracture, especially when comminuted and associated with severe laceration of the soft parts and division of the main vessels or nerves will probably require a primary amputation, though even in some of these cases conservative treatment may be tried. Methods. ( 1 ) Circular. (2) Skin flaps with circular division of muscles — (a) antero-posterior ; (b) lateral flaps. (3) Antero-posterior flaps, usually cut by transfixion. (4) Skin and transfixion flaps combined. (5) Single flap. ( 1 ) Circular method (Fig. 88) . Owing to the moderate size of the limb, its cylindrical shape, and its single centrally situated bone, this is the place, above all others, where this method can be employed, especially SURGERY I 12 178 OPERATIONS ON THE UPPER EXTREMITY in limbs which are not very bulky. Whether he make use of it in after life or not, the student should always practise circular amputation here on the dead subject. Standing on the outer side of either limb, the brachial artery having been controlled by a tourniquet placed as high as possible, the surgeon with his left hand draws the skin up strongly and passes his knife under the arm, then above, and so around it, till, by dropping the point verti- cally, the back of the knife looks towards him, and the heel rests on the part of the arm nearest to him. A circular sweep is then made round the limb, the completion of this being aided by the assistant in charge of the limb, who should rotate it so as to make the tissues meet the knife. A cuff-like flap of skin and fasciae is then raised, for about three inches, with light touches of the knife, these being especially needed along the lines of the intermuscular septa. In a very muscular arm it may be difficult to raise the skin as directed, and it will be sufficient here for an assistant to retract it evenly all round a? . Fig. 88. it is freed by the knife. When the skin has been sufficiently folded back and retracted the muscles are cut through close to the reflected skin, the biceps being cut rather longer than the rest, as, owing to its having no attachment to the humerus, it retracts more. The cut muscles are next retracted by the operator's left hand, and the remaining soft parts, with the main vessels and nerves, are severed clean and square.^ The bone is then cleared for three-quarters of an inch and, the periosteum having been divided, is sawn through as high as possible. The modified circular method (Fig. 89), as described for the forearm on p. 140, may also be employed. The vessels to be secured vAW be the brachial upon the inner side, the superior profunda in the musculo- spiral groove and the inferior profunda to the inner side of the brachial close to the ulnar nerve. The wound should be sutured so that the resulting scar is in the antero- posterior plane. (2) Skin Flaps with Circular Division of Muscles. This method should be made use of for bulky muscular arms. (a) Antero-posterior Flaps. The brachial having been controlled,^ and the arm supported, at a right angle to the body, the surgeon stands ^ In an amputation which passes through the musculo-spiral groove, great care must be taken to divide completely the nerve lying in this before the bone is sawn. The depth of this groove varies much. When it is considerable, the nerve may easily escape division and be frayed by the saw. giving rise, if overlooked, to a most painful bulbous end. 2 In amputation high up the application of a tourniquet may be impossible. The axillary must then be controlled by clastic tubing as described on p. 201, or the subclavian AMPUTATION OF THE ARM 171) outside the right and inside the left limb, with the forefinger and thumb of his left hand marking the site of the iiiteiulcd bone-section (Fig. 90). He then enters the knife on the side of the limb farthest from him, carries it first down three, three and a half, or four inches, according as he is going to make this flap longer than the other or not,^ next across c A Fig. 89. Amputation of the arm by the modified circular method. The dotted line rt c in A is the ordinary incision in the circular method, while the thick line a b c shows the modified circular incision. The skin flaps are shown in B as well as the circular division of the muscles. Two equal flaps of skin and subcutaneous tissue are cut, their lower limit being, in the case of an ordinary forearm, about 1^ inches below the seat of the circular division of the muscles, and then again about Ih inches below the point of section of the bones. In the arm each of these measurements will be increased to 2h inches or more. After the flaps are raised, the muscles are divided by a series of circular sweeps of the knife. After each cut they are firmly retracted until the bone is exposed at the 2:)roposed point of division. The periosteum having been divided circularly, it is strijiped up with a rugino along with the muscles. Thus, when the bone has been sawn, a cap of periosteum fall's over the cut end. The muscles and periosteum must be stripped off the bone together, not separately. (Cheyne and Burghard.) the limb, with square edges, and up the side nearest to him, to the point opposite to that from which the incision started. Then passing the knife under the limb, he marks out a posterior flap, usually somewhat shorter than the anterior. These flaps, consisting of skin and fasciae, are now dissected up, the muscles cut through at the flap-base with a must be controlled by a reliable assistant, or the vessels secured by Spence's method. The latter w"hich is described on p. 206, is, owing to its simplicity and reliability, strongly recommended. ^ Long anterior and short posterior flaps are preferable: if equal, the cicatrix will be opposite, and perhaps adherent to, the bone. This is undesirable, though of less im- portance than in the lower extremity. 180 OPERATIONS ON THE UPPER EXTREMITY circular sweep, and the bone sawn through as high as possible. The biceps should be cut rather longer than the other muscles, and especial care should be taken here to divide the nerve-trunks cleanly and as high as possible. In tying the arteries each must be thoroughly separated from its accompanying nerve. (&) Lateral Flaps. This method may be employed, one flap being cut longer than the other, when the skin is more damaged on one side. The surgeon, standing as before, marks the site of bone-section by placing his left forefinger and thumb, not now on the two borders ot the arm, both on the middle of the anterior and posterior surfaces of the limb. Looking over, he enters his knife at the latter spot, and cuts a well-rounded flap, ending on the middle of the anterior aspect, and then from this point, without removing the knife, another flap is marked out by a similar incision ending at the middle of the back of the arm. The flaps are then dissected up, and the operation completed as before. (3) Transfixion Flaps, usually antero-posterior. In an arm of moderate size, or where rapidity is required, as in warfare or in cases of double amputation, this method may be made use of. The objection to it is that it involves the removal of an undue amount of bone and, where the amputation is high up, interferes with the preliminary securing of the brachial artery by Spence's method. The surgeon, standing as before, and with his left hand marking the flap-base, and lifting up the soft parts anterior to the humerus so as to get in front of the brachial vessels, and thus avoid splitting them, sends his knife across the bone and in front of the above vessels, and makes it emerge at a point exactly opposite ; he then cuts a well-rounded flap, about three inches long, with a quick sawing movement, taking care, after he feels the muscular resistance cease, to carry his knife on a little, so as to cut the skin longer than the muscles, the knife being finally brought out quickly and perpendicularly to the skin. The flap being lightly raised, without forcible retraction, the knife is passed behind the bone at the base of the wound already made, and a posterior flap cut similar to the anterior, but somewhat shorter. Both flaps are then retracted, any remaining muscular fibres divided with circular sweeps of the knife, and the bone exposed a little above the junction of the flaps. The saw is then applied after careful division of the periosteum. The brachial artery will either be found in the posterior flap, or if, as both flaps are made, the soft parts are drawn a little from the humerus, the main artery and nerves will be left, and must be cut square with the circular sweeps of the knife. If it be preferred, lateral flaps can be made by transfixion, one, of course, being cut longer than the other if this is rendered desirable by the condition of the soft parts. (4) Combined Skin and Transfixion Flaps (Fig. 90). This, a speedy and efficient method, may be made use of here. An anterior flap of skin and fascia;, about three inches long, having been marked out and dissected up, the bulk of the soft parts behind the bone are drawn a little away from it, the knife passed behind the humerus, and a posterior flap, somewhat shorter, cut by transfixion. The operation is completed as described above. (5) Single Flap. The condition of the soft parts may render tliis method advisable. If possible an anterior flap is cut by transfixion and so arranged as not to include the large nerves. ; FRACTURE OF THE HUMERUS 181 In all cases of amputation high up in the arm some part of the inser- tion of the pectoralis major should be preserved in order to counteract the tendency to abduction of the stump. EXCISION IN CONTINUITY OF THE SHAFT OF THE HUMERUS Bv the term " excision in continuity, " deliberate removal of portions of the shaft of the humerus— c.r/. two to six inches — the periosteum being preserved as far as possible, is meant. If such operations as incision and removal of spHnters, for necrosis, and for pseudo-arthrosis be excluded the indications are very few. It has been performed for gunshot injuries and possibly might be required for a localised growth such as a chondroma and in some cases of necrosis. In the latter the surgeon will, in the great majority of cases, wait for the sequestrum Fig. 90. to separate and then remove the necrosed portion of the shaft by sequestrotomy {q.v.). With regard to its employment for gunshot wounds,^ Dr. Otis thus wrote in 1883 : " I cannot discern that the experience of the war lends any support to the doctrine of the justifiability of operations of this nature except in very exceptional cases. The numerical returns, and the necessarily abbreviated summaries, may appear, at first glance, to represent the results in a favourable light, but a more precise analysis reveals most lamentable conclusions. . . . The mortality rate is nearly double that observed in the cases treated by expectant measures, and more than 12 per cent, higher than the fatality in a larger series of primary amputations in the upper third of the arm." Free exposure of the shalt of the humerus is not easy, owing to the important vessels and nerves in more or less close relationship with it. It is best exposed by an incision commencing in the interval between the deltoid and the pectoralis major and continued downwards along the groove to the outer side of the biceps as low, if necessary, as the level of the external condyle. The bone is reached to the outer side of the coraco-brachialis and the brachialis anticus. Care must be taken to avoid injury to the circumflex vessels in the upper part of the incision, ^ See also the remarks on gunshot wounds of the radius and ulna, p. 134. SURGERY I 12' 182 OPERATIONS ON THE UPPER EXTREMITY while towards its lower end the musculo -spiral nerve should be identified and be drawn, together with the superior profunda artery, the supinator longus, and triceps, to the outer side. The periosteum should be care- fully peeled off the bone with the help of a sharp periosteal elevator. The requisite quantity of bone is then removed, the shaft of the bone being divided by a fine saw. Another incision sometimes employed commences, as described above, in the interval between the deltoid and the pectoralis major. Below the insertion of the deltoid it is carried more superficially (so as not to injure the musculo-spiral nerve) till it gets into the interval between the triceps behind and the brachialis anticus and supinator longus in front, whence it is carried down to a point just above the external condyle. The nerve is made sure of by opening the inter- muscular septum and drawing the triceps backwards and the brachialis anticus forwards, and then held carefully aside with an aneurysm-needle. The shaft is exposed and the necessary amount of bone removed, as described above. Causes of Failure after Excision of the Humerus in Continuity. Amongst these are : (1) Osteo-myelitis and pyemia. (2) Secondary haemorrhage. (3) Secondary necrosis. (4) Non-union, leading to a limb which dangles or is fiail-like, and is more or less useless in spite of a support. Operative Treatment of Acute Infective Periostitis. This disease may commence either at the upper or the lower epiphyseal line. The pus collects beneath, and strips up, the periosteum from the shaft. Acute osteo-myelitis always occurs at the same time. Necrosis of a part of the shaft is an inevitable sequela. In the acute stage one or more incisions, according to the extent of the abscess, must be made, care being taken to avoid the important vessels and nerves. The medullary cavity should be freely gouged open in all cases. No attempt should be made to remove the necrosed portion of the bone until the sequestrum is separated. This will occur in from ten to twelve weeks. The opera- tion of sequestrotomy is then required. A free incision is made, if possible, on the outer aspect of the limb, but this will depend upon the situation of the sinuses. The bone is exposed, the soft involucrum, consisting of newly formed soft periosteal bone, is freely gouged away until the sequestrum is thoroughly exposed. This is removed, and the cavity, often of considerable extent, is washed out with lot. hydrogen peroxide. A few stitches are inserted, but free drainage must be pro- vided and the wound allowed to heal by granulation — a long and tedious process. Methods for filling up the cavity and thus hastening the healing of the wound will be given below. Occasionally the periosteum of the entire shaft may be separated, which then is certain to necrose. Should this condition be found the diaphysis should be removed, but, unless separation has occurred, a small piece of the shaft adjoining the epiphysis should be left, to avoid injuring the cartilage at the epiphyseal line. Operative Treatment of Fracture of the Humerus. This will be required in some cases when it is impossible to get the fragments into apposition by manipulation, and in those cases where non-union occurs or where there is injury to the musculo-spiral or other nerves. The fracture is best exposed by a long vertical incision between the triceps and the brachialis anticus on the outer aspect of the arm. FRACTITUK OF THE HUMERUS 183 Any inteiveiiing portions ol muscle or fascia are removed, the frag- ments are brought into position by extension and are secured by a plate. An internal angle s})lint is applied ; massage is started as soon as the wound is healed and the stitches are removed. Operation for Psendo-arthrosis. A false joint is not an uncommon sequela to a fracture neai' the centre of the shaft of the huuKMiis. Jt probably depends upon imperfect immobilisation. Operative treatment is always required. The fracture is exposed freely throufih the long external incision described above. A portion of each fraf^ment nnist be icmoved l)y a tine saw so that the section ])assfs through healthy bone. The refreshed surfaces are then brought together and secured by a yjlate. Where there is much s(>paration this may be impossible. An attempt may then be made to till up this syiace by bone-grafting {vide infra). In any of the above operations, the treatment of the periosteum will be of \'ery great importance. Professor Oilier warns those who would expect that periosteum methodically detached from the bone will always and completely reproduce the bone that it normally covered, that they are under a dangerous illusion. It can only be relied upon to do so in early life in young subjects, and when there has been no infective suppuration destructive to the bone-producing cells and when some longitudinal splinters have been left attached within the periosteal sheath. If detached with a blunt elevator, the outer elastic tissue of the periosteum is alone detached. When separated w^ith a knife or a sharp periosteal elevator or rugine, however, the inner bone- forming layer and attached spicules of bone are preserved. When it is desired that new bone should be developed this method of separation should always be adopted. In these, and in similar operations on the other long bones, a con- siderable gap in the continuity of the shaft resulting in non-union and a useless limb, or a large cavity in the bone which will only slowly heal by granulation, may have to be treated. The following methods have been employed. (1) Bone- grafting. The bone required to fill up the gap may be obtained from the patient himself by chiselling away portions of the same or another bone (auto-plastic method), or by taking portions of bone from a freshly amputated limb, or by making use of a bone taken from one of the lower animals (hetero-plastic method). The former is naturally of very limited use. Sir W. McEwen ^ records a successful case in which a boy who had necrosis of the entire shaft of the humerus after acute infective periostitis with a useless dangling limb, in which he grafted portions of bone derived from cases of cuneiform osteotomy of the tibia between the widely separated extremities. These tilled up the gap to the extent of four and a quarter inches, the arm then measuring six inches in length. Seven years afterwards the shaft of the humerus was found to have increased to seven and three-quarter inches. The 2)atient could use his arm for a great many purposes — taking his iood, adjusting his clothes, and in many games. Sir A. Lane has recorded two cases in which he restored the shaft of the ulna by grafting bone from a rabbit. One case was that of a child with congenital maldevelopment of the bone. The ulna consisted of two separate portions, whose pointed extremities overlapped, and whose axes varied considerably in direction. Both were freely exposed and separated from the adjacent parts. Extension was then made on the lower one until the hand was in normal position. The femur of a rabbit was then split longi- tudinally, and its halves wired to the fragments of the ulna so as to bring their ^ Ann. of Surg., vol. vi, p. .301. SURGERY I 12" 184 OPERATIONS ON THE UPPER EXTREMITY axes into the normal line and to retain the lower one on a level with the radius. The result was most satisfactory, not only as to the deformity, but also because of the marked and progressive improvement in the usefulness of the limb. The- second case was that of a man, set. 19, who had lost the shaft of one ulna two years before. Radiographic examination showed the existence of a line spicu- lum between the two extremities. An incision exposed the two ends of the ulna and the spicule, and freed them from the adjacent parts. The femur of a very large rabbit was then securely wired to the ends of the ulna. The resulting limb was much stronger than it was before the operation. It is pointed out that in such a case the presence of new bone thrown out at the upper extremity of the ulna, as a result of the original inflammation, and some ankylosis of joints may interfere with a perfect result. In the latter of the two cases, however, a sarcoma subsequently developed about the grafted bone. As regards the technique of the operation the greatest care must be taken to secure the most rigid asepsis. The grafts in the auto-plastic method, and, unless there is a very large gap to be filled, in the hetero- plastic also, must be broken up into small pieces and placed accurately in the axis of the bone. Any periosteum must be carefully preserved. Where no connecting periosteum is present, as was the case in Sir W. McEwen's patient, a groove must be made between the muslces for the reception of the grafts. An interesting case, quoted from the German Surgical Congress Transactions, 1906,^ shows that a large graft may be employed and that living bone is not essential. Rausch, of Schoneberg. filled a gap 9 cm. long in the shaft of the tibia, the result of the excision of a portion of the bone for a myeloid growth, by grafting a portion of tibia of sufficient length taken from an amputated limb. Before this was secured in its new position by ivory pegs, it was boiled to ensure sterilisation. Nine months later the leg was amputated for reciurence of the growth, and examina- tion then showed that the grafted portion had firmly united at each end and that it was covered by new periosteum. (2) The use of Decalcified Bone. This is sometimes employed for filling cavities in bone, such as are left after removal of a sequestrum. Though occasionally successful the results are usually disappointing. This is owing to the septic condition of the cavities, the foreign sub- stance being usually disintegrated and discharged. (3) The Iodoform Bone-filling of Moestig and Moorhof. This also may be used for filling cavities in bone. The material consists of : Finely powdered iodoform 60 parts, spermaceti oil 40 parts, oil of sesam♦^ 40 parts. The cavity must be aseptic and should be thoroughly dried preferably by means of a hot-air blast. The iodoform wax is melted, shaken up, and then poured into the cavity which it completely fills to the normal surface of the bone. The soft parts are then brought together without drainage and the wound completely closed. The chief objection to this method is that mentioned for decalcified bone, viz. the difficulty in ensuring the asepsis of the cavity. It is stated that the best results are obtained when tuberculous cavities are treated in this way. Ann. of Surg., vol. xliv, p. 792. MUSCULO-SPIRAL NERVE 185 OPERATIONS ON THE MUSCULO-SPIRAL NERVE (Figs. 91 and 1)2) Owing to its proximity to the humerus as it lies in the nmscuhj- spiral groove, this nerve is Uable to injury in fractures about the middle of the shaft/ either by laceration by the fractured ends of the bone or by subsequently becoming involved in the callus. In either case operation Fig. 91. A, Deltoid. B, Outer head of triceps. C. Long head. D, Inner head. E, Supinator longus and extensor. C, Radialis longior. F, Latissimus dorsi. a. Superficial branch of posterior circumflex, h. Anastomotica. 1, ], Cutaneous branches of circumflex. 2, Intercosto-humeral. .3. Internal cutaneous of musculo-spiral. 4, Nerve of Wrisberg. 5, Posterior branch of internal cutaneous. 6. External cutaneous branches of musculo-spiral. * Acromion, f Internal condyle. (Godlee.) will be required. Occasionally the nerve is divided by a stab. Mr Lucas •^ has recorded two such cases. In one case, a lad set. 16, the axillary vein and superior profunda artery were wounded, as well as the musculo-spiral nerve, which was divided, and its lower part torn and notched. The damaged part was cut away and the ends united by catgut sutures. Complete recovery followed, about three months after the injury. The other case was seen two months after the injury. The scar was five inches from the acromion, opposite the insertion of the deltoid, behind and to the outer side of the humerus. On laying bare the nerve it was found that there was a high division into radial and posterior interosseous, the latter being severed just after its origin. The musculo-spiral just befoie its division, and the radial ai, its commence- ment, were involved in dense scar tissue. They were freed from this, and the ends of the posterior interosseous, after resection, were united by fine catgut. The arm gradually improved with three months' galvanism and a complete cure followed. 1 Much interesting information on this subject is contained in a paper by Dr. Charke Scudder and Dr. Walter Paul on " Muscular Spiral Paralysis Complicating Fracture of the Humerus." {Ayin. of Surg., 1909, vol. 1, p. 1118.) 2 Guy's Hospital Reports, vol. xlvi, p. 1. 186 OPERATIONS ON THE UPPER EXTREMITY Relations (Fig. 92). In the upper third of the arm the nerve runs vertically downwards, behind the brachial artery, to the inner side of the humerus, resting upon the long head of the triceps. In the middle third it passes obliquely downwards and outwards, with the superior profunda artery, close to the bone in the musculo-spiral groove, at first between the long and outer, and then between the outer and inner heads of the triceps. In the lower third it pierces the external inter- muscular septum and passes to the bend of the elbow in front of the external condyle, between the brachialis anticus and the supinator longus. Operation. It will most frequently have to be exposed in its middle third; as it here lies close to the bone in the groove and is especially J N^^^^ky Fig. 92. A, Deltoid cut and partlj' turned forwards. B, In- ' ".'Mj fraspinatus. C, Teres minor. D, D, Teres Major. F, F, Outer ■ head of triceps, part of which has been removed. G, Middle head. H, Inner head of triceps. I, I, Supinator longus, cut, and the upper part reflected. J. Extensor C. radialis longior. K, Anconeus. L, Common origin of extensors. M, Brachialis anticus. a. Posterior circumflex. h. Branch of dorsalis scapulae, c. Superior profunda. 1, 2, 2, Branches of circum- flex to deltoid. 3, Cutaneous branches of circumflex. 4, Branch to T. minor. 5, Musculo-spiral. G, 6, Branches to outer head of triceps. 7 and 8, External cutaneous branches of musculo-spiral. the former supplying outt-r head of triceps. 9, Branch to long head of triceps. 10, 10, Branches of musculo- spiral to brachialis anticus. 11, 11, Branches to supinator longus. 12, Branch of extensor carpi radialis longior. (Godlee.) liable to injury by fractures in this situation. An incision, four inches in length, should be made in the axis of the humerus on the posterior aspect of the arm. The centre of the incision is opposite the insertion of the deltoid. The posterior border of the latter muscle is identified, and then on separation of the long and inner heads of the triceps the nerve comes into ^^ew. For free exposure it is however necessary to incise and separate the fibres of the inner head in the vertical direction. If required, the nerve may be exposed in its upper third bj' an incision along the internal bicipital ridge opposite the lower extent of the posterior fold of the axilla. It will here be found resting on the latis- simus dorsi behind the brachial artery close to the inner aspect of the humerus. In the lower third it may be readily exposed by an oblique incision in the interval between the supinator longus and the brachialis anticus. The median cephalic vein should be drawn aside and, on separation of the above-mentioned muscles, the nerve comes into view. CHAPTER IX OPERATIONS ON THE AXILLx^ AND THE SHOULDER LIGATURE OF THE AXILLARY ARTERY (Figs. 93-96) Indications. (I) Wound of the artery.^ (2) Aneurysm of the brachial high up. The following instructive case 2 will repay perusal. It (1) enforces the importance of exploring at once a wound near a large artery that has bled " profusely " ; (2) it proves, if this step be not taken and a traumatic aneurysm arise, how much the old operation of tying the vessel above and below the aneurysm and emptying the latter of clot is to be preferred to the Hunterian method ; ^ and (3) it is an inter- esting instance that gangrene, which is by no means unknown in the lower limb after ligature of the external iliac {q.v.), may also occur in the upper extremity with its better collateral supply. A man, set. 30, accidentally stabbed himself in the outer aspect of the right arm, in its middle third. Profuse haemorrhage followed. The woiuid was cleansed and dressed antiseptically, and the arm was bandaged from the hand upwards. The patient was sent home, but at night severe bleeding again set in. This was aiTCsted by " plugging."' The following night haemorrhage recurred, and was again arrested by plugging. The Fig. 93. Incisions for ligature of the wound gradually healed, and, three weeks first part of the axillary artery and the later, a circumscribed traumatic aneur- third part of the subclavian, ysm of the brachial artery developed at " the seat of the original wound, but on a higher level." The aneurv'sm increased rapidly, soon occupying the whole of the inner and anterior aspect of the upper arm, causing oedema and loss of sensation of the hand and fingers. About fourteen days later, pressure having failed, it was decided to tie the axillary artery in its third part. This cured the aneurysm, but gangrene ^ of the thumb, together with 1 In some wounds of the artery, the surrounding parts, e.g. veins and nerves, may be so injured, that the vitaHty of the hmb is impaired beyond what ligature and nerve suture can do, and the advisability of amputating at the shoulder-joint must be considered. - Lancet. 1895, vol. i, p. 92. 3 It is always invidious to criticise cases, especially those which the writer has not seen, and it is only fair to the surgeon who publishes this to quote his words. " The only alternative would have been to open the aneurysm, turn out the contents, and attempt to tie both ends of the artery, an operation fraught with great danger to the hmb and to the patient in his then weakened condition." * In this case the repeated bleeding had reduced the size of the main vessel (as in the case mentioned at p. 152) and its anastomoses. Ligature of the axillary artery, very 187 188 OPERATIONS ON THE UPPER EXTREMITY sloughing of the tendons of the forefinger, commenced thirty hours afterwards. Amputation of the tnumb at the metacarpo-phalangcal joint was required later on, and the index finger remained stiff. More rarely still : (3) As a distal operation for aneurysm of the sub- clavian. (4) In some cases of axillary aneurysm. (5) For haemorrhage from malignant disease in the axilla. This last is extremely rare, but a good instance, and one showing the difficulties which may be present, was published by Sir W. Savory.^ Injury to CO^y4CO/D PRO. .C£PHAiL/c a:. MUSCULO- ■CUTAHE.OUSN. MEDIAN N/ /iX/LLARY A '^JC/LLAR.Y V.' BR/!CHI/JL PLEXUS ,- INNER HEAP OF MEDI/tN //. ULNAR N. -PECTORy^JUS MIHOR ^LESSSR /HT. CUTANEOUS N. Fig. 94. Anatoiiiy of the parts concerned in ligature of the axillary artery. the axillary vessels during removal of the breast is dealt with under this heading. Results of injuries from modern bullets to the axillary artery,- trau- matic aneurysm, varicose aneurysm, and aneurysmal varix. These are given by Mr. G. H. Makins : ^ External i)r{mary hcvmnrrhage from the great vessels of the limbs or even of the neck proved responsible for a remarkably small proportion of the deaths on the battlefield. Only one case of rapid death due to bleeding from a limb artery was recomited to Mr. Makins. In this a wound of the first part of the axillary artery proved fatal in the twenty minutes occupied by the removal of the patient to the dressing station. With regard to the treatment of primary haemorrhage probabh% further cut off the blood-supply through one of the most important collaterals, viz. the superior profunda (p. 150). 1 Med. Chir. Trans., vol. Ixix, p. 157. 2 Reference may be made to an interesting cure of a wound of the axillary artery by a pistol bullet recorded by Dr. F. W. Murray (Ann- of Sur(j., 1909, vol. 1, p. .448). The first part of the artery was ligatured and the patient made an excellent recovery. 3 Surgical Experiences in South Africa, 1899-1900. LIGATURE OF THE AXILLARY ARTERY 180 while tlu' roadincss with which sponlanoous cessation of lia'inorrliage from small calibre wounds was secured was very marked, tlie fre(|uenev witli which tra\imatic aneurysms of every variety followed shows that tlie ultimate result is in many such cases by no means satisfactory. " Under the circumstances it may be said that the classical rule of ligation at the j)oint of injury should never be disregarded. Against this, however, certain objections may be at on(^e raised ; thus in many cases both artery and vein need ligature, a consideration of much imjuntance in the case of such vessels as the carotid and femoral arteries. . . . On t he whole it seems clear that the military surgeon must be guided by circumstances, since it may be far better to risk the chances of recurrent ha'morrhage or the develo])ment of an aneurysm or a varix, than those of gangrene of a limb, or softening of the brain. As a general rule, therefore, on the field or in a lield-hospital, primary ligature of the great vessel is best reserved for those cases only in which haemorrhage persists, while in those in which si>ontaneous cessation has occurred, or in which bleeding is readily controlled by pressure, rest and an expectant attitude are to be preferred." Secnndarif hannorrhage in simple wounds by small calibre bullets was decidedly rare: in compound fractures, especially of the "explosive" kind, it was not un- common. Lesions of vessels short of jxnforation, but causing devitalization of the walls, perforation by a sharp spicule of bone, and, in the large majority, sepsis and suppuration were the chief causes. The treatment to be adopted depends on the nature of the case. \Yhen tlie wound is aseptic and bleeding, the result of separa- tion of sloughs (this was found to be very tardy in aseptic wounds), local ligature is the proper treatment. In septic cases, on the other hand, it is usually far better to amputate, unless the general state of the patient and the local conditions are especially favourable.- When neither amputation nor local ligature is practicable. proximal ligature may be of use. Thus one case is given in w'hich ligature of the common carotid was successful for hemorrhage from an arterial hsematoma in connection with the internal maxillary arter^'. Traumntic aneurysms. The experience of the campaign fully bears out that of the past as to the steady increase of the number of aneurj^sms from gunshot wounds in direct ratio to diminution in the size of the projectiles employed. Every variety was met with, and most frequently of all, perhaps, aneuiysmal varices and varicose aneurysms. The following are instances of traumatic aneurysms of this region. False traumatic aneurysms or aneurj'smal haematoma of the axillaiy artery. Entrance wound in posterior fold of axilla, exit one and a half inches below the junction of the anterior fold with the arm. The man rode four miles after being hit, but the horse then fell and rolled over him twice. The wound healed, but the whole upper arm was swollen and discoloured, while an indurated mass extended along the vessels into the axilla. This was not obviously distensile. and pulsation was very slight. The pulses below were absent. A fluctuating swelling w-as present along the anterior border of the deltoid. Tactile anaesthesia existed in the area of the median nerve. On the thirty-first day considerable enlargement was noticed This, together w'ith continued rise of temperature, aroused suspicion of suppura- tion, and an exploratory punctuie was made by Major Longhead. R.A.M.C.. after consultation with Prof. Chiene. Clot escaped, followed by profuse haemorrhage. The incision was enlarged, while compression of the third part of the subclavian was maintained, and an oval wound half an inch long was found in the axillary artery. Ligatures were applied above and below the opening between the converging heads of the median nerve. All the swelling disappeared with the healing of the wound, but the diminished median tactile sensation persisted. A somewhat similar case, but one of true traumatic aneurysm, treated by double ligature of third part of the axillary artery, came under Mr. Jacobson's care in the spring of 1902, at Guys Hospital. The patient had been shot through the inner and upper part of the pectoral region, the wound of exit being in the posterior fold. He received the wound in one of the night attacks on our camps, and his assailant was so close that he killed him by a snapshot with his rifle resting on his thigh. Both wounds healed by first intention, and he was admitted for diminished tactile sensation over the area of the musculo-spiral. The radial pulse was normal, and there was nothing to call attention to the existence of an aneurv'sm. A bruit was not, however, listened for. The musculo- spiral nerve, which alone appeared damaged, was explored by an incision along the axillary vessels, with partial division of the great pectoral. Xo damage could be found in the course of the nerve, but, as it was traced upwards, a small ovoid sac of a traumatic aneurysm was found between the two heads of the median nerve. Ligatures were placed above and below, the aneurj'sm opened, and some 190 OPERATIONS ON THE UPPER EXTREMITY old clot turned out. Owng to the intimate association of the nerve it seemed wiser not to try and remove the aneurysm. It was hoped that any pressure which the aneurysm might be making on the nerve would gradually diminish with the shrinking of the ojiened sac. This, however, was not reahzed. When the patient left the hospital there was no evidence of recovery of the diminished tactile sensation over the musculo-spiral area. A very similar case is given by Mr. Makins.^ The Mauser bullet entered two and a half inches below the acromial end of the right clavicle, and emerged over the ninth rib in the posterior axillary line. Three' weeks later the wound being healed, a large pulsating hajmatoma was noted in the axilla. Signs of injury to the musculo-spiral were also observed. The swelling altering little, Major Burton, R.A.M.C, cut down upon it through the pectorals a fortnight later. The aneurysm was of the third jiart of the axillary, and a ligatiu-e was applied at the lower margin of the pectoralis minor. The wound healed by primary union, and when the man left for England a month later, the musculo-spiral paralysis was improving. Aneurysmal Varix and Varicose Aneurysm. The frequency with which these occuri ed and the larger proportion of the latter has already been alluded to. With regard to treatment Mr. Makins (p. 145) warns us that " while modern surgery has lightened the difficulties under which our predecessors approached these operations, none the less the experience of this campaign fully supports the objection to indis- criminate and ill-timed surgical interference, as accidents have followed both direct local and proximal ligature." ThefollowingareMr.Makins's chief conclusions: (1) In aneurysmal varix there should be no interference in the early stage, in the absence of symptoms. " In many cases an expectant attitude may lead to the conviction that no interference is necessary, especially in certain situations where the danger of gangrene has been fully demonstrated. In connection with this subject Mr. Makins relates two cases in which an aneurj^smal varix, in one patient of the femoral vessels, in the other of the axillary, had existed for years, and had not interfered with the patient "s work. In the second case, after twenty years' existence of the varix, the patient as a combatant in South Africa was subjected to very hard manual work. This brought about increase in size, cervico-brachial neuralgia, &c., and in con- sequence, the man was invalided. (2) The arteries of the upper extremity are the most suitable for operation, and the axillary may, perhaps, be the vessel in which interference is most likely to be useful. The vessels of the arm and forearm may in almost all cases be interfered with, but in many instances the absence of any serious symptoms renders operation unnecessary. (3) The operation most in favour consists in ligature of ihe artery above and below the varix, the vein remaining un- touched. . . . Failure is due to the presence of collateral branches, which are not easy of detection. Even when the vessels lie exposed, the even distribution of the thrill renders determination of the exact point of communication difficult, and the difficulty is augmented bj^ the t- mporary arrest of the thrill following the applica- tion of a proximal ligature. ... If the vein cannot be spared, excision of a limited part of both vessels may be preferable, especially in those of the upper extremity." Single ligature or proximal ligature is useless in aneurysmal varix. (4) " Given suitable surroundings and certain diagnosis, the ideal treatment of this condition, as of the next, is preventive — i.e. primary ligature of the wounded artery. Many difficulties, however, lie in the way of this beyond mere unsatisfactory surroundings It suffices to mention the two chief : uncertainty as to the vessel wounded, and the necessity of always ligaturing the vein as well as the artery in a limb often dis- sected up by extravasated blood, to show that this will never be resorted to as a routine treatment." (5) Arterio-venous aneurysm. Many of the above remarks find equal application here, but in the presence of an aneurysmal sac non-intervention is rarely possible or advisable. . .. In the early stages the proper treatment in any ca.se consists in as complete a position of rest as possible, and affording local support to a limb by a splint, preferably a removable jilaster of Paris case. Should no further extension, or what is more likely, should contraction and diminution occur, it will be well to continue this treatment for some weeks at least. When the aneurysm has reached a quiescent stage, the question of further treatment arises, and whether this should consist in local interference or proximal ligature. ... In the case of arterio-venous aneurysms in the limbs the possibilities of treatment are enlarged, and here the alternatives of («) local interference with the sac and direct ligature of the wounded point ; (6) simple ligature above and below the sac ; (c) proximal ligature (Hunterian operation) present themselves. ^ Loc. supra ciL, p. 129. LIGATURE OF THE AXILLARY ARTERY 191 Mr. Makins's opinion is strongly " to the effect that none of these operations should be undertaken before a period of from two to three months after the injury, unless there is evidence of progressive enlargement. In every case which came under my own observation, ])rogressive contraction and consolidation took place up to a certain point luider the influence of rest. When this process has become stationary, and the surroiniding tissues have regained to a great extent their normal condition, the operations are far easier, and beyond this more likely to be followed by success." Writing five years later in a paper, in which a later history of several of his cases of arterio- venous aneurysm are given, Mr. Makins, speaking of operative treatment generally, says : " A ligature placed as near as possible above the aneurysmal sac has been shown to be safe, to afford a reasonable prospect of cure, and not to prejudice a further operation, should this become necessary." And with more especial reference to the arteries of the upper extremity, the same authority writes : " My personal experience of published cases shows that a proximal ligature may with safety and a good chance of success be applied to the vessels above the elbow, and for wounds at the elbow itself, this procedure is to be generally preferred. In the midarm a local operation is simple, and in the forearm the same may be said. In either of the latter situa- tions a local is to be preferred to a proximal operation, as more nearly approaching the ideal and necessitating no obvious risks." LIGATURE OF THE FIRST PART Collateral circulation (Fig. 86). (a) If the artery be tied in its first part, and the ligature be placed above the acromio-thoracic, the vessels concerned will be the same as those which carry on the blood- supply after ligature of the third part of the subclavian {q.v.). (b) If the artery be tied in its third part, and the ligature be placed below the circumflex arteries, the anastomosing vessel will be the same as after ligature of the brachial above the superior profunda {see p. 173). (c) If the artery be tied in its third part, and the ligature be placed between the subscapular and the circumflex arteries, the chief vessels concerned are : Above Beloiv The supra-scapular ^^j^ ^^^^ posterior circumflex. i he acromio-thoracic ^ (d) If in tying the third part of the artery the ligature be placed above the subscapular, the anastomoses are more numerous, viz. in addition to those just given : Above Below The supra-scapular ^.^^ rj,^^ subscapular, ihe posterior scapular Operations. Ligature of the first and the third parts of the artery will be first described, and then the old operation. (1) Ligature of the first part (Figs. 93 and 94). This operation is very rarely performed on the living subject. Owing to the depth of the vessel here, its most important and intimate surroundings, and the risk of secondary haemorrhage from the vessels which lie so close to the knot, ligature of the third part of the subclavian is preferred if ligature be required for axillary aneurysm. On the dead subject the 192 OPERATIONS OX THE UPPER EXTREMITY student should always take the opportunity of tying the first part of the axillary, as it is an excellent test of anatomical knowledge and skill. Line. From the centre of the clavicle (with the arm drawn from the side) to the inner margin of the coraco-brachialis. Guide. The above line, the coracoid process, and the inner margin of the coraco-brachialis. Relations. In Front Skin ; fasciae ; fibres of platysma. Supra- cla\'icular nerve. Pectoralis major with the external anterior thoracic nerve. Costo-coracoid membrane. Cephalic vein. Acromio-thoracic vessels. Ouiside Inside Outer and inner cords of Axillary artery Axillary vein, brachial plexus. first part. Beh ind First digitation of serratus magnus. First intercostal space and muscle. Posterior thoracic nerve. Operation. The vessel may be secured in the following ways : A. Bij a curved incision beloiv the clavicle. This gives the necessary room, but has the disadvantage of dividing the pectoralis major and its large muscular nerve. B. By an incision in the interval between the fectoralis major and deltoid. This method scarcely gives room, especially if the parts are displaced by effused blood, &c., and it is well to supplement the incision in the interval by one partly detaching the pectoralis from the cla\ncle. While this plan involves less haemorrhage from the pectoralis major, care must be taken to avoid the cephalic vein and acromio-thoracic branches which lie in this interval. This end is best secured, whichever method be adopted, by going down on the artery as close to the cla\acle as possible, the sheath of the subclavian being opened, and some of its fibres detached, if needful. C By an incision in the line of the artery, viz. one three and a halj to four inches long, starting from just outside the centre of the clavicle and fussing dmvmvards and outwards. This has the disadvantage of cutting the muscular branches to the pectoralis major, and gives less space than the first two. A. The limb being at first abducted, the surgeon, standing between it and the body, which is brought to the edge of the table, makes a curved incision, with its convexity downwards and about half an inch from the clavicle, reaching from just outside the sterno-cla\acular joint to the coracoid process, the knife being used lightly at the outer end of the incision, so as to avoid wounding the cephalic vein and branches of the acromic-thoracic vessels. The cla\acular origin of the pectoralis major is then di\'ided in the whole extent of the wound, and any muscular branches which require it tied or twisted at once. The arm should now be brought down to the side to relax the parts. The cellular tissue beneath the muscle being next explored \nth the tip of the finger and TJGATITRK OF THE AXILLARY ARTEUY 193 lUrector, the upper border of the pectoralis minor is defined, and this imisck^ drawn downwards. 'JMie costo-coracoid niendjrane must next be most carefully divided in the vertical direction, the acromio-thoracic vessels and the cephalic vein being most scrupulously avoided. Tiie latter forms a useful guide to the position of the axillary vein. The wound all this time must be kept dry, and, if needful, a large laryngeal mirror or an electric head lamp may be usefully employed in throwing light into the bottom of tiie deep wound. The pulsation of the artery CORDS OF BRACHIAL PLEXUS H. TO PE.CTORALIS M'AJOR. PFXTORALIS t^AJOP _ \- SUBCLAI^IUS ~AXILLAR.Y A. CEPHALIC y. CORA CO ID PRO. AXILL-APY V. ^CUT EDGE OF COSTO- CORACOID MEMBRANE Fig. 95. Ligature of the first part of the right axillary artery. being felt for in the living, and its flattened cord- like feel made out in the dead subject, the sheath is exposed, and the vessel itself carefully cleaned and separated from the vein, which lies below and in front, and from the brachial cords, which are above the artery. The needle should be passed from below so as to avoid the vein. B. By an incision made between the pectoralis major and the deltoid. The limb and the surgeon being in the same position as in the operation just given, an incision is made obliquely downwards and outwards between the above muscles, commencing at the clavicle opposite to the coracoid process. Care being taken to avoid the cephalic vein and branches of the acromio-thoracic vessels, the muscles are separated and, to gain more room, a transverse incision is made running inwards along the lower border of the clavicle, and detaching as much as is required of the clavicular origin of the pectoralis major. This flap can be turned inwards and downwards without any interference with the nerve- supply of the muscle, and, owing to its division high up, less hgemorrhage is met w^ith by this method. The deltoid being strongly drawn outwards with a retractor, the upper border of the pectoralis minor is defined, and the operation completed as in the account already given, the parts being relaxed at this stage by abduction of the arm. SURGERY I 13 194 OPERATIONS ON THE UPPER EXTREMITY (1) Ligature of the third part o£ the axillary artery (Fig. 96). Line. From the centre of the clavicle, with the arm in the abducted position, to the inner margin of the coraco-brachialis. Guide. (1) The above line. (2) A line drawn from the junction of the middle and anterior thirds of the axilla, along the inner border of the coraco-brachialis. C OR/i CO- BRA CHMUi ,^ MED IAN N. AX/LLAHy A. ^ -/NT. CUTANEOUS n} ULNAR N. l£:SS£R /A'; TANEOUS N. AXILLARY Fig. 96. Ligature of third part of the left axillary artery. Relations. In Front Skin ; fasciae. Pectoralis major (at first). Outside Musculo-cutaneous, median. Axillary Inner border of artery coraco-brachialis. third part Behind Subscapularis. Latissimus dorsi. Circumflex nerve. Inside Internal cutaneous ; ulnar. Axillary vein or vense comites. Teres major. Musculo-spiral. somewhat that for ligature As with the brachial, so with Operation (Fig. 96). This resembles of the brachial in the middle of the arm. the axillary here ; though the vessel is comparatively superficial, it is not an easy one to hit off at once, owing to the numerous surrounding nerves, which may resemble the artery closely, especially if blood- stained. The axilla having been shaved and thoroughly cleansed. LIGATURE OF THE AXILLARY ARTERY 195 the arm being extended from the side and rotated sHghtly outwards (not too forcibly, as this will alter the relations), the surgeon, sitting between the limb and the trunk, makes an incision three inches long at the junction of the anterior and middle thirds of the space along the inner border of the coraco-brachialis (Fig. 9G). The incision may be begun above or below, as is most convenient. Skin and fascia) being divided, and the point of a director used more deeply, the coraco- brachialis is identified, and the axillary vein and the median nerve are distinguished from the artery, the former drawn inwards, and the latter, together with the coraco-brachialis, outwards.^ The artery is then clearly defined, the sheath opened, and the needle passed from within outwards, the neighbourhood of any large branch, such as the subscapular or the circumflex, being avoided, and the needle being kept very close to the artery. Instead of one axillary vein, two venae comites and the basilic as well may bo present. (3) " Old " operation of ligature of the axillary artery (" OperatioD of Antyllus ") for some cases of axillary aneurysm and injured axillary artery. This method may be called for (1) in the following cases of spontaneous aneurysm (a) when pressure is considered undesirable or has failed, (6) when, owing to displacement of the clavicle, ligature of the subclavian is not practicable ; (c) when the condition of the coverings of the aneurysm is such that this step, even if carried out, will not avert suppuration, sloughing, &c. Professor Syme"^ quotes the following case, in which this method was employed. " I made an incision along the outer edge of the sterno-mastoid through the platysma myoides and fascia of the neck, so as to allow a finger to be pushed down to the situation where the subclavian lies upon the first rib. I then opened the tumour, where a tremendous gush of blood showed that the artery was not effectually compressed ; but while I plugged the aperture with my hand, Mr. Lister, who assisted me, by a slight movement of his finger, which had been thrust deeply under the upper edge of the tumour and through the clots contained in it, at length suc- ceeded in getting command of the vessel. I then laid the cavity freely open, and with both hands scooped out nearly seven pounds of coagulated blood. The axillary artery appeared to have been torn across,and as the lower orifice still bled profusely, I tied it in the first instance, next cut through the lesser pectoral muscle close up to the clavicle, and, holding the upper end of the vessel between my finger and thumb, passed an aneurysm-needle so as to apply a ligatiure about half an inch above the orifice. The extreme elevation of the clavicle, which rendered the artery so in- accessible from above, of course facilitated this procedure from below. Every- thing went on favom-ably afterwards." (2) In many cases of traumatic aneurysm and injury of the artery. Lieutenant-Colonel Sylvester ^ collected five cases of injury to the axillary artery followed by traumatic aneurysm, treated in this way, all of which recovered. The following is a good example. Wounded at Elandslaagte. Seen at Wynberg fourteen days later. Anterior-posterior wound (Mauser) at upper end of humerus, bone not damaged ; no severe haemorrhage at time of woimd. Diffuse aneurysm, occupying axillary space, suddenly formed on twelfth day, and anterior wound began to ooze blood. An incision was made over line of vessel, large quantity of *■ Earabeuf {loc. supra cit, p. 44) gives the following directions for making sure of the artery. Make an incision running just behind the anterior wall of the axilla. Identify the coraco-brachialis by opening its sheath. Draw it outwards, and with the finger of the left hand sunk in the wound, depress the whole bundle of vessels and nerves. The first cord which escapes upwards, when the finger is withdrawn a little, is free, perforating no muscles : this is the median. Isolate it and have it drawn outwards with the coraco- brachiahs. The second large cord, uncovered by withdrawing the first, is the artery. 2 Observations in Clin. Surg., p. 148. ^ Bept. on Surg. Cases in the South African War. SURGERY I 13 196 OPERATIONS ON THE UPPER EXTREMITY clot turned out, and wound found in third part of axillary artery. The outer coats of the vessel had been grazed for the space of an inch, and the artery had given wa^^ in the middle of tliis. Vessel ligatured above and below, and divided between. Uninterrupted recovery. Sir J. Paget and Mr. Callender^ made a — |-shaped incision, cutting parallel with the lower margin of the pectoralis major, and a second, at right angles to the first, straight up through the whole width of the pectoralis major. Mention may also be made here of that most important accident which has happened to so many surgeons, viz. rupture of the axillary artery while dislocations of the shoulder are being reduced. K(irte, of Berlin,- is of opinion that in many cases the injury to the artery is caused at the time of the accident, but htemorrhage does not come on till after reduc- tion is brought about, as the vessel is compressed by the head of the bone. As to the exact cause of the injury to the vessel when it takes place at the time of the reduction, it is probable that some condition exists to account for it, e.g. atheroma ; adhesion of the artery to the head of the bone ; too great or misapplied force in reduction, viz. use of the boot in elevation ; projection of a fragment or a spicule of bone. It is usually the axiUary artery, or one of its branches, which gives way ; much more rarely (four out of forty-four cases, the axillary vein. The following case, under the care of Dr. N. Raw, of Liverpool,^ teaches a point which may be most valuable in the treatment of these rare but very grave cases, viz. putting a temporary ligature round the axillary artery until it is certain whether both this and the vein have given way. The patient was aged 45, and, five weeks after a dislocation of the humerus had been reduced, a surgeon had manij^ulated the arm with his heel in the axilla. The arm began to swell the same night. There was slight pulsation in both radial and ulnar arteries. As the accumulation of symptoms had been gradual, rupture of the axillary vein was diagnosed. The swelling increased, and burst with serious loss of blood. An incision was made from the clavicle to the anterior fold of the axilla, dividing the pectoral muscles. The axillary vessels were ligatured under the clavicle, the artery with a temporary ligature. The incision was then prolonged through to the axilla, down the inner side of the arm to the elbow, and several pounds of clot turned out. The axillary vein was found torn completely across, and was tied at both ends ; arterial blood was seen to be flowing, and the subscapular artery was found cut across about one inch from the main trunk, and tied. The temporary ligature was then removed from the first part of the axillary arteiy, and followed by redness and warmth in the limb, but no pulsation in the radial artery. The patient made an excellent recovery, and, six months later, had a fairly useful limb. Treatment should be on the lines indicated above, though in some cases, especially in elderly patients, disarticulation at the shoulder joint may be called for. AMPUTATION AT THE SHOULDER-JOINT Indications. (1) Compound comminuted fractures, e.g. railway and machinery accidents. (2) Gunshot injuries. Amputation here is divided by Dr. Otis ^ into (1) primary, or before the third day ; (2) intermediate, or cases in which the operation was performed between the third and the thirtieth days ; and (3) secondary, in which the operation was performed later than the thirtieth day. ^ St. Bartholomew's Hasp. Repyrtx, vol. ii. 2 Arch.f. Uin. Chir., Bd. xxvii. Heft .3. 3 Liverpool Med. Chir.Journ., July 1899, p. 328. 4 Med. and Surg. Hist, of the War of the Rebellion, pt. ii, p. 613. AMPl TATION AT THE SIIOULDKR-JOINT 197 (1) Primary. The indications for amputation so soon after the injury are chiefly : (a) a limb torn ofl partially, but too high to admit of any other amputation ; {b) Severe comminuted fracture of the upper end of the humerus, with extensive injury to the vessels and nerves ; (c) Such a fracture high up, with severe splintering extending down below the insertions of the pectoralis major and the latissimus dorsi.^ (2) Intermediate. The mortality here was nearly double that of the primary. This seems to have been brought about largely by the fact that the operation was now ])erformed through soft parts, the seat, at this time, of unhealthy inflammation, and thus prone to lead to secondary hannorrhage, pyaemia, sloughing, &c. (."?) Secondary. The causes for this deferred operation were chiefly ha-morrhage, gangrene, profuse suppuration, hopeless disease of the humerus, sometimes with cohsecutive implication of the joint, chronic osteo-myelitis, or necrosis of the entire humerus. (3) Neiv groivths. If these involve the scapula or its processes the upper extremity should be removed by the method of interscapulo- thoracic amputation {see pp. 234-239). The question of the possibility of saving the limb and removing the growth by excision of the head of the humerus is considered at p. 214. (4) Disease of the shoulder- joint unsuited for, or persisting after failure of, excision. (5) For osteo-myelitis and necrosis of humerus resisting other treatment or complicated with early blood-poisoning. (6) For rapidly spreading gangrene or gangrenous cellulitis with threatening septicaemia. (7) For removal of the upper extremity when painful, oedematous, and heavy owing to pressure on the axillary veins and brachhial plexus by recurrent carcinoma. Here removal of the upper extremity by M. Paul Berger's method {see p. 234) is to be preferred. For the advis- ability of such operations see " Removal of the Breast." (8) Amputation at the shoulder- joint may be called for in the following cases of aneurysm : A. In some cases of subclavian aneurysm where other means have failed or are impracticable ; where the aneurysm is rapidly increasing ; where the pain is con- stant and agonising ; and where the limb is threatening to become gangrenous. While the principle of this operation appears to be physiologically sound, i.e. to enable distal ligature to be performed on the face of the stump, and that, by removal of the limb, the amount of blood passing through the aneurysm may be diminished — the results hitherto have not been very successful. Thus, in Prof. Spence's case^ a man, aged 33, with a subclavian aneurysm, probably encroaching on the second, if not the first, part of the artery, with ex- cruciating pain and threatening gangrene, amputation at the shoulder- joint was followed by diminution in the pulsation and size of the sac, but with little formation of coagula. Death took place four years afterwards, probably froni extension of the aneurysm to the imiominate and aorta. In this case the operation, though it had but little effect in consolidating the sac, undoubtedly prolonged life, as gangrene was threatening, and the second part of the artery was almost certainly affected, thus rendering the case a most unfavourable one. B. With the same objects in view, amputation at the shoulder- joint may be required in some cases of axillary aneurysm complicated with extension of the sac upwards, much elevation of the shoulder, conditions which may render compression or ligature of the subclavian impossible, removal of the limb being additionally called for if agonising pain or threatening gangrene be present. Prof. Syme 3 briefly alludes to two such successful cases, in one of which gangrete was threatening : " In a case of axillary aneurysm in a gentleman of about 52 yeais of age, where ligature was prevented by intense inflammation of the arm, rapidly 1 In some of these the adoption of the Fumeaux Jordan method (p. 191) might lead to diminished loss of blood. 2 3Ied. Chir. Trans., vol. lii., p. 306. 3 Ibid., vol. xliii, p. 139. SURGERY I 13* 198 OPERATIONS ON THE UPPER EXTREMITY running on to gangrene, I performed amputation at the shoulder- joint, cutting through the sloughy sides of the aneurysm and tying the artery where it lay within the sac." C. In some cases of inflamed axillary aneuri/sm threatening suppuration. Sir J. E. Erichsen ^ pointed out that the question of this amputation may arise. As the old ojjeration of opening the sac, turning out the clots, and securing the vessel above and below is impossible, owing to the fact that the coats of the vessel, now softened, will not hold a ligature, two course only are open to the surgeon — viz. ligature of the third part of the subclavian, or amputation at the shoulder-joint. While the former may be followed when the aneurysm is moderate in size and when there is no evidence of threatening gangrene, amputation must be resorted to when less favourable conditions are present. If haemorrhage occur from an inflamed axillary aneurysm which has ruptured after the subclavian has been already tied, the same writer, of the two courses open — viz. either to open the sac and try and include the bleeding spot between two ligatures, or to amputate at the shoulder-joint — strongly advises the latter. D. In the words of Sir J. E. Erichsen, ^ " there is another form of axillary aneurysm that requires immediate amputation at the shoulder-joint, whether the subclavian artery have previously been ligatured ot not ; it is the case of diffuse aneurysm of the armpit, with threatened or actual gangrene of the limb. Different methods. Of some thirty-six methods which have been described, most will be found to differ in some unimportant detail. Five alone will be given here ; they will be found amply sufficient, if modified when needful, for all cases ; and of these five, Spence's, for the reasons given below, is the best, and the one with which all operators should be familiar, The circumstances under which this operation is performed do not admit of any one definite method being followed. Thus, after a railway accident or gunshot injury, the soft parts will be destroyed on at least one surface. In amputating for malignant disease, skin flaps must be made use of, transfixion being usually inadmissible, as the muscles should be cut as short and as close as possible to their upper attachments, to minimise the risk of extension and recurrence. Instead of remembering the length and size of differently named flaps, the surgeon will have to be familiar with the anatomy of the parts, the position of the vessels, and the best means of meeting haemorrhage. The joint is so well covered that sufficient flaps^ can nearly always be provided, while the blood-supply is so abundant that sloughing very rarely occurs, and even if it does, the tissues of the chest will come forward sufficiently to close the wound. While the cavity of the axilla favours exit of discharges below, the abundance of cellular tissue opened up favours diffuse inflammation and calls for adequate drainage.^ The following methods will be described here : in the first two, skin flaps are made ; in the others (save in the Furneaux-Jordan method), transfixion is made use of, in part at least. In all cases of doubt, the conditions of the bone and, if needful, that of the vessels and nerves, should be first cleared up by a free incision as if for excision (Figs. 109 and 110, p. 215). (1) By lateral skin flaps. The oval or en raquette method. (2) Spence's method. (3) Superior and inferior flaps. 1 Surg., vol. ii, p. 217. ~ Loc. supra cit., p. 218. ^ In some cases of f;;unshot injury it is necessary to get the chief fl.ap from the axillary region, and to bring this up and unite it to the cut margin of the skin over the acromion. 4 Finally the tendency of the skin to retract when this has been much stretched, as over a large growth, should be remembered. AMPUTATION AT TlIK SIIOULDKH-.JOIXT 191) (4) Superior or deltoid flaps. (5) Anterior and posterior flaps. (()) Fiiriieaux-Jordaii ini^tliod. While the most rapid methods are those of superior and inl'eiior (Figs. 106 and 107), or anterior and posterior flaps, in each case cut by transfixion, these re(]uire the presence of an assistant who can be thoroughly relied upon to seize the artery just before it is cut. Fig. 97. Where there is time, and where the soft parts admit of it, one of the methods with a vertical incision — e.g. Spence's method, the en raquette, or that by lateral skin flaps — is far preferable, as (1) it allows of securing the artery before this is cut, thus dispensing with the preliminary pressure on the subclavian, in many cases a difficult procedure, or the seizing of the artery in the flap ; (2) of exploring the condition of the head of the bone ; (3) one flap can be cut longer, according to the state of the soft parts. Means of arresting haemorrhage in amputation at the shoulder- joint. Any of the following may be employed. The first two are by far the best. (1) Ligaturing or tivisting the vessels on the inner aspect of the limb before they are cut (Figs. 99 and 102). This method is an excellent one and suitable to all cases. The ligature should be placed as high as possible, so as to get above the circumflex arteries. The surgeon must be careful in the final use of the knife, high up in the axilla, not to prick the artery above his ligature. 200 OPERATIONS ON THE UPPER EXTREMITY (2) Compression hij an assistant of the inferior or anterior flap, and so of the vessels before they are cut (Figs. 106 and 107). (3) Pressure on the subclavian as it crosses the first rib. Pressure is, however, always liable to be inefficient in short, fat necks ; in thin patients, however well applied at first with the thumb aided by a Fig. 98. Disarticulation at the slioulder-joiut, the humerus being fractured high up. The operator with his left hand twists the humerus outwards, while, with his right, he divides the cajisule and insertion of the scapularis. (Farabeuf. ) padded key or weight, it is too often rendered uncertain by the necessary changes in position of the limb during the operation, a violent gush of blood at the last showing the surgeon that his confidence in the artery being secured is misplaced. Furthermore, an assistant so employed is necessarily much in the way. For the above reasons one of the first two methods is to be preferred. (4) Ligature of the subclavian artery. Circumstances may render this desirable as in a case of Mr. Howard Marsh's, in which he amputated at the shoulder- joint for an enormous " osteo-sarcoma " of the humerus. AMPUTATION AT THE SHOULDER-JOINT 201 (5) Ligature of the first fart of the axillary artery. This step, originally recommended by Delpech and more recently by Professor Keen, may be used in those cases where a growth has extended high up into the axilla. A free incision between the pectoralis and the deltoid will then trivc free access to the apex of the axilla, and enable the extent of the (Trowth to be determined. (G) Wi/eth\s method by pins and elastic tuhing. This method will be described" in the section dealing with amputation through the hip-joint. Fig. 99. Amputation at the shoulder-joint by lateral flaps. These are turned aside, while the axillary artery is secured by torsion before disarticulation is completed. It is not recommended, for, unless the pins are inserted very exactly— not an easy matter in operations of emergency— the tubing may slip. (7) Securing the vessels lower down, in the Furneaux- Jordan method {see p. 209). (8) Use of an india-ruhber band. This is applied in the same way as that fully described in " Amputation at the Hip-joint." _ It is not a reliable method, especially in those cases of accident in which, the limb being mutilated high up, this operation is largely required. For in these the band, being applied under the axilla and across the body, 202 OPERATIONS ON THE UPPER EXTREMITY slips up as soon as the head is disarticulated, allowing of bleeding from the vessels, and coming, itself, most inconveniently, and as a possible source of infection, into the way of the operator. (1) Lateral flaps. The patient having been propped up sufficiently, brought to the edge of the table, and rolled over to the opposite side, the surgeon, standing outside the abducted limb on the right side, and inside it on the left; and ha\ang marked out with his left forefinger and thumb a point just below and outside the coracoid process and a corresponding point behind (Fig. 97), then reaches over and, entering Fig. 100. Amputation at the shoulder-joint by the en ruquelte method. the knife in the axilla, close to the thumb, cuts an oval flap, about four inches long, consisting of skin and fascia from the side farthest from him. and ending close to his finorer. Without removing the knife the surgeon next marks out a similar flap on the other side, cutting from above downwards, commencing just below the finger, and ending where the first flap began in the mid-axilla. The assistant in charge of the limb aids the above by rotating the arm into convenient positions. The flaps are then dissected up and held out of the way. The vessels are next exposed, separated from the surrounding nerves, and secured, either by applying two pairs of Spencer- Wells forceps, di^^ding the vessel between them and twisting both ends, or by passing an aneurysm needle, threaded ^vith catgut, under the artery, and thus securing it with two ligatures. The limb being then carried across the chest, the outer part of the capsule is freely opened by cutting on the head of the AMPUTATION AT TIIK SIIOULDKR-JOINT 208 bone, and the muscles attached to the outer tuberosity thoroughly severed. The limb is next rotated outwards, and the subscapularis tendon severed ; the biceps tendon being cut and the capsule freely divided the joint is well opened on the iinier side. The head being then dislocated,' by an assistant pressing the elbow forwards and against the side, the knife is passed from the outer side behind the dislocated head, and, being kept close to the inner side of the bone, is brought out through the structures on the inner aspect of the arm, care being taken, as the knife cuts its way out that it does so below the point where the large vessels have been secured. In tliis or any other amputation here for tul)crcnlous or malignant disease, it will he needful to senitinise earefully the eonditioii of the i)aits left, to di.ssect out any glands, whether enlarged or not, together with the synovial membrane, and in some cases, to remove the glenoid cavity with bone forceps, or preferably a fine sharp saw. (2) Method en raquette with preliminary exploration (Farabeuf) (Figs. 1()0-103). In this modification the point of the knife having been sunk just below and in front of the tip of the acromion, an incision is made downwards, sufficiently long and deep to admit of exposing the head of the humerus. The condition of the bone is then explored : If amputation is decided on, the above is converted into one ew raquette by making an oblique incision which passes from about the centre of the longitudinal one (Figs. 100 and 101) across the inner or the outer aspect of the limb (according as it is right or left), and the ends behind on a level with the lower extremity of the longitudinal one. A second exactly symmetrical to the first is next made over the opposite aspect of the limb, be- ginning where the first ended, and terminating in the longi- tudinal incision opposite to the •first (Fig. 101). The next step is the exposure of the artery by division of the muscles. In the curved inner incision (Fig. 102 are seen the anterior fibres of the deltoid almost blended with the insertion of the great pectoral. This is raised with the finger, and the insertion of the great pectoral detached from the bone. If now the inner flap be folded inw^ards, the coraco-bicipital fasciculus comes into view. The aponeurosis over it being ^ In any case where the leverage of the humerus is wanting owing to this bone having been broken higher up, the use of lion-forceps will facilitate disarticulation. Fig. 101. Amputation at the right shoulder- joint by the en raquette method. 204 OPERATIONS ON THE UPPER EXTREMITY opened by a free longitudinal incision, the muscular fasciculus is drawn over the front of the humerus and cut across. If an assistant now thoroughly retract the inner flap the axillary vessels and nerves are ex- posed. The artery should be isolated and tied as high up as possible, so as to get above the posterior circumflex. The knife being again inserted into the outer oblique incision, the deltoid is boldly cut through as far as the back of the axilla. An assistant retracts the outer and inner flaps, while the surgeon opens the capsule freely, the limb being rotated as directed {see p. 203). The head is next thrown out of the socket, Fig. 102. The anterior fibres of the deltoid, the insertion of the pectoralis major, and tlie coraco-brachialis and biceps have been cut. The left hand of the operator draws the large nerves downwards, and thus exposes the axillary artery for ligature. (Farabeuf.) and the knife is carried behind the head, skirting the posterior- internal aspect of the humerus very closely, so as not to cut the secured artery, and finally brought out through the incision on the inner side, severing the latissimus dorsi and teres major. If the artery has not been tied, an assistant secures it between his thumb, sunk deeply into the wound, and his fingers, which are in the axilla, or by using both hands. (3) Spence's method (Fig. 104). This excellent method is strongly recommended on account of its simplicity, and the ease with which the vessels may be secured. It is further especially suited to cases of failed excision,^ or to cases of injury, e.g. gunshot, where the surgeon has to cut into and explore the condition of the joint before deciding on excision or amputation. By its means an excision can readily be ^ At the present da/, in cases of failed excision, the surgeon will often prefer to make use of the modification of the Furneaux- Jordan method (p. 209}. AMPUTATION AT THE SIIOULDER-JOINT 'JO 5 converted into a disarticulation, if this step be found needful. It has other advantages, but less important ones : (1) The posteiior circumflex artery is not divided, except in its small terminal branches in front, whereas, both in the large deltoid flap and the double flap methods, the trunk of the vessel is divided in the earlv steps of the operation and, retracting, often gives rise to embarrassing haemorrhage. (2) The great ease with which disarticulation can be accomplished. Kg. 103. Jr'arts composing the flaps made in the en raqnette method. (3) The better shape of the stump. Professor Spence pointed out that, however excellent are the results soon after other methods, later on, the shape of the stump is much altered, not merely from the atrophy common to all stumps, but from retraction of the muscular elements of the flaps, the pectoralis major retracting towards the sternum, and the latissimus dorsi and teres major towards the spine and scapula. Thus a deep, ugly hollow results under the acromion. Fig. 105 shows an instance of this, in a case of amputation of both limbs in a young subject. E. D., age 10, was admitted under Mr. Jacobson's care in Guy's Hospital for a terrible crush of both upper extremities, from his having been run over by a timber-waggon. Amputation was performed at once through the left shoulder- joint by superior and inferior flaps. An attempt was made to save the right limb, but 206 OPERATIONS ON THE UPPER EXTREMITY Fig. 104. Amputation at the shoulder-joint by Spence's method. (Stimson.) owing to gangrene setting in, amputation became necessary, and was performed high up through the humerus by 3Ir. G. A. Wright. The resulting projection of the left acromion from wasting of the muscles was well shown when, nine years later, he was again admitted for a conical and tender stump on the right side, due here to the unbalanced growth of the upper epiphysis. The writing below the figure was done by the lad with his teeth. (4) Professor Kocher ^ points out that the longi- tudinal incision in this method has the advantage of being situated in the interval between two muscular groups supplied by different nerves and that muscular atrophy is thus avoided. The operation is thus described in Professor Spence's words : ^ " Supposing the right arm to be the subject of amputation. The arm being slightly abducted, and the head of the humerus rotated outwards if possible, with a broad strong knife I begin by cutting down upon the head of the humerus, immediately external to the coracoid pro- cess, and carry the incision down, through the cla\^cular fibres of the deltoid and pectoralis major, till I reach the humeral attachment of the latter muscle, which I di\dde. I then, with a gentle curve, carry the incision across and fairly through the lower fibres of the deltoid towards the pos- terior border of the axilla, unless the textures be much torn. I next mark out the line of the lower part of the inner section by carrying an incision through the skin and fat only, from the point where my straight incision terminated, across the inside of the arm. to meet the incision at the outer part. This ensures accuracy in the line of union, but is not essential. If the fibres of the deltoid have been thoroughly divided in the line of incision, the flap so marked out can be easily sepa- rated (by the point of the finger, without further use of the knife) from the bone and joint, together with the trunk of the pos- terior circumflex, which enters its deep surface, and is drawn upwards and backwards, so as to expose the head and tuberosities. The tendinous insertions of the capsular muscles, the long head of the biceps, and the capsule are next divided by cutting directly on the tuberosities and head of the bone, and the broad scapular tendon es- pecially, being very fully exposed by the incision, can be much more easily and completely divided than in the double flap method. By keeping the large outer flap out of the way by a broad copper spatula or the finger of an assistant, and taking care to keep the edge of the knife close to the bone, as in excision, the trunk of the posterior circumflex is protected. Disarticulation is ^ Operative Surg., p. 37G. 2 Lancet, 1867, vol. i, p. 143 ; and Lee. on Surg., vol. ii, p. 662. Fig. 105. AMPUTATION AT THE STTOri.DKR-.TOINT 207 Fig. 106. then accomplislied, and the limb removed by dividing the remaining soft parts on the axilhiiy as])ect. The only vessel which bleeds is the anterior circumflex divided in the first incision, and here, if necessary, a pair of catch-forceps can be placed on it at once. In regard to the axillary vessels, they can either be com- pressed by an assistant before completing the division of the soft parts on the axillary aspect or, as I often do in cases where it is wished to avoid all risk, by a few touches of the knife, the vessel can be exposed, and then tied and divided between the two ligatures, so as to allow it to retract before dividing the other structures." ^ (4) Amputation by superior and inJerior flaps. (Figs. lOG and 107.) The patient having been brought to the edge of the table, turned sufficiently over, and his shoulders supported by pillows the assist- ants are arranged as before. The arm being a little raised so as to relax the deltoid, the surgeon standing inside the limb on the right side and outside it on the left, lifts the deltoid muscle with his left hand, and sends the knife (narrow, strong, and no longer than needful) across beneath the muscle. entering it on the right side, just below the cora- coid process, and bring- ing it out a little below the most prominent part of the acromion ^ or vice versa, according to the side operated upon. The knife should pass close to the anatomical neck of the humerus, without hitching upon it, and the flap should be cut broadly rounded, and well down to the inser- tion of the deltoid. It is then raised and re- tracted and, the capsule being now exposed, the joint is opened by cutting strongly upon the head of the bone. The arm being now rotated vigorously outwards by an assistant or by the surgeon, the subscapularis, ^ \\Tiere the limb is very muscular, Prof. Spence recommended to raise the skin and fat from the deltoid at the lower part, and then to divide the muscular fibres higher up by a second incision, so as to avoid excess of muscular tissue. - Unless care is taken to keep thus below the acromion process there will be some tendency for this bone to protrude in the wound. Fig. 107. To show the manner in which bleeding is controlled in the inferior flap : the axillary vessels are compressed by one thumb, the posterior circumflex by the other. 208 OPERATIONS ON THE UPPER EXTREMITY thus made tense, and the biceps are brought into view and severed ; the limb is next rotated inwards, being carried across the chest, and the muscles attached to the great tuberosity are divided. The capsule is then still more freely opened, and the head of the bone, now freed, is pushed up by the assistant and pulled outwards from the glenoid cavity. The knife is next slipped behind the head (Fig. 106), and cuts its way along the under aspect of the neck and shaft of the humerus, so as to shape an inferior flap half the length of the upper one.^ As soon as the knife is passed behind the bone, an assistant slips his hands in behind the back of the knife (Fig. 106), following it so as to grasp firmly the soft parts in the inferior flap, and thus con- trol the axillary vessels (Fig. 107). The large vessels are next secured, then the circumflex, and muscular branches that require it ; any large nerves that need trimming are then cut short, drainage, if necessary, proxdded, and the flaps brought into position. This amputation has the advantage of being very quickly done, and of giving a flap which keeps in position by its own weight, and thus gives good drainage. If the soft parts below the humerus are much damaged, the upper flap nmst be cut proportionately long. (5) Amputation by deltoid or upper flap. This is merely a modification of the last. The deltoid or upper flap may be cut by transfixion, or made by cutting from with- out inwards. In either case it must be of very full size, and thus is useful when the axilla is damaged, but it has the disad- vantage of leaving next to no flap in which an assistant can seize the axillary vessels ; and, owing to the powerful retraction of the muscles in the axillary folds, unless the upper flap is cut full in length and size, it will not cover the resulting wound. Finally, as the trunk of the posterior circumflex is cut, sloughing of the large deltoid flap may take place, especially if the tissues composing it are at all damaged previous to the amputation. Owing to these disadvantages which outweigh its rapidity, this method is not to be recommended, a short under-flap being always cut if possible. When the surgeon, having disarticulated, is cutting straight down, unable to make any flap below, an assistant should try to draw up the skin of the axilla, otherwise, owing to the laxity of the skin in this situation, any downward traction will bring the skin of the thoracic wall under the knife. (6) Amputation by anterior and posterior flaps. This is only indicated when the soft parts on the front and the inner aspects are damaged. The position of the patient being as advised at p. 307, and the hmb being ^ The surgeon should not cut this till he is told that the flap is held firmly ; and, in cutting it, he must be careful of his assistant's fingers. Fig. 108. Amputation by deltoid flap. EXCISION OF THE SHOULDER- JOINT 200 carried somewhat upwards, backwards, and outwards, the surgeon, standing, if'ou the left side, behind and outside the shoulder, enters his knife just in front of ,the posterior fold of the axilla, thrusts it across the back of the humerus as near the head as possible, so as to get in front of the tendons of the teres major and latissimus dorsi, and bringing it out close to the acromion, cuts with a sawing movement, a flap four to live inches long.^ which is next well retracted. The arm being then carried across the chest, the joint is freely opened behind, the muscles attached to the tuberosities severed, the knife passed between the head and the glenoid cavity (to facilitate this, the limb should now be carried over the chest, and the head of the bone pushed backwards), then between the bone and the pectoraUs major, and an anterior flap.- four inches long, cut from within outwards. Hiemorrhage from the large vessels is arrested either by an assistant grasping this flap as it is cut, much as at p. 207, Fig. 107, or by the surgeon isolating the axillary vessels (the biceps and coraco-brachialis will guide him), and securing them by torsion or ligature (p. 204) before he completes the operation by cutting the anterior flap. When operating on the right limb, the patient being tvirned well over on to his left side, the surgeon, standing here inside the arm, which is held upwards and backwards so as to relax the deltoid, lifts this muscle up with his left hand, and then passes his knife from just below the acromion, transfixing the base of the deltoid, grazing the back of the humerus, and Anally thrusts the point dowaiwards and backwards through the skin till it comes out at the posterior margin of the axilla. This flap, four or five inches long, should be dissected up, the joint opened behind, and the operation completed as before. (7) Furneaux-Jordan method/^ This may be made use of both as a primary and a secondary amputation. The following are suitable cases : (a) Certain cases of injury. Where, though the parts about the shoulder- joints are intact, the humerus is badly split up into the joint. The soft parts are divided down to the bone by the circular method, three to four inches below the axilla, the main vessels secured, and the humerus then shelled out by a longitudinal incision along the outer and posterior aspect of the limb, meeting the circular one at a right angle. (b) In cases of failed excision. Here, after amputation of the limb by the circular method, the rest of the bone is turned out through the excision wound prolonged into the circular one. (c) After amputation in the middle of the arm in some cases. E.g., when the stump is the seat of osteo-myelitis, necrosis, or otherwise does not do well. EXCISION OF THE SHOULDER-JOINT (Figs. 109-115) This operation is but rarely performed: (1) Owing to the com- parative infrequency of disease of the above joint, especially of tuber- culous disease, which requires operative measures ; (2) from the fact that epiphysitis and infective syno\itis usually give, after free incision and drainage, as good a result as can be obtained after excision. This is mainly owing to the fact that much of the stiffness that otherwise would be present is made up for by the supplementary mobiUty of the scapula, especially in young subjects. Generally speaking, the objects of the operation will be for the removal of a tuberculous focus, to improve the mobility of the joint, or in some cases for the relief of pain. The above remarks lead up to the consideration of the amount of movement which is gained after the operation of excision. The arm cannot usually be abducted and elevated beyond the horizontal line ; too often it lies close to the chest. Even if the deltoid retained its power of elevation, it could not often exert it, as in most operations, owing to the amount 1 In the posterior flap wiU be the posterior part of the deltoid, the latissimus dorsi, and teres major. • In this anterior flap will be the remaining fibres of the deltoid, the pectoralis major, and the large vessels and nerves. 3 For the details of this method see " Amputation at the Hip-joint." SURGERY I 14 210 OPERATIONS ON THE UPPER EXTREMITY of bone removed, the fulcrum of the head of the humerus against the glenoid cavity has gone. Sir J. E. Erichsen^ spoke of the four chief movements of the shoulder- joint, \\z. '■' (1) abduction and elevation, (2) adduction, (3) and (4) move- ments in the anterior-posterior direction — these are requisite in all ordinary trades for the guidance of the hand in most of the common occupations of Ufe. The movements of elevation are seldom required save by those who follow climbing occupations, as sailors, masons, &c. Now, the mode of performing the operation, as well as the operation itself, will materially influence these different movements. Thus, if the deltoid be cut completely across, the power of abduction of the arm and of its elevation will be permanently lost. If its fibres be merely split by a longitudinal incision, they may be regained in great part.^ " All those movements of rotation, &c., which are dependent on the action of the muscles that are inserted into the tuberosities of the humerus will be permanently lost ; for, in all cases of caries of the head of the humerus requiring excision, the surgeon will find it necessary to saw through the bone below the tuberosities^n its surgical, and not its anatomical, neck.^ Hence the connections of the supra-spinatus and infra-spinatus, the teres minor, and subscapularis will all be separated, and their action on the bone afterwards lost. But those muscles which adduct, and which give the anterior-posterior movements — \\z. the coraco-brachialis, the biceps, the pectorahs major, latissimus dorsi, and teres major — will all be preserved in their integrity ; and hence it is that the arm, after this excision, is capable of guiding the hand in so great a variety of useful underhanded movements." Dr. Scudder in a paper on excision of the shoulder-joint,* has collected the late results after this ojieration in nineteen cases, fifteen for injurv' and foiu' for tuberculous disease. " Following the excision of the ujaper end of the humerus there will be limited power in the shoulder ; a distinct diminution in strength ; muscular atrophy; possibly the formation of plaques of new bone about the old joint from detached periosteum. These pieces of new bone may seriously impair the motion. Deformity and pain may follow an excision of the shoulder-joint. . . . After injmy the result following an operative reposition or reduction is better always than the result of an excision." Indications. (1) Different forms of arthritis disorganizing the joint, resisting careful treatment, in subjects whose age, general condition, &c., are satisfactory, viz. (a) Tuberculous disease, resisting other treatment and, as in aU excisions the stages of advanced caseation, sinuses and mixed infection should be ante-dated. Another reason for early excision here is given by Watson Cheyne and Burghard : ° " Shoulder- joint disease is very frequently associated with or followed by disease of the lungs ; the exact connection of the two is difficult to understand, ^ Surgery, yoI. ii, p. 2.51. 2 Prof. Longmore (Resection of the Shoulder-Joint in Military Surgery, p. 12) writes: " The loss of the elevating power of the deltoid must be accepted, like the loss of the rotating power from the division of the muscular insertions into the two tuberosities, as a necessary consequence of resection of the head of the humerus. But the supporting power of this muscle exerted upon the whole upper extremity owing to its position, its extensive origin, and the manner in which it embraces and protects the mutilated parts, as well as its faculty of assisting in carrying the arm backwards and forwards, are all functions which may still remain, and serve to point to the great importance of preserving its integrity as fully as possible." 3 This opinion apjjears to be too definite and inelastic. The reader is referred to the remarks below on the site of section of the bone, and on subperiosteal resection (220). 4 Ann. of Surg., vol. xlix, p. 696. 6 Man. of Surg. Treat., vol. iii, p. 237- EXCISION OF THE SHOULDER- JOINT 211 but it is certainly a clinical fact that a large number of patients suffering from this affection suffer also from phthisis and, in a very- considerable proportion, the latter affection only occurs after the joint disease has lasted for some time." (6) Disorganization of the joint after rheumatic fever, gonorrhoial arthritis, wrenches, &c., resulting in crippling ankylosis, in a young subject, (c) Epiphysitis, or infective arthritis where the long continued suppuration is exhausting the patient, and the outlook as to natural cure is not good. (2) Gunshot injuries, where the large vessels and nerves have escaped, where fragments of shell bullets, &c., are lodged in the head of the bone, especially if the shaft of the bone is not much damaged {see p. 223). (3) Compound dislocation and compound fracture with much damage to the capsule and cartilage of the head of the bone, the larger vessels and nerves being intact. In some such cases primary excision is indi- cated. Generally replacement should be effected after careful cleansing of the damaged parts. Secondary incision may be required for suppuration or necrosis. (4) Some cases of ankylosis, e.g. after acute rheumatic or traumatic arthritis and suppuration. Here the question of operative interference will mainly turn on how far the additional movements of the scapula and humerus together have made up for the ankylosis, and the degree of atrophy of the muscles. Dr. E. Souchon, of New Orleans, has dealt with this subject. "^ He considers that operation is only justifiable in recent cases in full-grown sub- jects or in patients of sufficient age to ensure that the removal of the head of the humerus will not be followed by too great shortening. It is especially indicated in ankylosis following arthritis with a rapid course (dry, acute arthritis), observed sometimes in subjects affected with acute rheumatism, and especially bleimorrhagic arthritis ; also in cases consecutive to suppurating traumatic artlnitis. In these cases the ankylosis occiu's before the atrophy of the muscles. The cases of ankylosis which should not be operated upon are — (1 ) those with a fairly useful limb as it stands, unless there is positive assmance of improving the movements, especially those that are particularly needed for the patient's work ; (2) where atrophy of the muscles is present. The application of electricity and massage may be required for some time before it is decided that the operation will be useless. Operation is contra-indicated, especially when the muscles are irretrievably degenerated, as is the case in a great number of old ankyloses, and particularly those following long articular suppuration. (5) In some cases of unreduced dislocation of the head of the humerus.^ In such a case there will be serious loss of power and movement, and not infrequently, especially in sub-coracoid dislocations, severe s}Tnptoms of pressure on the axillary vessels or the nerves of the brachial plexus. In such a case, if of only a few weeks' duration, an attempt may be made to effect reduction by manipulation or by traction under an anaesthetic ; the greatest care must be taken, or the axillary vessels may be injured. If this does not succeed, an open operation should be carried out and every effort be made to replace the bone by leverage and by di\dding any structures which hinder reduction. Should this fail excision of the head of the humerus is indicated. While this operation is one of recent date in England, credit should bo given to those surgeons who have practised it, years ago, elsewhere. Cases will be found recorded by Post, of New York, 18G1 ; by Warren, of Baltimore, in 1869. In Germany, Langenbeck, Volkmann, Cramer, Kuster, Kronlein, and others operated for recurrent dislocation and ^ Trans. Amer. Surg. Assoc, 1896, p. 409. 2 Reference may be made to a paper by Dr. A. F. Jonas on " Old Irreducible Dis- locations of the Shoulder " ( Ann. of Svrg., 1910, vol. li, p. 890). 212 OPERATIONS ON THE UPPER EXTREMITY old dislocation of the humerus. M. Leon Tripier published a successful case of resection of the head of the humerus, which, fractured as well as dislocated, was pressing on the brachial artery and threatening gangrene. A full bibhography is appended to Dr. Souchon's Article, the best on this subject (vide infra, p. 213). Mr. Sheild brought before the Medico-Chirurgical Society^ a man, Coracoid process. Edge of divided tendon of insertion of pectoralis major. Cephalic vein. Long head r of biceps Fig. 109. Field of operation in habitual dislocation of the shoulder. (Burrdl.) aged 45, on whom he had performed excision for a neglected sub-coracoid dislocation of twelve weeks' standing. Owing to pressure on the median and ulnar nerves, the hand was almost useless. Moderate attempts at reduction having failed, the head was removed through the anatomical neck, this site being chosen in order to disturb the parts as little as need be. The end of the bone was made as like the real head as possible by careful rounding. Twelve weeks afterwards the patient was able to resume work as a waiter. The movements of the shoulder were satisfactory, and the hand gradually regained strength. Lord Lister published - two similar cases treated by operation, but somewhat differently. 1 Trans., vol. Ixxi, 1888, p. 173. ^ Brit. Med. Journ., 1890, vol. 1, p. 1. EXCISION OF THE SIIOULDEU-JOINT 2i;3 Mr. Peai'ce Gould and Sir W. Watson Cheyne showed cases at the Medical Society.^ Reduction was in each case effoctcd after divi.sion of the muscles. In on^ case tlie range of movement was somewhat defective, and there was a tendency for the head of the humerus to sHp forward. Jiut liere four months had elapsed between this dislocation and the re(hu'tioi\ ; it was needful in this case to clear out the glenoid cavity, and the patient failed to attend subsequently. Mr. Thorburn ^ excised the head of the humerus through the surgical neck, in a case diagnosed as subclavicular dislocation and fractiu'c with irregular formation of callus. He points out that division of tendons would here have been insuificient, as such a deformed head, if even thus reduced, would not have iittcd into the glenoid cavity. Mr. F. C. Wallis published ^ a case in which an instructive condition was found at the operation. The jiatient had had a dislocation of the shoulder reduced three weeks after the accident. The joint was ankylosed. The muscles of the arm were wasted and paralyt-ed, the movements of the elbow and wrist-joint very limited and the fingers quite stit?. The limb was the seat of neuralgic pains. When the head of the humerus was excised, the cords of the brachial plexus were adherent to the imier side of the bone and required detachment. Massage was begun early. The patient lost all her pain, regained good movements of the shoulder-joint, and could again dress and feed herself. The fingers, remaining stiff, still requu'cd her attention. The most complete contribution on this subject is a paper by Dr. E. Souchon, of New Orleans, " Operative Treatment of Irreducible Dis- locations of the Shoulder-Joint, Recent or Old, Simple or Complicated."^ This elaborate study, based on 154 cases of operation, abounds with those details which are so valuable to surgeons who may have to deal with these occasional but most difficult cases. The following are the chief conclusions of Dr. Souchon : " The anterior incision is the route. Reduction of the dislocation is the more desirable operation, because it preserves the head and all the movements depending thereon. Reduction should be done only in cases where the head and glenoid cavity are in good condition : when no extensive dissections have to be made ; when it is easily effected without any great effort ; when the head does not need to be trimmed, or the cup to be too deeply scooped or enlarged ; when the head readily remains in place, but not too tightly. All this, regardless of the time of standing of the dislocation. It should, however, always be attempted coiLscientiously, because many have resected, perhaps, when the dislocation could have been reduced.* Disregard of these rules may lead to necrosis of the head, recurrence of the dislocation, or in ankylosis, with their inevitable consequences. Resection shoul I be practised in all other cases. When in doubt, it is preferable to resect. Ho v much to resect — i.e. when to saw through the anatomical neck or obliquely and down- ward outside the tuberosity, or horizontally on a level with the lower margin of the head — must be determined in each case ; it is better to remove too much than too little. Of course, all efforts should be made to secure aseptic results. A most important point is to get primary union." The folloiving are the chief obstacles to reduction. (1) The capsule may be replaced by a thick fibrous mass. (2) Adhesions of the capsule to the glenoid cavity. (3) Such complete healing of the rent in the capsule as to prevent reduction. (4) Strong adhesions between the new cavity and the neck or head of the humerus. Such bands may be adherent to the vessels and nerves {see p. 212). (5) Sclerosis of the muscles, rendering their section necessary. (6) Alteration in the shape of the head of the humerus. Usually several of the above causes combine 1 Lancet, 1892, p. 474. 2 Med. Chron., vol. xiv, p. 8. 3 Clin. Soc. Trans., vol. xxxi, p. 291. * Trans. Amer. Surg. Assoc, 1897, p. 311. ^ In young subjects reduction should always be preferred to resection, and if the latter is employed the epiphysial cartilage should not be injured if possible. 214 OPERATIONS OX THE UPPER EXTREMITY to interfere with reduction or resection. Dr. Souchon shows that amongst the difficulties and complications which may be expected during the operation the chief are : A very thickened capsule or much fibrous tissue about the head of the humerus, necessitating a tedious dissection, with persistent oozing. The head may lie very deep and be adherent to the adjacent parts, e.g. the ribs, and the deeper the position the greater the risk of serious haemorrhage. When thus firmly fixed, the head may be prised into its natural position by elevators, scoops, or blunt scissors, and this failing, division of the bone may be needful, the head being then lifted out by the above-mentioned instru- ments or loosened with lion-forceps. In other cases it may be wiser to remove it piecemeal. The glenoid cavity may be so filled up as to need refashioning.^ The vessels and nerves may lie across the head of the bone. In the manipulations needful to get the head into place, the neck of the humerus may give way. (6) In some cases where dislocation of the head of the humerus is associated with fracture of the upper extremity of the bone, especially through the anatomical neck. In these cases reduction of the dis- location by such an incision as that described at p. 215, combined with wiring or plating of the fracture will be preferable to resection of the fractured head. Occasionally the head is completely separated, or it may become detached during manipulation ; under these circumstances it should be removed. Resection may also be called for as a secondary operation if union fails and the joint is stifi. The small size of the upper fragment may render its manipulation a matter of difficulty. To overcome this the upper fragment may be grasped by Peter's bone- forceps or McBurney's traction hook may be employed. (7) A few cases of growth {e.g. exostosis, chondroma, myxochondroma, myeloid growths, and ossifying sarcoma) connected ^vith the upper extremity of the humerus. Whilst the priceless value of the hand fully justifies the attempt in some instances, such cases must be extremely rare. A well -reported case is one in which the late Sir W. Mitchell Banks 2 endea- voured to save the upper extremity of a patient by excising the upper end of the humerus, the site of a sarcomatous growth originally regarded as a chondroma. After removal in 1878, the growth recurred, and in three years had attained a very large size, filling up the axilla and extending beneath the pectorals. An attempt was made to excise the upper half of the humerus, but owing to the involvement of the brachial vessels and nerves this had to be abandoned and the limb was amputated at the shoulder-joint. Though the shock was severe, the patient recovered and was aUve and well two years after the operation. Mr. Southam ^ has recorded a successful case of resection of the upper end of the right humerus for an endosteal (mixed-ceU) sarcoma : A large deltoid flap was made, and the head and four inches of the shaft of the humerus removed. Six months later, the patient, aged 30, covdd raise her hand to her mouth, and employ her arm for household work and in using a small sewing machine. Though, with the arm hanging by the side, there was an interval of about four inches between the acromion and upper end of the humerus, the distance could be considerably diminished by the action of the biceps and triceps, and coraco- brachialis. A good illustration accompanies this instructive case ^ If both the glenoid cavity is refashioned and the head of the humerus resected, and the two are then placed in contact, ankylosis is likely to follow. 2 Clinical Notes upon Two Years' Work in the Liverpool Royal Infirmary, p. 6. 3 Med. Chron., Jan. 1887, p. 291. EXCISION OF THE SHOULDER JOINT 215 M. Oilier ^ mentions a most interesting case in which, by early inter- vention, resection of the upper half of the humerus for a sarcoma, central and subperiosteal, saved both the life and the limb of a child, 6\ years old. The growth made its first appearance as a filbert-like swelling close to the insertion of the deltoid. As the swelling increased slowly and resisted treatment, it was explored by M. Heurtaux. The sarcomatous nature of the swelling having been made clear, the upper half of the humerus was removed, this step being thought safer, though the joint itself was not involved. No en- larged glands could be felt in the axilla. Three years later the condition, locally and generally, was excellent. There was no reproduction of the part re- moved. The resected end terminated in a small osteophytic prolongation joined to the scapula by a fibrous band. The humerus was thus unable to find any steadying point so essential for its movements. The limb was therefore a flail, but a very useful one, thanks to the mobility of the elbow and fingers, and to a supporting apparatus. Methods. ( 1 ) By an anterior incision (Figs. 110-113). (2) By a posterior inci- sion, straight or curved. (3) By a del- toid flap. The first two only will be referred to at any length here. The third interferes so seriously with the after-power of the deltoid that the indications for its use must be of the rarest. ( 1 ) By anterior incision. The patient being rolled a little over and the humerus abducted from the trunk to an angle of 60 or 80 degrees, according to the mobility of the joint, the surgeon, standing at the shoulder facing the body, with an assistant opposite to him, and another seated to manipulate the limb, makes an incision three and a half inches long, commencing at the base of the coracoid process and on a level with it through skin and fasci?e ; the interval between the deltoid and great pectoral ^ is then looked for, and opened up for the same length, 1 Loc. supra cit., t. ii, p. 57. 2 The advantage of an anterior incision starting from just outside the coracoid instead of from the acromion is that the deep incision is made either in the inter-muscular space or through the anterior fibres of the deltoid. In the latter case all the posterior and outer part of the deltoid (so powerful in abduction) is left intact, together with the circumflex vessels and nerve, with the exception of the terminal filaments going to the anterior part of the muscle, which alone is inteifered with. M. Oilier (loc. supra cit.) prefers the incision through the anterior part of the deltoid, as owing to the varying width of this muscle the above inter-space does not always correspond to the coracoid process, and because the cephalic vein lies between the muscles. Where the soft parts are much swollen and where the arm cannot be abducted so as to bring the deltoid into rehef, the operator must take as his landmarks the position of the coracoid process and the junction of the upper and middle third of the shaft of^the^^humerus, and make his incisions carefully. If the incision in the muscular inter-space does not suflSciently expose the joint, a flap of Fig. 110. Anterior oblique incision for excision of the shoulder. 21 G OPERATIONS ON THE UPPER EXTREMITY retractors inserted and, if the arm has been rotated outwards, the bicipital groove will usually be seen lying at the bottom of the wound. ^ The condition of this important tendon will vary much: (I) It may be normal; (2) it may be surrounded with tuberculous material; (3) it may be frayed and adherent to the bone ; (4) it may be ulcerated or absent. The bicipital tendon having been identified, the capsule is opened by a free incision, the head examined with the finger, and the incision in the capsule next carried downwards along the bone just outside the bicipital groove to the level at which it is proposed to saw the bone. With a sharp-pointed, curved, periosteal elevator (Fig. 80) the three muscles attached to the greater tuberosity are now carefully detached Fig. 111. Separation of the periosteum from tlie great tuberosity,' the arm being turned inwards. (Farabeuf.) from it. The assistant in charge of the limb, by strenuous rotation inwards, brings each part of the tuberosity in contact with the elevator. The operator next turns his attention to the lesser tuberosity, the limb being now rotated outwards, and separates the attachment of the sub- scapularis. The left thumb, aided by retractors, protects the soft parts. The biceps tendon and its sheath, if healthy, are detached bodily with the soft parts and the periosteum on the inner aspect of the incision. If diseased the sheath must be opened, and the tuberculous material removed with curved scissors or a curette while the tendon is carefully held aside with a blunt hook or aneurysm-needle. In detaching the tendons, and also, later on, in sawing the bone, if this be done in situ, care must be taken, by keeping the arm somewhat separated from the body, and the elbow a little raised, to relax all the parts of the capsule. Unless this be done, the edges of the wound in the capsule are stretched tight, deltoid may be turned outwards from its insertion, if vigorous retraction of this muscle does not suffice. ^ Farabeuf advises, to ensure the bicipital groove being found easily, that the arm be kept midway between abduction and adduction, a position secured by placing the hand (the body being horizontal) on the anterior superior spine. KXCiSIOX OF TlIK SIIOrLDKH-JOINT 217 the finger is nipped, and there is no room for working with a saw, knife, or elevator. The bone may be divided in two ways: (1) In situ (Fig. 113). A blunt dissector is passed under the bone from within outwards, so as to protect the soft parts ; the bone is completely sawn through with a narrow- bladed or a Gigli's saw (Fig. 127), seized with lion- forceps and twisted out, the levering movements of an elevator, or a few touches with the knife, aiding this. The actual bone section {see p. 220) should be made so as to remove the worst of the disease ; usually Fig. 112. Separation of the poriosteum from the le.sser tuberosity, the arm being turned outwards. (Farabeuf.) it will pass through the tuberosities, any remaining mischief — e.g. in the tuberosities — being thoroughly dealt with by the gouge. (2) The head is first thrust out of the wound by an assistant, who pushes the elbow upwards and backwards and holds the humerus almost vertical, and then sawn off. This method is certainly the easier, but disturbs the soft parts more. The former is perfectly safe, and inflicts less damage on the surrounding tissues ; finally, where ankylosis is present, it may be most difficult to thrust the head out. Sir F. Treves, on the other hand, considered that this method is less precise, that it gives little opportunity of examining the parts fully, and that the tissues around may be damaged by the saw. Whichever plan is adopted, the soft parts should be scrupulously protected. The truncated end of the shaft should be carefully rounded off with a saw^ or cutting- forceps, especially in the neighbourhood of the nerves, and Mr. Sheild's plan of trying to reproduce the shape of the old head may be adopted. 218 OPERATIONS ON THE UPPER EXTREMITY (2) As tuberculous disease of this joint, which alone is likely to need access to every part, is not common, and as the anterior method by a free incision and the careful use of retractors allows of sufficient exposure of the parts operated upon, this method has hitherto been generally adopted. The excellent results obtainable by Professor Kocher's posterior curvedincision (Fig. 115) more than justify a trial of his method. Professor Koclier figures a patient who, after excision of the head of the humerus by the above method, was able to raise the arm vertically by the side of his head. The operation was here performed for fracture through the tuber- osities with rotation of the head of the humerus. The skin incision is carried from the acromio-clavicular joint over the top of the shoulder and along the upper border of the acromion to the outer part of the spine of the scapula, and from thence downwards in a curved direction towards the posterior fold of the axilla, ending two fingers'-breadth above it. The upper limb of the incision passes through the superior ligament right into the acromio-clavicular joint (the strong fibres of which are divided), and in the rest of its course divides the inser- tion of the trapezius along the upper border of the spine of the scapula. The descending limb of the incision divides the dense fascia at the posterior border of the deltoid, and exposes the fibres of the latter. The thrmab is now introduced beneath the smooth under-surface of the deltoid, so as to separate it from the deeper muscles (with which it is connected merely by loose cellular tissue) up to its origin from the acromion and its posterior fibres are divided. The finger is now carried along the upper border of the infra- spinatus muscle, so as to free it opposite the outer border of the spine and the root of the acromion. In a similar manner the supra-spinatus is detached with a blunt dissector from the upper border of the spine of the scapula, in order that the finger may be passed from above underneath the root of the acromion. The root of the acromion, which is now freed, is chiselled through obliquely and, along A^ith the deltoid, is forcibly pushed forwards with the thumbs over the head of the humerus. In chiselling through the bone care must be taken not to injure the supra-scapular nerve, which passes under the muscles from the supra-spinous into the infra-spinous fossa ', the nerve is also protected by the transverse ligament of the scapula. It is desirable before chiselling the bone to bore the holes required for the subsequent suture. Instead of dividing the root of Fig. 113. Excision of shoulder, bone. Section of the EXCISION OF THE SHOULDER-JOINT 210 the acromion, the formation of the posterior flap may be simplified by merely detaching the scapular origin of the deltoid subcortically ; this allows of a very firm union subsequently. After reflecting the acromio-deltoid flap, the head of thebone is readily accessible in its upper, outer, and posterior aspects, covered by the tendons of the external rotators, viz. the supra-spinatus, infra-spinatus, and teres minor muscles. The posterior surfaces of these muscles are also exposed. An incision is now made over the head of the bone and, in order to avoid unnecessary injury, this must be done accurately. The arm being rotated outwards, a longitudinal in- cision is carried down to the bone in the coronal plane. Commencing at the upper part of the lip of the bicipital groove, it extends upwards through the capsule along the an- terior edge of the insertions of the external rotator muscles and over the highest part of the head of the humerus, so as to expose the tendon of the biceps as far as its attach- ment to the upper edge of the glenoid ca\'ity. The insertions of the ex- ternal rotators are now separated from the greater tuberosity and drawn backwards. The biceps ten- don is freed from its groove and drawn forwards, so that its sheath mav be inspected. The whole pro- Fig. 114. The above represents a fair aver- cedure is made easier by carrying age amount of movement, such as may be . ,, , , - •'- 1 expected after incision in cmldren, in the elbow backwards, and at the whom the securing of adequate active and same time rotating the arm out- passive movement is always difficult. The wards. In this wav the entire head ^'^^^^^ ^\^ tubercular mischief in the . - . upper epiphvsis. Numerous sinuses were of the humerus and the glenoid fossa present "in front and in the axiUa. can be freely exposed and, if it is not necessary to do a complete excision, the anterior wall of the capside and the insertions of the anterior muscles can be preserved. •In other cases the insertion of the subscapularis into the lesser tuberosity is detached upwards and inwards. The circumflex vessels and nerve which come out from under the teres minor can be pre- served ; indeed, if the operation be properly performed, there need be no fear of injuring them. When the head has been thoroughly cleared, and especially if it be excised, an excellent view of the glenoid cavity is obtained, much better than is possible by the anterior incision ; and as it is most important to remove all infected tissues in tuberculous disease, this complete exposure of all parts of the joint is the great advantage of the method. Moreover, this free exposure is obtained without interfering with the function of the deltoid or other muscles of the shoulder. Yet another advantage over the anterior is, that when the disease in the head is limited or absent, only the posterior muscles require to be separated, while the anterior part of the capsule, the coraco-humeral band, and the subscapularis muscle are preserved intact, 220 OPERATIONS ON THE UPPER EXTREMITY and in this way there is no tendency of the head of the bone to be dis- placed upwards towards the coracoid, which so frequently occurs as the result of the anterior operation. The method is, therefore, especially valuable in partial arthrectomics. (3) The deltoid flap gives more room, and thus facilitates the opera- tion considerably, but the larger scar and, far greater, in fact almost total, impairment of deltoid power, are such serious drawbacks that it is, nowadays, hardly ever used. If the head of the humerus is very much shattered, if the soft parts are much matted and thickened, if there is any special reason for completing the opera- tion rapidly, in the rare cases of excision attempted for large growths, for the sake of more complete exposure, this method may, though very seldom, be made use of. Site of section of the bone (Fig. 113). It being most import- ant to leave the humerus as long as possible.not an atom more than is needful should be removed. The section should be made just below the articular surface in every case where this will remove the whole of the disease, and where all the head must go. The advantages of sawing here over division through the surgical neck are : (1) A long humerus is left to be brought against the glenoid cavity and aid, as a fulcrum, the action of the deltoid in elevating the arm. (2) The section is made within the capsule, after, of course, freely opening this, but not damaging its attachments to the neck of the bone. (3) The tendon in the bicipital groove is less likely to be- interfered with. In every case of excision, save the rare one for new growths, it is advisable to begin by removing as little as possible, then plugging the wound with sterilised gauze to test the freedom in abduc- tion, rotation, &c., of the humerus and only to resort to further removal of bone if mobility is much restricted. 'The late Mr. J. N. Davies-Colley has related^ a case of partial resection followed by unimpaired movement of the joint. As, at the time of the operation, a portion of the head of the humerus seemed healthy, and the disease consisted chiefly of a carious erosion of the great tuberosity and the adjacent portion of the articular surface, these portions only were removed, without dislocating the head of the bone. The part removed was chiefly the articular surface above the greater tuberosity, together with what remained of that process. The lesser tuberosity appears not to have been touched. About three- fifths of the articular surface was left, being healthy. There was some erosion of the ^ Guy's Hosp. Rep., third series, vol. xx, p. 525. Fig. 115. Kochcr's posterior incision for excision of the shoulder. EXCISION OF THE SIIOULUERJOINT 221 bone below the epi])hysial line, but the greater part of the disease was situated in the ei)iphysis. Tlie section of the bone was hard. Seven months hiter the move- ment of the joint '' was perfect in every direction. He swings the arm round above his head, and rotates it and performs every action with as great freedom and rapidity as with the left shoulder-joint." If the disease extends lower down, gouging may be resorted to or if needful one or two further sections may be made till healthy tissue is reached, but as in the case of the elbow, periosteal deposits or rouglionings, which will subside when the irritation is removed, must not be mistaken for disease which calls for extirpation. The glenoid cavity is then examined and gouged, or its cartilage peeled off with a blunt knife, if carious. Cases where its complete removal is called for must be most rare. If really called for, it may be effected by an osteotome, fine sharp saw, or cutting bone-forceps, after the glenoid insertion of the capsule has been peeled off to a suffi- ciently high level ; but taking away the glenoid cavity must interfere with attachments of the biceps and triceps, and cause risk by the opening up of additional cancellous tissue. The above operation must be somewhat modified in cases of ankylosis and new growths. In cases of bony ankylosis the operator may adopt one of the two following courses : he may divide with a chisel or gouge the line of fusion and then, the humerus being movable on the scapula, complete the operation on the lines already given ; or, having sawni through the humerus in situ, he may seize the bone with lion-forceps, or drill a hole and insert McBurney's hook, and strip it out of its periosteo- capsular covering. Much care must be taken to put the humerus freely through its different movements before it is decided that sufficient bone has been removed,^ lest ankylosis recur. In those rare cases of resection of the upper end of the humerus for new growths {see p. 214), the operation must be outside the periosteum, and the vessels and nerves will require additional attention. More room will be required now and, to gain this, the pectoralis major and deltoid may each be detached from the clavicle. The shoulder- joint itself is very rarely invaded by the growth. Owing to the free removal of the humerus, which is necessary, the after-result is often imperfect, though, if the insertion of the deltoid can be preserved, the limb will still be very useful. Any vessels w^hicli require it, e.g. branches of the circumflex arteries, are then secured, sinuses are laid open, tuberculous tissue, any remnants of diseased capsule and synovial membrane removed, and the sub- deltoid bursa, if involved, dissected out, drainage provided, and the upper part of the wound closed. The drainage-tube should pass from the lowest part of the wound in front (whether this be within or below the capsule), by means of a counter- puncture, to the back of the upper arm, so that the site of the operation may be well drained while the patient is recumbent. In making the counter-puncture, from within outwards, the close contiguity of the circumflex vessels and nerve must be remembered. 2 Where excision has been performed for tuberculous disease, w^th sinuses, iodoform emulsion, and small tampons of iodoform gauze, which ^ In young subjects the epiphysial cartilage must be left undamaged, if jDossible. 2 At least two cases of fatal injury to the circumflex artery have been recorded. One is given by Gurlt {Obs., 175, p. 750), the other by Prof. Annandale {Med. Times and G'az., May29, 1875). 222 OPERATIONS ON THE UPPER EXTREMITY has been kept in a solution of carbolic acid (1 in 20) or lysol (2 per cent.) will be employed. At other times, where the tissues are healthy, the above tampons will be much less needed, and the wound may be sutured in the upper part. In every case a triangular pad of sterilized gauze, three or four inches thick at its base, should be placed in the axilla, and the arm carefully secured to the side, the elbow being kept a Httle forward, and comfortably kept away from the thorax by a suffi- ciently thick layer of salicyhc wool. The first dressing should not be changed for five or six days if possible, especially in children. After the first dressing the limb should not be fastened to the side, the fore- arm only being supported in a sling. The tendency to displacement forwards must be met by a firm pad over the front of the joint. The axillary pad is of the greatest importance and should be worn for six weeks. Otherwise, a limb fixed to the side is almost certain. Where the parts are lax, as in old tuberculous disease, the necessary inter- ference with the bone, attachments of tendons, &c., has been extensive, less liberty must be given, or the new joint will be too loose. While the fingers and elbow- joint must be gently exercised daily from the very first, the date of commencing movements of the shoulder- joint will depend on the lesion for which the operation was performed, and the condition of the parts around. Where these are healthy, when but little bone has been removed, where it is probable that new bone will be quickly reproduced, the date must be an early one. As a general rule it is of no use to begin before the deep parts of the wound are sufficiently healed ; and this should be some time between the second and third weeks. The chief points to pay attention to are : (1) Care in carrying out abduction, lest the new head of the bone be lodged close to the coracoid process instead of in the glenoid cavity ; (2) massage and electricity to the muscles, especially the deltoid and the muscles attached to the tuberosities ; (3) exercise of the rotator muscles ; (4) making the patient carry out the movements of his humerus inde- pendently of those of the scapula — an end very difficult to ensure in the case of a child or in cases where the ankylosis has long existed. The above must be daily and assiduously carried out, with the occasional aid of an anaesthetic if needful. The practice of such movements as bringing a gun up to the shoulder, sweeping with a short brush, lifting and carrying light weights with the limb abducted, are valuable aids. Question of subperiosteal resection. As one of the chief draw- backs of the operation is the poor amount of abduction and elevation which remains owing, in large measure, to the humerus being too short to be brought into the glenoid cavity when the deltoid acts, it may be strongly urged that in this joint a trial of the sub- periosteal method should be carefully made, to ensure as much repro- duction of bone as possible. Von Langenbeck^ gives more than one case in which the arm could be raised vertically, and the movements were excellent. While it is true that these were cases of resection for gunshot injury, and therefore the patients probably healthy adults, on the other hand preservation of the periosteum is not likely to be so easily eft'ected here as in those cases where it is softened by disease. Even if the periosteum cannot be completely preserved, an additional half inch or inch in length gained, and an irregular knob or nodule-like mass which may be moulded into a rudimentary head within the new 1 Arch. J. Min. Chir., 1874, vol. xvi. GUNSHOT INJURIES OF THE SHOULDER- JOINT 22.3 capsule, may make much difference in the future mobiUty and useful- ness of the limb. M. Oilier ^ ligures and describes a specimen of a resected humerus nine years after the operation. The patient, a>t. 20, had had miscliief in tlic joint for tlu'cc years, with, latterly, suppuration and live listuhe. Five centimetres of the hum(;ruH, measured from the summit of the head, were removed. After the operation he was able to follow his work as a hawker, and to use both arms equally well in lifting weights. The upper end of the humerus was irregularly expanded, showing numerous bosses and de2:)res- sions into which the insertion of the capsule and different muscles could be followed. Treatment of gunshot injuries oJ the shoulder- joint. Lieutenant- Colonel Hickson, R.A.M.l^,- writes : " From the small number of reported cases, wounds of this joint seem to be relatively rare. Only twenty-seven cases have been noted, of which nine were perforations and eighteen comminutions or fissures of various degrees of severity. Of the nine perforations all were aseptic, and of the eighteen comminutions sixteen were septic, one was aseptic, and the remaining one, in which a primary amputation proved fatal, has been classed as doubtful. (1) Perforations. As in other joints, the issue of pure perforations was most favourable. Eight of these cases recovered without any operative measures being necessary, the treatment consisting of antiseptic dressings, with rest ; they re- mained aseptic throughout. Incision for the extraction of a retained bullet in the dorsal region was required in one case of perforation ; in this case also sepsis did not occur. (2) Comminuted Fractures. These resulted either from serious fractures of the upper end of the diaphysis of the humerus with fissures extending into the joint, or from the impact of the larger-bore bullets, such as the Martini -Henry, from expanding bullets, or from fragments of shell. The very destructive natiu-e of some of the injuries of this type will be seen from the fact that in sixteen of the eighteen cases of this description of wounds, operative interference was called for. Thus, in three cases recovery followed the removal of fragments ; in eight, excision of the shattered head of the humerus was successfully carried out; in four, amputation at the shoulder- joint was required, one of wliich died, and in one Berger's interseapulo- thoracic amputation was successfully performed. The two remaining cases which recovered without any operative measures were the two examples of aseptic com- minutions. It will be seen from the above analysis that either partial or complete excision of, or amputation at, the shoulder-joint was carried out in sixteen septic comminutions out of a total of eighteen such wounds, or in nearly one-half of the total number of reported cases of every variety." ^ The following advice of Professor Oilier as to the treatment of gun- shot and other injuries of the shoulder- joint will be found most useful. If the head only be fractured, and not in more than two or three fragments, and if these are held together and not widely separated he would trust to anti- sepsis. If suppuration occurred, he would advise resection ; and he points out that a deferred excision has one advantage, i.e. that time may have elapsed for inflamma- tion of the periosteum to have occurred, and thus its osteogenetic properties may be aroused. If the head of the humerus be badly shattered, and the fragments much separated from each other and from their periosteum, he would perform a primary excision, endeavouring to reshape the extremity into a new head. If the splintering and damage to the bone does not affect more than three or four ^ Loc. supra cit., t. i, p. 35, t. ii, p. 85. 2 Rept. of Surg. Cases noted in the South African War. ^ Mr. G. H. Makms (Surg. Experiences in South Africa, 1899 1900, p. 236) gives the following experience of the results of small bullets of high velocity : '• Wounds of this articulation were by no means common. This depended, I think, on two points in the architecture of the joint : first, a bullet to enter the front of the cavity and transverse the joint needed to come with a great exactitude from the immediate front ; secondly, wounds received from a purely lateral direction calculated to pierce the head of the humerus and the glenoid cavity were naturally of very rare occurrence. Wounds of the prominent tip of the shoulder received while the men were in the prone position were not uncommon, but it was remarkable how rarely the shoulder- joint was impUcated in these. 224 OPERATIONS ON THE UPPER EXTREMITY centimetres of it, all the damaged bone may be resected ; but if the mischief extends lower down, some risk must be run and the injured bone left. And his course would be the same in the case of a comjiound fracture of the neck of the humerus with dislocation. If jjart of the head had escaped splintering, he would leave this attached to the shaft. Removal of splinters Prof. Oilier directs to be done with the greatest care of the periosteum, every atom of this being left in the wound. Wliile bullet-wounds may be used for drainage, it is rarely well to enlarge them or to throw one into another so as to employ them as the operation wound ; this should be made in the usual place. With regard to the comparative value of primary and later excision, Prof. Oilier allows that bone production is less likely in the former owing to the periosteum being uninflamed and more difficult to save. On the other hand, he points out that, as yet, we scarcely know what antiseptic precautions and the use of proper periosteal elevators will effect. Moreover, in primary resection for gunshot injuries the patients are usually young adults, and their muscles in excellent order. In the case of gunshot and other injuries in which the damage is not limited to the head and surgical neck of the humerus, but splinters the upper half or three- quarters of the humerus, resection is still urged by Prof. Oilier (vide supra) as long as the soft parts are sufficiently sound to survive. Though the function of a limb thus preserved will be very imperfect, the result will be far superior to that of amputation at the shoulder-joint. In any such resection the antiseptic precautions should be as comijlete as possible, and any long splinters, which, however much the bone be shattered, preserve their relation to the periosteum should be left, as, with the aid of the bone production of the periosteum around them, they will maintain the continuity of the bony column. Recurrent dislocation of the shoulder. Dr. Burrell and Dr. Lovett, of Boston, have contributed a paper on this subject, with six cases, two of which were operated upon, with an excellent result in each case.^ Amongst the pathological conditions, which vary widely, these writers consider the following to be established : (1) Laxity of the capsule ; (2) Tearing away of the capsule from the glenoid cavity ; (3) and 4) Partial fracture of the head of the humerus or the glenoid cavity ; (5) Tearing away of muscular insertions, or rupture of the biceps tendon ; (6) Altered shape of the head of the humerus, probably the result of chronic inflammation. The following are the chief steps of the operation performed by Dr. Burrell in the two cases referred to above. Where a trial of primary fixation for a few weeks, combined with massage of the muscles, followed by careful movements of the joint, fails after ten weeks, partial resection and suture of the capsule - is recommended, unless any abnormalities be found which require removal of the head of the humerus. A free incision having been made in the pectoro-deltoid interval, the cephalic vein drawn aside, the coraco-brachialis and biceps are recognised in the upper and the pectoralis major in the lower part of the wound. Division of the ujjper three- quarters of the insertion of the latter muscle is recommended so as to expose thoroughly the head and neck of the bone. The long tendon of the biceps will be seen and felt through its sheath. The incision should be carried in its whole depth up to the coracoid jjrocess, and the tendons of the biceps and coraco-brachialis cleared up to this point. By rotating the head outwards and drojiping it backwards, the insertion of the subcupularis is stretched over the bone. A portion of this insertion should be divided. The arm is next abducted, raised to a horizontal position, and the head of the bone pressed backwards so as to prevent its coming up under the coracoid process, which it tends to do in these cases,* and also to relax the front of the caspule. If the joint ajipear normal the loose part of this ligament is then grasped with vulsellum forceps, and a fold three-quarters of an inch in length and three-eights of an inch wide excised. The gap is then sutured, rendering the capsule distinctly tighter and shorter. Mr. Southam * published a case in which he had excised the shoulder-joint for a frequently recurring dislocation in a woman, aged 45. 1 Trans. Amer. Surg. Assoc, 1897, p. 293. 2 The credit of first taking this step is due to Dr. Gerster, of New York. * Two details in the operative and after-treatment intended to meet this displacement are given at pp. 219, 222. * Brit. Med.Jovrn., 1892, vol. ii, p. 1193. FRACTURES OF THE HUMERUS 225 Nothing abnormal, beyond slight grating, could bo detected on examination, but under anaesthesia, a sub-oaracoid dislocation could bo readily produced, and as readily reduced. At the operation a small part of the anterior rim of the glenoid cavity was absent. Tlie head of the humerus was sawn through the anatomical neck ; gentle passive movements were begun three weeks after the o])eration, and, twelve months later, tliere had been no recurrence of the dislocation. The arm was then very useful, with good movements, the patient being able to perform her ordinary house- hold duties. Operative treatment of simple fractures of the upper extremity of the humerus, lu these injuries, especially fractures of the surgical neck and through or of the tuberosities, it may, owing to the small size of the upper fragment, be impossible to secure good position by mani- pulation. Owing to the proximity of the articular surface, which may itself be involved, any excess of callus is likely seriously to impair the mobiUty of the joint. Under these circumstances, if the age and general condition of the patient are satisfactory, the joint should be opened by an anterior incision similar to that above described, the fragments manipulated into position and secured by a plate or sutured by silver wire. The arm must be bandaged to the chest to immobilise the joint. Massage and passive movements are commenced on the tenth day when the stitches are removed. Needless to say, a careful considera- tion of radiograms should be made before operative measures are decided upon. Reference should be made to the remarks on p. 213 on the advantages of reposition over excision. In fractures of the great tuberosity the small fragment will be dis- placed backwards and rotated outwards while the shaft of the humerus is rotated inwards. Satisfactory union is very unlikely to occur with splints or by fixing the arm in a position of external rotation. An incision should be made over the tuberosity which is then fixed in position by a screw or peg. Operative treatment of separation of the upper epiphysis of the humerus. This is often a difhcult lesion to treat. Under certain cir- cumstances operative treatment, with the safety that modern pre- cautions, duly carried out, give nowadays, should be resorted to. We may divide the cases that call for it into the following groups : A. Cases of simple injury. B. Cases of compound injury. A. Simple. These may be further divided into : (a) Those of recent date. (6) Those of longer standing. (a) Simple cases of separation of recent date. Here interference is justified when there is very great difficulty in effecting reduction owing to complete separation of the two parts, aided by the rotation of the epiphysis and the very small size of the upper fragment. Mr. Poland, in his " Traumatic Separation of Epiphyses " (p. 226), states that one of the chief difficulties in reduction occurs from the insertion between the fragments of bands of periosteum, fascia, or muscle, or from the penetration of the periosteal sheath by the diaphyseal end." Other cases are those where, if the displacement is corrected, there is much difiiculty in maintaining the reduction, when a sharp portion of the lower fragment, having penetrated the deltoid, is projecting under the skin, and where there is evidence of pressure on the vessels and nerves. The operation should be performed on some such fines as these. An incision is made freely in the interval between the pectoral and SURGERY I i- 5 226 OPERATIONS ON THE UPPER EXTREMITY deltoid ; the cephalic vein is drawn aside or tied between double liga- tures. The soft parts having been widely retracted, the ends of the two fragments are next identified and examined, any rent in the peri- osteum being carefully enlarged if needful. It will now be found possible, in some cases, to replace the fragments in position, and then, owing to the conical shape of the epiphysis, fixation by plate or wire will not be necessary. The edges of the rent in the periosteum and capsule should be carefully sutured, and it may be well at the same time to close any opened-up periarticular planes of connective tissue. It may be needful, when the fragments cannot otherwise be brought into position, to remove any projection from the lower fragment. If there is any difficulty in retaining the fragments in position it will be best to wire them together. In those cases where the epiphysis is not only separated, but dis- located owing to the severity of the injury having lacerated the capsule freely, Poland ^ advises as follows : ' Seeing that it is almost impossible to reduce the head of the bone in these extremely rare cases, an incision should be made through the skin and deltoid down to the seat of separa- tion, and the epiphysis replaced in position. It will be found necessary to open the capsule of the shoulder- joint before the epiphysis can be reduced. This should be accomplished by direct manipulation of the head into its place by pressure of the thumb and fingers, or by means of a traction hook inserted into a hole drilled in it after the method advocated by McBurney. The fragments should then be fastened together in their normal position by means of pegs or sutures." (2) Cases of older date. Here, where some weeks or months have elapsed, interference may be called for, owing to the limitation of move- ment, especially as regards abduction, elevation, and rotation, brought about by the overlapping of the fragments, their union in a faulty position, and the projecting callus. Here, after exposure of the seat of union, and free retraction of the soft parts, the surgeon will have to follow the advice of M. C. Walther,^ and then decide between the necessity of completely resecting the callus in order to place the fragments absolutely in position, or to freely remove any pro- jecting ends of the diaphysial fragment, and plane away any excessive callus. B. Compound cases. Here resection of the projecting end of the diaphysis will usually be required before reduction can be effected, a step that will facilitate the thorough cleansing of the parts which is so much required. Wiring with sufficiently stout wire, and suture of the rent in the periosteum, will be required, as already indicated above. About a fortnight after any of these operations, passive movements should be begun, and perseveringly continued, together with friction and massage. Arthrotomy of the shoulder. This operation will be indicated in cases of acute suppurative arthritis, usually pyeemic in origin. In order to avoid the tendon of the biceps an incision should be made for two inches just below the acromion, dividing the skua and the fibres of the deltoid. The capsule is then easily exposed and may be opened by a vertical cut. For effective ^ Loc. supra cit., p. 243. * Rev. d'Orthop., Jan. 1897, p.'43, quoted by Poland, loc. supra cit, p. 240. ARTHROTOMY OF THE SHOULDER 227 drainage a counter iiuMsion is required in flie lowest part of the caj)sule. Burghard advises tliat this sliould be made as follows: "The best plan is to raise the arm above the head so as to render the liead of the hunierus as prominent in the axilla as possible, and then to cut down upon this by an incision about two inches long just below the axillary vessels. The.^e are identified and ])ulled upwards so as to expose the capsule below and behind. The head of the bone can be made out by the finger in the axilla. The capsule may be o])ened by cutting down directly upon the head of the bone ; this may be facilitated by bringing the arm dowii. and pa.ssing a long pair of dressing forceps across the joint from the ujjper incision and making their points project beneath the capsule so that they can be cut down upon and made to seize the drainage tube and pull it into position." CHAPTER X EXCISION OF THE SCAPULA Indications. (1) New growths, especially sarcoma. (2) Caries and necrosis. (3) Accidents, e.rj. railway and machinery accidents. ( 1 ) As the first of the above is practically the only condition which calls for the removal of the bone, and as these cases present the greatest difficulties, it is to removal of the scapula for new growths that most of the follo^^^ng remarks will apply. A. Partial removal o£ the scapula. In a very few cases {e.g. where the surgeon, operating on an exostosis, is uncertain as to the nature of its base and does not feel satisfied with gouging this, or where he is certain that he is dealing with a chondroma and not with a chrondrifying sarcoma, partial removal of the bone may be sufficient. Caries or necrosis, too, will only in very rare cases call for more than a partial excision. The chief points here are : (1) To expose freely the growth by appropriate flaps, so that the limits may be clearly defined ; (2) to be provided with reliable instruments of keen temper, owing to the exceeding hardness which may be met with here. While some continental writers have given elaborate directions for partial removal of the scapula, it is only in the above few cases that this operation is likely to be used by English surgeons. Mr. Pollock, in a paper on two cases of removal of the scapula, ^ thus advises on this matter: "If a portion of the scapula be removed, it should only be the lower portion. But even if this be attempted, the loss of blood would probably be much greater than if the whole bone were removed ; for the wound is more confined, and the wounded arteries are more apt to retract behind the bone above, and offer great obstacles to their being secured. However, should the lower angle be alone the seat of disease, the attempt to remove the lower portion only is justifiable." It must, however, be borne in mind that, when a bone is once the seat of disease which requires removal, the disease is very apt to recur in the portion left, and is less liable to re-appear if the whole bone be removed. When in doubt as to partial or complete removal of the scapula for a cartilaginous tumour, the surgeon will be chiefly guided by the duration and the rate of progress of the growi:h, its density, how far it is strictly localised, and whether there is any evidence of adjacent nodules of cartilage, pointing to an infection of the medulla. B. Removal o£ the entire scapula by itself {e.g. cases where the growth is primary in the scapula, and where there is no extension to the humerus or into the axilla).- Preparations against shock should be taken, the 1 St. George's Hospital Reporf.% vol. iv, p. 236. " In cases where the question lies between removal of the scapula and interscapulo- 228 EXCISION OF THE SCAPULA 229 extremities being bandaged in cotton wool, the head kept low, and the materials for infusion in readiness. The patient is placed at the edge of the table and rolled over to the opposite side. If the growth is verv vascular, or the patient weakly, pressure on the subclavian, if effectual, may help ; or if, from the extension of the growth, this is rendered difficult, it may be effected by making an incision down to and through the deep fascia over the artery itself, in order to enable an assistant to put his thumb or finger directly upon it. This may be done by a separate incision, or by an extension of that by which the clavicle is divided. But as movements of the limbs may easily dislodge the assistant's finger, the operator will do better to trust to plenty of Spencer-Wells forceps and tying the vessels as they are divided. Sir W. Watson Cheyne recommends preliminary ligature of the subscapular artery. This surgeon has made use of a preliminary anterior incision in the removal of the scapula for a large chondroma which filled up the axilla, '■ projecting the pectoralis forwards to a marked degree," an incision which he recommends in all cases. ^ "In the first instance an incision was made, beginning below at the junction of the axillary and brachial vessels, and running up in the line of the former, so that the axilla was freely opened in its whole extent. The anterior fold of the axilla was raised so as to expose the coracoid process ; the three muscles attached to this were next divided w^ith blunt-pointed scissors kept close to the bone. This fully exposes the axillary artery and its subscapular branch is at once ligatured. The patient was then turned over, and the operation completed in the ordinary way. ... The ligature of the subscapular artery answered admirably. In this case the patient lost extremely little blood, probably not more than an ounce altogether. The detachment of the muscles attached to the coracoid process also enabled the operation to be completed very rapidly, for after the posterior scapular muscles had been divided, and the trapezius and the deltoid had been raised, the acromio- clavicular joint and the muscles going to the head of the humerus were practically the only things which had to be divided." The patient being turned over, flaps are quickly and freely turned back, usually by a T-shaped incision, one limb running from the acromio- clavicular joint inwards to the superior angle of the scapula, while the other and longer is made at right angles to the first down to the ai gle of the scapula. In another case the surgeon may prefer to make an incision along the vertebral border of the scapula, and the other at right angles to it across the centre of the growth. ^ (Fig. 116). In either case care must be taken not to open the capsule of the tumour. thoracic amputation, J. J. Buchanan, who has considered fully the three operations of partial and complete removal of the scapula and interscapulo-thoracic amputation (Philadelphia Med. Journ., 1900), advises that the proposal of Jennel (Le Mid. Med. 1895, vol. i, p. 251) be followed. " In every case in which it is suspected that the axillary vessels and nerves may be involved in a growth of the scapula, the operation should be so conducted that it may, if desirable, be converted into a formal interscapulo-thoracic amputation. He makes the posterior and clavicular incision of Berger, divides the attach- ments of the deltoid, and through this incision makes a digital examination of the relation of the growth to the vessels and nerves. If satisfactory information cannot be thus gained he resects the outer third of the cla^dcle, separates the muscular attachments to the coracoid, and thus gains better access to the vessels and nerves." Probably it would be safer to follow Berger, and in all doubtful cases to begin with resection of the clavicle. 1 Kiyig's College Hospit'd Report^\ vol. ii, p. 83; Clin. Soc. Trans., 1895, vol. xxviii, p. 284. ^ If the skin is involved the flaps must be shaped so as to isolate this. 230 OPERATIONS OX THE UPPER EXTREMITY When the whole mass is thoroughly exposed, the trapezius and deltoid are first severed, the arm being pulled away from the trunk. The levator anguli scapulae and the rhomboids are next cut through,^ the posterior scapular artery secured, and the serratus magnus divided, being first made tense by lifting the scapula off the ribs upwards and outwards. The muscles on the upper border are now dealt with, viz. any remains of the deltoid, the omo-hyoid, and the supra-spinatus — and the supra-scapular artery secured. The acromio-clavicular joint is next opened, or else the acromion or clavicle, according to the extension of the growth in this direction, severed by bone forceps or a narrow saw. If the acromion can be safely left, the resulting deformity — viz. dropping of the shoulder and entire loss of the action of the trapezius — will be lessened. The lower angle being freed and the latissimus dorsi (if involved) resected, the scapula can now be dragged away from the chest by slip- ping two or three fingers over the upper or vertebral border. Thus, by tilting the scapula outwards, the axillary border can be inspected, the teres and infra-spinatus muscles severed, the position of the sub- scapular artery defined by a finger passed beneath it. and care taken that this vessel, already tied through the preliminary incision, remains safely secured. The scapula being still further pulled away from the chest, the muscles attached to the coracoid process will be seen severed, Fio. llG. Incision for excision and the scapula is removed by cut- of the scapula. ting into the shoulder joint and severing the capsule and the tendons of the biceps and triceps. The coracoid process may become detached at this stage if partially eroded by extension of the growth, or if the patient be young. If this happens it must be carefully dissected out afterwards. 2 The different arteries, besides the subscapular, must be secured if ' It is a bad sign if any of the muscles severed are infiltrated with growth. That this is not incompatible with a good recoverj' is, however, shown by the case quoted on p. 232. - If the growth has involved the axillary vessels and nerves, this outlj-ing portion may be dealt with later on, after the main mass has been separated and removed. If it is desired to remove this extension of the disease now while in continuity with the scapular growth itself, the surgeon will liave both his hands free for what is a troublesome dis- section, by asking an assistant to drag the main mass strongly backwards. But it wiU be well, in cases where there is evidence of the scapular growth having encroached upon the large vessels and nerves, to obtain leave for the performance of an inter-scapulo thoracic amputation. The first step in the operation should now be division and sufficient removal of the clavicle, so as to clear up the state of the above important structures. If they are involved by the growth the more extensive operation should at once be resorted to " EXCISION OF THE SCAPULA 231 possible before they are cut. Too many Spencer- Wells forceps must not be left in at one time, or they will be found to interfere with the needful manipulation of the bone. Every vessel must be carefully secured by lij^'ature ; otherwise oozing is liable to occur a few hours later. ' • Haemorrhage may be best avoided by attention to the following points : (1) Making use of Sir W. Watson Cheyne's method and securing the subscapular artery early. (2) Where this method is not available a trial of adequate pressure on the subclavian, this being effected by a special incision, if needful, to command the vessel. Reasons for not trusting to this have been given at p. 229. (3) Dealing with the axillary border and scapular artery last. (4) In any case rapid use of knife or scissors by the operator, aided by intelligent help from assistants in securing bleeding-points, and from an anaesthetist who will not be unduly anxious, is essential. (5) Taking care not to cut into the growth itself. (G) By some it is recommended to make the incisions gradually, not larger than are required at the time, as a means of minimising the haemorrhage. It must be remembered, with regard to this point, that small and cramped incisions interfere with a free and rapid hand and sufficient exposure of the parts, conditions which con- duce to thorough dealing with bleeding-points, and thus facing one of the chief difficulties of this important operation. Adequate drainage is now provided on account of the liability to subsequent oozing, the attachments of the trapezius and deltoid sutured together with fine sterilized silk, the flaps united, and the arm secured to the side for a few days, after which it may be supported in a sling if the head of the humerus does not tend toprotrude. The malignancy of these sarcomata is well known, ^ together with their tendency to involve surrounding parts and to creep into regions inaccessible to the surgeon. Early operation is imperatively required. In the case of operation, the prognosis will be best, however large the growth, when the rate of progress has been slow, when the growth is uniformly hard, or if only a certain amount of elasticity is combined with the hardness, when the outline is distinct and well defined, and the mass movable upon the ribs.- 1 The malignancy of these cases and the indifferent results of excision of the .scapula are shown in a paper by Dr. Charles B. Nancrede, on the End Results of Excision of the Scapula for Sarcoma (.4n/i. of Surg., 1909, vol. 1, p. 1). Dr. Nancrede collected 65 cases. Of these 26 died in less than one year, 3 inside eighteen months, 2 in two years; 2 survived for three years and 1 for five years. Only one case was certainly cured and 6 probably cured. 2 That this mobility is a matter of great importance is shown by the following case, quoted by M. Scdillot at p. 5.50 of his Traite de Medicine operatoire : " Nous refusames un jour d'operer un jeune homme atteint d'un cancer enorme du scapulum, dont les limites n'etaient pas ncttement fixees, et nous dumes nous applaudir de notre abstention en decouvrant plus tard, a la nccropsie, que la tumeur avait penetre dans la poitrine et cnvahi un lobe pulmonaire." The following case, under the care of the late Mr. Marma- duke Shield, shows how easily a sarcoma of the subscapular fossa may implicate the thorax, without any exact diagnosis of the position and extent of the growth being possible. A boy, fct. 10, was admitted under his care with a swelling, the size of an orange, on the axillary border of one scapula. This swelling was somewhat fixed, moving but slightly when the arm and scapula were raised at the operation. The intercostals and pleura were found to be blended with the growth. In the attempts to separate them the pleural sac was opened. Pneumothorax ensued, and death took place the next day. The specimen which illustrates this instructive case will be found in the Hunterian collec- tion, R.C.S., No. 586B. 282 OPERATIONS ON THE UPPER EXTREMITY On the other hand, the prognosis is less favourable when the outline is uniform rather than nodulated or bossed, the feel semi-elastic instead of hard, the progress rapid and painful, the different parts of the scapula much obscured and its mobility much impaired, the outline of the growth ill defined and lost indistinctly in the axilla. Pulsation, bruit, enlarged glands, infiltration of the skin, and any local rise in tempera- ture are also of evil omen. In these cases, when the prognosis is un- favourable, the surgeon will do well to resort to interscapulo-thoracic amputation. Condition of the limb after removal of the scapula. A limb thus preserved will be strong and useful. If the clavicle has not been much interfered with, the clavicular fibres of the deltoid will remain, and these, especially if sutured to the trapezius, together with the latissimus dorsi and pectoralis major, will probably confer a fair amount of move- ment on the limb. In one of Professor Syme's cases, after removal of the scapula and the outer third of the clavicle and, by a previous operation, the head of the humerus, the patient was able to lift heavy weights, and to fill the appointment of provincial letter-carrier. In a very successful case of Mr. Symonds,^ in which the scapula was removed for osteosarcoma, the man was in good health two years and a half after the operation. He was able to do all the light work of a carpenter, including the use of a plane. Overhead work he could not do. In this case the articular surface of the humerus had also been removed about a month later, as it was thought to be the cause of prolonged suppuration. The following case is of interest from the extension of the sarcoma into one of the scapular muscles, the ill- defined outline and soft feel of the growth, its long duration, and yet the long period of relief which has followed : In March 1892 one of the nurses at the Canterbury Hospital was sent to Mr. Jacobson by Dr. Alexander of Faversham. The outline of the left scapula was replaced by a large mass, of uniform outline, fairly defined over the lower two- thirds of the bone, but above very indistinct, semi-elastic to the feel, without any nodules or bosses of harder growth. The scapula was movable upon the ribs. The history was one of pain for eight months. For the last three months the increase in the size of the swelling and in the pain had, alike, been rapid. The scapula was removed in Guy's Hospital. The most interesting point about the case was that the sarcoma, which appeared to have begun in the infraspinous fossa, had perforated the bone, and in many places greyish masses of growth could be seen blending with and replacing the delicate fasciculi of the subscapularis. The chief difficulty met with in the after-treatment was keeping the patient quiet. The wound did not run an aseptic course. Ten days later, incisions were required for drainage of the suppuration which followed. Later on, the articular surface and epiphyses of the head and tuberosities of the humerus became detached. Two years after the operation the antero-posterior movements of the shoulder- joint were good. The patient could nurse a delicate mother, use her needle, &c., but abduction and elevation were almost completely abolished. In spite of infiltration of one at least of the muscles, there was no evidence whatever of any recurrence. Age of the 'patient. The scapula has been successfully removed for growth at ages varying between "about seventy" and "about eight." The former was a patient of Professor Syme, who died about two months after the operation, apparently of internal deposits. The latter case 1 Clin. Soc. Trans., vol. xx, p. 24. EXCISION OF THE SCAPULA 233 occurred in India, the upper extremity being removed at the same time. Mr. Stephen Paget has recorded^ a successful case of excision of the scapula for sarcoma in a boy a't. 9. Dangers of the operation and causes of death. Tliesc will be the same as those given at the end of the next cliapter. (2) Removal oj the scapula for caries. This, which will be very rarely called for, needs no especial mention. The parts being sufficiently exposed, the operation will be conducted, as far as possible, sub- periosteally, by means of appropriate blunt dissectors or periosteal elevators. ^ Clin. Soc. Trann. vol. xxxvi, p, 244. CHAPTER XI REMOVAL OF THE UPPER EXTREMITY, ARM, SCAPULA, AND GREATER PART OF THE CLAVICLE INTERSCAPULO-THORACIC AMPUTATION ^ This operation, performed chiefly for growths of the humerus which cannot be completely removed by amputation at the shoulder joint, ^ occasionally for growths of the scapula, and for those of the axilla, as in Mr. Stanley Boyd's case {see p. 237). More rarely it may be called for in cases of injury, for persistent carcinoma of the breast {see p. 756), for tuberculous disease, or for spreading gangrene. It has been advo- cated and described by M. Paul Berger, by wdiose name it is commonly distinguished ^ amongst continental surgeons, and by Sir F. Treves arid others in this country and America. The method described below is that of M. Berger ; a very clear account is also given by M. Farabeuf, by Sir F. Treves,* and by Professor Kocher. These have been largely consulted. First step. Division of the clavicle and securing the vessels. The patient being brought to the edge of the table, with his shoulders raised, the surgeon, standing outside the limb, makes an incision with a stout scalpel along the whole length of the clavicle, from just outside the ster no- mastoid to a point immediately beyond the acromio-clavicular joint. The incision divides the periosteum down to the bone over the middle of the clavicle. At this stage venous oozing from the large superficial veins here met with may be very free. With a curved elevator the periosteum is separated from the middle portion of the clavicle.^ A large blunt hook or a blunt dissector being passed under the inner end of the bared part of the clavicle, this is divided with a narrow saw. The outer part of the clavicle being now raised and steadied with lion- forceps, and the periosteum completely separated from its under surface, 1 Dr. Norman B. Carson has published (Ann. of Surg., 1913, vol. Ixvii, p. 796) an interesting paper on this subject giving details of a number of cases. ^ As in Mr. Barling's case (Brit. Med. Journ., 1898, vol. i, p. 883). any surgeon in doubt as to the necessity of submitting his patient to so severe an operation, should begin by an incision between the deltoid and the pectoralis major, and then, when the muscles are thoroughly retracted, examine the condition of the axilla, the glands, and determine the extent of the growth and whether the large vessels and nerves are involved. In other cases division and partial removal of the clavicle may be required to clear up the doubtful point. In every case this preliminary incision should be made at the time when the operation is to be completed, not as a preliminary step. On this point see a paper by Dr. Cobb, of Boston {Ann. of Surg., February 1905, p. 267). 3 U Amputation du membre. superieur dan.s la contujuite du trpnc, Paris, 1887. * Oper. Surg. s Preliminary detachment of periosteum was recommended by M. Oilier as a safeguard against wounding the vessels. It, however, obscures the subclavius and has to be divided immediately. In addition in malignant disease it may favour recurrence of the growth. 234 INTERSCAPULO-TIIORACIC AMPUTATION 235 the l)()iie is again divided at the outer end of its middle third. If re- section of part of the clavicle is performed, the removal of bone must be free enough to facilitate the finding of the subclavian vessels. Limited removal of bone will much increase the difficulties of the above step. The tendency of the upper extremity to fall outwards after division of the clavicle will increase the space between the two parts of this bone. The exposed subclavius with its sheath is now isolated and cut through close to the site of the iinier section of the clavicle, dissected up so as to expose the large vessels, and turned outwards.^ Fasciae of varying thickness will have to be divided before the vessels are reached. During this step the great pectoral should be freely divided, especially in muscular subjects, and the upper border of the pectoralis minor should, if possible, be defined ; the surgeon must be prepared for troublesome bleeding from the cephalic vein and branches of the acromio-thoracic vessels, and he may find a guide recommended by Berger — viz. the external anterior thoracic nerve — easy to see or feel. This nerve, if followed upwards, leads to the interval between the artery and vein.^ These large vessels are then secured and divided between double ligatures, pushed well apart in each case and tied securely before the vessel is cut. The ligatures should be placed upon the subclavian vessels them- selves, at a point to which the tubercle on the first rib will be a guide. The artery should be secured first, and the arm well raised while the ligatures are placed around the vein, so that as little blood as possible be left in the extremity. Tying the artery first will lessen the size of the vein and render the securing of it less difficult ; furthermore, as pointed out by Professor Keen, if the vein be injured, as happened in his case, while it is being tied, the wound will not be flooded with blood. If, however, the vein be so much distended as to obscure the artery, the former vessel must be taken first. In either case the greatest care must be taken not to injure this vessel for fear of air entering the cir- culation. If any such accident occurs, the spot must be instantly closed and the wound flooded with sterile saline solution. While exposing the subclavian vessels, the supra- scapular artery and vein will probably be seen crossing the upper part of the wound and should be secured. The nerve-cords should be cut square and as high up as possible. Before they are severed each should be injected with novocain or eucaine to guard against shock. Mr. Stanley Boyd in his case {vide infra) finding that removal of the inner third of the clavicle was insufficient to permit of easy ligature of the vein, which lay beneath the inner third, removed another inch from the bone. He also found that division of most of the brachial plexus facilitated ligature of the artery, the plexus at once starting into relief on division of the clavicle. Dr. Le Conte, of Philadelphia,^ recommends disarticulation of the sternal end of the clavicle as preferable to resection. In the latter the large vessels are ex- posed in a narrow field and at a considerable depth. Disarticulation he believes to be simpler, quicker, and safer, by giving a much fuller exposure of the vessels. The incision is begun over the sternal end of the clavicle, carried to its middle, and then curved downwards to the anterior axillary fold. The skin and superficial fascia are dissected up, exposing well the inner two-thirds of the clavicle. The bone is then disarticulated by severing its attachments to the sternum and rhomboid ligament, the clavicular part of the stemo-mastoid and pectoralis major. The clavicle is 1 The subclavius must be thoroughly divided in order to obtain room for securing the vein. 2 Feeling for the pulsation of the artery will be another guide. ' Ann. oj Surg., September 1809. 236 OPERATIONS ON THE UPPER EXTREMITY now pulled upwards and outwards, and the subclavius stripped off or divided, and the vessels thus well exposed. ' Second stage. Formation of the flaps. These are pectoro-axillary and cervico-scapular, and in forming them the surgeon must be guided by the extent of the disease. The patient being so placed and steadied that the whole of the scapular region is free of the table, and the surgeon standing to the inner side, i.e. between the limb and the trunk, the pectoro-axillary flap is cut as indicated in Fig. 117. As there Fig. 117. Interscapulo-thoracic amputation. Outline of the flaps (leftside). The posterior or cervico-scapular flap is shown dotted. (Farabeuf.) shown, it commences at the middle of the incision over the clavicle, runs downwards and outwards just above the coracoid process, and then parallel with, but a little external to, the depression between the deltoid and the pectoralis major. On reaching the point where the anterior fold of the axilla and the arm j"oin, the knife is carried over the lower edge of the pectoralis major across the axillary aspect of the arm (Fig. 117), and then backwards and downwards (the limb being well raised by an assistant) so as to pass over the lower edges of the latissimus dorsi and teres major and end over the apex of the scapula (Fig. 117). The above incision only divides skin and fasciae. The pectoralis major is next cut, and the pectoralis minor found and severed near the coracoid process. The top of the axilla being now well opened up, the cords of the plexus, if not already severed, are divided at the same level as the great vessels, great care being taken of the central ligatures on these, the patient being rolled over on to his sound side, 1 Dr. Le Conte also points out that complete removal of the bone is safer in cases of growth than leaving the sternal end. This step would also be indicated where there are great dilEculties in finding the subclavian artery where the clavicle itself is involved. In the latter case, however, it may be questioned whether any operation is advisable. TNTKRSCAPULO-THORACTC AMPUTATION 237 and the limh drawn across the chest. The cervico- dorsal flap is now nia(h» by drawiiifj; the knife from the outer extremity of the clavicular incision, straight back over the spine of the scapula to the lower angle of this bone, where it meets the first incision. The skin and fascia divided by this incision are reflected to the vertebral border of the scapula. Nothing now remains but the third mid last stage, viz. the removal of the limb. This is elVected by the division of the trapezius, omohyoid, latissimus dorsi, levator anguli, rhomboids, and serratus magnus. While these muscles are severed the flaps are well held back, and the limb suitably manipulated, partly by an assistant and partly by the left hand of the operator. During this stage the posterior scapular and the supra-scapular nmy or may not require ligatures, according as they spring from the first or the third part of the subclavian, in the latter case being on the distal side of the ligature (Spencer). But, of course, the mere mention of normal arteries gives no idea of the number of both veins and arteries that will be met with, enlarged, in cases of new growths. This makes it all the more important to secure first the subclavian artery and vein. The flaps and all the recesses of the large wound are most carefully scrutinized for any evidence of infiltration or extension of new growth. The muscles, especially the pectorals, should be cut short to avoid any possibility of infiltration. Where it is thought advisable to shorten the nerve-cords, each of these should again be injected with eucaine {see p. 235). The condition of the glands in the posterior triangle should also be investigated. Drainage should always be employed on account of the subsequent oozing. Mr. Stanley Boyd ^ has reported the following instructive case : Five weeks previously a man, set. 25, had come under his care at the Charing Cross Hospital for sarcoma of the axilla, which had attained the size of two fists in three months. It was not fixed to bone, but was closely attached to some soft parts. There was no evidence of pressure on the great vessels or nerves, of involve- ment of the supra-clavicular glands, or of secondary growths in the viscera, &c. Operation proved that the great vessels and nerves were so surrounded by growth that only an interscapulo-thoracic amputation would remove the disease. As con- sent had not been obtained, nothing further was done then. Four weeks later the mass round the vessels had increased considerably, and amputation was performed on Berger's lines, with certain improvements in two or three details, which have been mentioned above. The patient, at the time of the report, was making an excellent recovery. Dangers of the operation and causes of death. These are : (1) Hcemorrhage.^ This may be met with from the main trunk, the scapular branches of the subclavian, the branches of the axillary, and the enlarged anastomizing veins in cases of growth. The first two of 1 Brit. Med. Journ., vol. 1, 1898, p. 883. - Control of this is the key to the situation. The following cases show what dififi- culties may be met with in meeting it. Mr. Macnamara {Lancet, vol. i, 1878, p. 669), after resecting part of the clavicle, was unable to find the artery owing to the large veins exposed. The haemorrhage was very great, and the patient died on the following day. A portion of growth was found to have passed upwards behind the scaleni muscles. Prof. Keen (Amer. Journ. Med. Sci., June 1894) met with great trouble in securing the subclavian vein. " A large vein under the inner sawn end of the clavicle tore, and gave me much tro>ible. but finally, partly by a hgature round the tissues in which lay the vein, and partly by a ligature which was applied temporarily round the tissues and round the sawn end of the clavicle in a groove sawed in the bone, so as to prevent the slipping of the Hgature, I was able to control it." Another most instructive case is given by Prof. Keen (Ann. of Surg., June 1895). 238 OPERATIONS ON THE UPPER EXTREMITY these dangers and the third, to a large extent, will be met by tying the subclavian vessels after Berger's method. This also prevents entrance of air into the large veins, allows of section of vascular muscles like the great pectoral with scarcely any bleeding, while division of the posterior muscles, where the arterial supply has not been cut off, is reserved for the last step of the operation. If, after resection of the clavicle, it is found impossible to secure the third part of the subclavian vessels owing to the profuse venous oozing, or to the displacement of the parts from invasion of the growth. Sir F. T. Chavasse advises proceeding at once to make the upper part of the anterior flap, dividing the two pectoral muscles and, after fully exposing the first part of the axillary vessels, tracing these up to the scalenus anticus and tying the subclavian artery and vein. Other courses open are to tie the subclavian vessels in their part in the usual way. If all the precautions described above be taken, the amount of blood lost will be very small. Professor Kocher ^ says : "We performed this oiieration in 1902 on a boy for a diffuse sarcoma of the scapula, which involved the shoulder- joint and the upper portion of the humerus. Only two teaspoonfuls of blood were lost, and in jfive days the wound was simply covered with a strip of collodion, a single glass drainage tube having been inserted through a special opening in the posterior fold of the axilla." (2) Shock. This will be met by taking every step to prevent shock and hasmorrhage, bandaging the limbs and abdomen, keeping the body warm on a hot-water table, administering ether, emptying[the limb of venous blood before the vein is tied, and completing the 'operation as speedily as possible. Afterwards, infusion of saline fluid 'should be resorted to, while subcutaneous injection of strychnine, ether, or brandy, enemata of port wine and beef- tea, and bandaging of the other limbs may also be employed. This will be a fitting place to refer to an important point raised by Harvey Gushing- in the avoidance of shock in major amputations by cocainization of large nerve-trunks preliminary to their division as first advised by Crile.^ " The term ' shock ' represents a peculiar state of depression of the central nervous system. Such a condition is usually brought about by injury of one sort or another to peripheral afterent nerves, the impulses from the injury having acted reflexly upon the vaso- motor mechanism in the medulla, so as to cause a marked fall in the blood-pressure. While shock may be diminished by perfect hsemostasis and preventing chills, in cases where shock is already present before operation, the possibility of prolonged anaesthesia and some further loss of blood render it certain that a further especial risk is attendant upon the division of important sensory nerve-trunks. As cocaine injected into a nerve-trunk effectually blocks the transmission of all centripetal or sensory impulses, cocainization of main nerve- trunks central to the proposed site of their division in a major amputa- tion prevents the conduction of those impulses resulting from this further injury, which otherwise, by acting reflexly through the medullary centre, might become further factors in the production of shock." In illustration of the above principle, Cushing relates two cases of interscapulo- thoracic amputation, one of which was done without, the other with cocainisation of the chief nerve-trunks. In both hsemostasis was complete, and, except for the 1 Oper. Surg., p. 382. 2 jinn. of Surg., September 1902. ^ Problems Relating to Surgical Operations, Philadelphia, 1891. INTEUSCAPULO-TIIOUACIC AMPUTATION 2.30 above difTorencc in operative technique, the cases were in every respect similar. Two eliarts recording the {)ulse-rat(i are given, showing distinctly that in the case in whicli t he nerve-t runlcs were divided without cooainization (hen; was marked evidence of shock, which was absent in the case wliere cocaine was emjiloyed. Jjund ^ relates a case of the above operation for sarcoma of the brachial plexus, probably dating to an injury and originating in the median nerve, in which each cord of the brachial ])lexus was injected with ten minims of a 0'25 per cent, solution of cocaine before division. The pulse was iniafTected. (3) SeftiocBtnia. This is a very probable danger, if the flaps (perhaps left needlessly full) slough, or if retention and bagging of discharges are allowed to occur in the large cavity which will be present in the stump, unless this is obliterated by pressure, or sufficient drainage employed. (•i) Entrance of air into veins. This very nearly proved fatal in a case in which Mr. Jessop, some years ago, removed the scapula, outer half of the clavicle, and the upper extremity.''^ In this case the scapula seems to have been removed owing " to considerable deficiency of cover " after removal of an upper limb much damaged by a machinery accident. " Whilst cutting through the last attachments of the scapula, two dis- tinct loud whiffs were heard, caused by the rush of air into the subclavian vein." The operation was completed while artificial respiration ^ was being performed, and the lad recovered. (5) Recurrence. While the results of this severe operation are, as far as immediate recovery goes, good, recurrence, in the case of periosteal sarcomata, takes place, as a rule, within six or twelve months. Sir F. Treves * writes on this point : " Although interscapulo-thoracic am- putation is probably the best measure in all cases of sarcoma (ossifying or not) of the upper part of the humerus, the prognosis is very gloomy. In at least 75 per cent, fatal recurrence has followed within a year." The statistics collected for M. Berger show that the prognosis is better in cases of sarcoma of the humerus than in those where the growth affects the scapula or the soft parts, and that it is best of all in chondromata. (6) If the patient survive, an artificial limb should be fitted at an early date. It may not admit of active usefulness, but it will be of service in preventing the feeling of most irksome lopsidedness which in the convalescence and early getting about causes these patients so much discomfort in balancing themselves. (7) With regard to the mortality of the operation, some recent statistics are those collected by MM. Jeanbrau and Riche for M. Berger and brought by him before the Society of Surgery of Paris.^ It will be seen that it varies widely according to the origin of the growth. In cases of growth of the humerus the mortality is stated to have been 2-75 per cent. ; in growth of the scapula 23-80 per cent. ; and in growths of less certain origin, e.g. soft parts, glands, &c., 11-76 per cent. ^ Boston Med. and Surq. Journ., April 16, 1903. 2 Brit. Med. Journ., 1874, vol. i, p. 12. ^ Unless the wound is kept flooded, this step is not without risk of drawing in more air. * Oper. Swrgf., 2nded., vol. i, p. 381. 5 Bull, et Mem., May 16, 1905, p. 435. CHAPTER XII OPERATIONS ON THE CLAVICLE REMOVAL OF THE CLAVICLE Removal may be occasionally required for new growths or necrosis. In either case it is but rarely called for. That for necrosis differs in no way, save for the importance of surrounding parts, from the same operation elsewhere. Removal of the entire clavicle Jor new growths. The following are the chief points to bear in mind, viz. that (I) the degree of malignancy of sarcomata of bone varies here, as elsewhere, within very wide limits. (2) That slowness of growth, a well-defined outline, regularity of expansion, together with absence of swelUng of the hand, will be favourable. (3) A free incision is needed along the curves of the bone, with any additional one that is required. (4) Plenty of Spencer- Wells forceps must be at hand. (5) The acromial end should be set free first, either by opening the joint or by sawing the bone, if healthy. (6) The freeing of the coraco- and costo-clavicular ligaments is often a matter of much difficulty owing to their depth and the way in which the bone may be tied down by the growth. (7) With periosteal sarco- mata of any duration, outlying processes may be present. (8) If this be the case towards the inner end of the growth, it will require the greatest caution to avoid opening up connective tissue which is con- tinuous with that of the mediastina. (9) Division of the clavicle— a step sometimes taken to facilitate its removal— should be avoided, if possible, as the wound may thus become infected with growth. (10) As in all removal of bones infiltrated with growth, the clavicle may fracture during operation ; the outer end should then be seized with lion-forceps and dissected out so as to give more room for dealing with the sternal extremity. Operation. A horizontal incision is made along the whole length of the clavicle, with a vertical incision if necessary over the most prominent part of the growth. The skin and fasciae are reflected so as to thoroughly expose the superficial aspect of the tumour. The clavicular head of the sterno-mastoid, the clavicular attachments of the pectoralis major, the deltoid, and the trapezius are then divided beyond the limits of the growth. The acromio- clavicular joint is then opened and the outer extremity of the bone drawn strongly forwards and upwards by means of a blunt hook. The subclavius muscle and the coraco- clavicular and rhomboid ligaments are then severed by a knife or scissors, the greatest care being taken to avoid injury to the subclavian vein. These points are illustrated in the following case by Mr. Bowerman Jessett ^ of removal of the entire clavicle for a large periosteal sarcoma. 1 Lancet, 1889, vol. i, p. 1077. 240 EXCISION OF THE CLAVICLE 241 The patient was a girl, a't. 1(1 ; the growth was of more than a years duration, and extended over the iinier two-thirds of the clavicle. The following were the chief i)oints which led the surgeon to reeonunend operation. The age of tlie patient. The fact that the growth extended nuieh further on to the chest wall than it did into the neck. It had originated on the front of the clavicle and had only lately caused any pressure on the vessels. The skin was not implicated. A '■— )-shaped incision was made, the long limb along the clavii-le and the shorter one over the sti'rno-tlavicular joint and growth. Fla])s being reflected, the muscles were detached from the bone as far as possible, and the outer fibres of the sterno-mastoid divided. The bone was next divided at the junction of the outer and middle thirils by a narrow saw and bone forceps. The inner fragment was then pulled for- wards with lion-forceps, while the subcla^dus was carefully detached with scissors curved on the Hat. Home difficulty was met with in o])ening the sternoclavicular joint, as this was operlapped by the growth.^ A further extension of this over the top of the first rib made it difficult to divide the costo-clavicular ligament, which was effected with scissors after suitable dragging up and rotation of the fragment and the growth. Care was taken to leave untouched the sternal head of the sterno- mastoid. The outer part of the clavicle was then seized with lion-forceps and removed after division of the muscular and ligamentous attachments. There was very little loss of blood. The patient made a good recovery, and three months later " the movements were equally good with those of the opposite side." In 1893, speaking at a meeting of the Medical Society, Mr. Jessett said that several small recurrent growths had been removed. In Prof. Mott's case 2 the subclavius could not be seen, being incorporated with the diseased mass. This greatly increased the difficulty of keeping above the sub- clavian vein which, though firmly adherent, was finally detached by cautious use of the handle and blade of the knife alternately. The patient lost from sixteen to twenty ounces of blood, but made a good recovery. The growth was an osteo- sarcoma, the size of two adult fists. The necropsy, fifty-four years later (the patient's death not being due to the growth), showed that three-quarters of an inch of the acromial end had been left, the rest of the site of the bone being occupied by a ligamentous band. And the latter, no doubt, is the condition present in other cases where the after use of the limb has been so good. The use of the arm is said to have been perfect. Dr. Vaughan ^ performed complete excision for a mixed-celled sarcoma. Twelve months later the man was in good health, and had been carrying on his work as a fireman on a steamboat. Here it was thought that suture of the detached sterno- mastoid and trapezius to corresponding points in the pectoralis and deltoid had con- tributed to the excellent functional lesuit. In February 1899 Mr. Symonds removed the clavicle for a mixed-cell sarcoma. The outline of the bone was here masked by the growth, and the boundaries of the latter not well defined. The operation was rendered difficult throughout by the very free bleeding at all jDoints, the extent to which the bone was tied down, and the consequent difficulty of getting at the coraco-clavicular and costo-clavicular ligaments. The patient made a rapid recovery, and remained well a year later. A case of angeio-sarcoma of the clavicle is recorded by Dr. Beatson, of Glasgow."* The drawing accompanying the paper shows the usual globular swelling, and gives as good an idea of the fixity which may be met with as it is possible for an illustration to do. The second rib, where eroded by the growth ,required gouging, and some enlarged glands, the nature of which is not given, were removed from the posterior triangle, and six months later a further removal of glands was performed which the microscope left undecided whether they were sarcomatous or inflammatory. Yet the patient was alive and well two years after the first operation. ^ In a case of Mr. Caddy's, of Calcutta, (3Ied. Bee, November 19, 1892), in which the inner two-thirds of the right clavicle were removed for a periosteal sarcoma, the pleura and innominate vessels were exposed in dissecting away a tongue of growth which i^assed down behind the manubrium. The patient recovered with perfect movement of the arm. 2 Amer. Journ. Med. Sci., vol. iii, O.S. p. 100. 3 Med. News, January 8, 1898. * Brit. Med. Journ., 1902, vol. i, p. 128. SURGERY I 16 242 OPERATIONS ON THE UPPER EXTREMITY A good instance of partial removal of the clavicle is recorded by Sir J. Bland Sutton : ^ Here the acromial half was removed for a myeloid growth in a woman, aged 26. The chief difificulties met with were, first, the tightness with which the bony capsule was tied down over the coracoid process by the coraco-clavicular ligaments, these structures requiring careful division with scissors. Secondly, the supra-scapular nerve ran in a shallow groove in the eapusle of the tumour, and was reflected without injury. Nearly four years later there was no evidence of recurrence. A fibrous band united the remains of the clavicle and the acromion, and the patient could l^erform all movements of the extremity perfectly. Mr. S. B. Radley and Mr. W. Duggan give an. account ^ of an interesting case of a thyroid tumour of the clavicle treated by excision. The patient, a muscular man aged 46, had been operated upon for an adenoma of the thyroid in September 1910. In October 1912 he was admitted to the Manchester Royal Infirmary for a painful swelling of the right shoulder ; the thyroid was then normal in size and moved freely. The operation of total excision of the clavicle was performed by Mr. Thorburn. Histologically the tumour closely resembled a secondary thyroid carcinoma, though colloid material was absent. OCCASIONAL CONDITIONS OF THE CLAVICLE, ACROMION, OR THEIR JOINTS WHICH MAY CALL FOR OPERATION A. Fractures of the clavicle. (Operative interference may, very rarely, be called for in some of the following cases : (1) In recent cases with very marked displacement difficult to reduce or keep in position, as in fracture of the acromial end, outside the coraco-clavicular liga- ments. (2) In compound and comminuted cases, after the wound has been enlarged so as to promote asepsis, wiring of the fragments will be quite justifiable, especially if they are comminuted. (3) In cases where there is injury to, or pressure upon, the vessels or nerves, either at the time of the accident, or later owing to excessive callus. (4) In rare cases of pseudarthrosis, the non-union being probably due to the interposition of a portion of the subclavious. (5) Where an ugly union or pointed process of bone presses on the skin or causes disfigurement. An excellent instance of pseudarthrosis ^ in which pressure on the nerves supervened later, most successfully treated, has been recorded by Mr. Barker.* A boy, aged 12, was noticed soon after birth to have a fracture of the right clavicle the cause of this being uncertain. Ujd to nine years of age the child had no inconvenience. He was then gradually more and more troubled with pressure on the brachial plexus, pain down the arm, and a tendency of the fingers to become stiff and fixed in a flexed position in writing, this condition soon amounting to one of painful spasm, rendering the writing quite illegible. Mr. Barker made an incision about two inches long, with its ends on the clavicle and its convexity downwards. The flap of skin thus formed was turned upwards to expose the false joint. The outer end of the inner fragment was then divided obliquely in a plane mnning from within outwards and from before backwards. The inner end of the outer fragment was divided in a plane corresponding to that of the section of the inner fragment. The inner end of the outer fragment was then separated from the brachial plexus and its cut surface placed upon that of the inner portion of the bone. The two were then united by silver wire. The wound was closed, and after the dressing was applied the arm was fixed to the side by a plaster of Paris bandage. This was removed at the end of fourteen days, when the healing was complete and a mass of callus could be felt at the seat of the operation. A week ^ Clin. Soc. Trans., vol. xxiv, p. 12. * Bril. Journ. Swg., vol. i. ^ As a rule, non-union or psoudai-throsis of the clavicle does not cause the patient much trouble, if it has occurred in early life. Though the ends of the bone may be atrophied, the muscles will be found hypcrtrophied. * Clm. Soc. Trans., vol. xJx, p. J.04. EXCISION OF THE CLAVK LE 2iH later the power of writing was found to be inurh iininovcd, and tlic arm eventually beeame perfect in all its functions. Mr. Bilton Pollard ^ records a case of ununited fracture of about four months' duration, in an infant aged eighteen months, in which he resected aiid wired the fragments with an excellent result. Sound union followed, and the arm, previously hardly used at all, was moved as wx'll as the other. In those cases where much deformity has followed union of a fractured clavicle, especially where a pointed process of bone projects under the skin, it will be quite justifiable, with strict aseptic precautions, to explore and to remove the projecting bone with an osteotome or saw. B. Dislocations. It is well known that occasionally dislocations of the clavicle, especially those of the sternal end, are most difficult to maintain in place after reduction. In these cases, especially where the sternal end has been displaced backwards or upwards, in which situation it is liable to press upon the trachea, cesophagus. or large veins, operation is indicated. The displaced bone is exposed by a suitable incision, and then, after resection of a portion of the extremity, the dislocation can be reduced and the bone wired in position. In 1890 Mr. Jacolson removed the sternal end of the clavicle for an old disloca- tion upwards and backwards in a patient at Guys Hospital. Only the cartilage required to be removed from the sternal facet. The wire was removed in three weeks. When the patient left the hospital, five weeks after the operation, the deformity was entirely removed and the parts were somidly consolidated. Four weeks later he had resumed his work. He could raise his arm to a right-angle, and the movements were increasing. Resection of the acromion-clavicular joint was performed as long ago as 1861 by an American surgeon. Cooper of San Francisco.- He resected the joint in three eases of acromio-clavicular dislocation. In each case the lesion was of several years' standing, and the usefulness of the limb much impaired. In all three the result was excellent. ]\lr. Jacobson has operated bj- resection and wiring in three cases of acromio-cla^^cular dislocation, two of these being primary and one a secondary operation. In two the result was perfect. In the third, one of the primary cases, infection followed, and the wire had to be removed. The deformity was, however, removed, and the union was secure. C. Disease o£ the ioints. It is well known how obstinately tuber- culous disease sometimes attacks the sterno-clavicular joint. The simplicity and the superficial position of this joint render erasion, followed, if need be. by removal with a chisel or osteotome of one or both bone ends, a most successful operation. 1 Brit. Mcd.Journ., 1887. vol. i. p. 676. * Atiier. Journ. of Med. Set'.. April 1861. PART II THE HEAD AND NECK CHAPTER XIII OPERATIONS ON THE SCALP But few — viz. those for large fibro-cellular growths and the vascular tumours known as aneurysms by anastomosis or cirsoid aneurysms, &c. — will require mention in a work like this. FIBRO-CELLULAR GROWTHS, MOLLUSCUM FIBROSUM, OR PACHYDERMATOCELE OF THE SCALP These rare growths, occasionally require removal, on account of their hideous deformity.^ The chief points of importance in such operations are : (I) The haemorrhage. This may be terrific- copious, and weeping from every part, owing to the huge size of the growth and the vascularity of the parts. It is best met by an ingenious precaution of Mr. Hutchinson's,^ who prevented all arterial haemorrhage during an extensive operation of this kind by applying round the head, just above the ears, a Petit's tourniquet with a narrow strap, cotton-wool being placed over the eyes. Nowadays india-rubber tubing which can be sterilised, or Makka's clamps {see Fig. 118, p. 255) would be preferable. (2) The need of maintaining strict asepsis. As nearly the whole thick- ness of the scalp affected must usually be sacrificed, the pericranium may be damaged and the bone necessarily exposed. The risk of septic osteitis and then phlebitis of the veins of the diploe is well known, with the inevitable result of pyaemia. In very large growths two or more operations may be required. Thiersch's method of grafting {see p. 43) will be very useful, either at the close of the operation or later on. Recurrence is not unlikely even after extensive operations, and von Recklinghausen has shown that the proliferation of the connective tissue takes place along the nerves ; it is therefore obviously possible that such tissue left along any of the nerves may serve as a fresh starting- point. ^ A gooi illustration of these growths is given by Mr. Hutchinson [Lond. Hosp. Rep., vol. ii, frontispiece), and another by Sir J. E. Eriehsen {Surg., vol. ii, p. 533). The drawing in this case is said to be taken from a patient of Sir W. Stokes. 2 It is so described by Sir W. Stokes {loc. supra cit.). The patient, a man aged 33, in good condition, almost died on the table. 3 Loc. suprn cit., p. 118. The piece of scalp removed here was twice as large as the palm of the hand. Owing to the precautions taken, there was no arterial hcemorrhage. In Sir W. Stokes' case the base of the growth was very wide, reaching from above and in front of the right ear to the left of the occipital protuberance, upwards as high as the vertex, and hanging down as low as the shoulder. 244 OrKKATIONS ON TllK SCALP 24.5 ANEURYSM BY ANASTOMOSIS (CIRSOID ANEURYSM) The treatiueiit ot these .sometimes most dillicult cases is given under the head of " Ligature of the External Carotid." QUESTION OF OPERATIVE INTERFERENCE IN GROWTH OF THE CRANIAL BONES AND DURA MATER CucUh' this heading reference will be niadi; to ( 1 ) Exostoses ; (2) those malignant growths, usually sarcomata, which, springing from the scalp (often the pericranium), the diploe,^ the meninges, and, more rarely, the brain, are capable of perforating the skull from within outwards or in the reverse direction. (3) Epitheliomata. These growths are the ones in which the advisability of operation is most likely to arise. (1) Exostoses. It is only the ivory variety that needs reference here. These exceedingly hard slowly growing tumours usually grow from the fiat bones of the skull, especially in the walls of the frontal sinus or in the external auditory meatus. The best incision to expose it, in the former situation, is one transversely outwards from the root of the nose, through the eyebrow, and another upwards along the middle line of the forehead. The anterior wall of the frontal sinus must be freely removed with trephine or chisel, for it is essential to get at the root or base of the exostosis and to divide this, and not merely to break ofi pieces of the exostosis. For division of the extremely dense bone a burr worked by electricity is preferable to chisels and saws. Where the latter are relied upon several must be at hand. When the pedicle is detached there is often much difficulty in prising out the exostosis. The surgeon must be prepared for opening the posterior wall of the sinus and exposing the meninges, and perforating the roof of the orbit, and the delicate tissue of the ethmoid. In some cases it will be well to obtain leave to remove the eyeball. Careful drainage must be pro- vided for the first few" clays in case of infection from the nose, and for the same reason the wound should not be too closely sutured at first. (2) Sarcomata. Periosteal, endosteal, and those originating in the dura mater. The following remarks by von Bergmann,^ by von Bruns, and von Mikulicz may be useful. Sarcomata of the skull may be periosteal or central. The temporal bone is most frequently attacked, after this the frontal, parietal, and occipital. Even at an early stage the surgeon has to face the c[uestion whether he is dealing with a sarcoma of the skull or one perforating from within. In the majority, whether periosteal, central, or from the dura mater, spindle-cells predominate Those arising in the dura mater are characterized by calcification. In large periosteal sarcomata the abundant blood-supply may lead to distinct pulsation. At a very early stage this form shows a tendency to increase by secondary nodules, seated at first near the base of the original growths. This tendency to local dissemination, which can only be determined by the microscope, explains the frequency of recurrences. Metastases in the viscera, especially the lungs and in the bones, are very common. The lymphatic glands, as a rule, are not involved. ^ While the vault is affected more often than the base, sarcomata of the skull may be present in both situations, simultaneously. ^ Syst. of Pract. Surg., by von Bergmann, von Bruns, and von Mikulicz (Amer. Trmis., by Drs. Bull and Martin, vol. i, p. 124). 246 opp:rations on the head and neck Only ill the early stages, and under conditions rarely present, is it possible to determine whether a sarcoma of the skull is central, periosteal, or arises from the dura mater. If the surface be hard and bone-like it can only be a central sarcoma or possibly a local periosteal hyper- ostosis. In central sarcoma the surface soon becomes altered by softer areas which bulge outwards ; often the summit of the swelling is soft while the periphery remains hard. In this way the appearance is very similar to that of a perforating sarcoma of the dura mater. The latter, however, never lifts up the bony wall of the skull, but destroys it by infiltration ; the growth is therefore surrounded by a bony ring. The latter is, however, on a level with that of the general surface of the skull, and does not, as in the case of the central sarcoma, extend from the base of the growth towards its summit. In the case of the central sarcoma the outer and inner tables feel as if they had been forced apart, while in that of the periosteal sarcoma the tables show a jagged edge. If every periosteal sarcoma were composed only of soft tissues it would be easy to distinguish it from a central sarcoma, as long as the latter possessed a bony shell at its base, if not at its summit. However, osteo- sarcoma of periosteal origin, a frequent growth, has a bony feeling also, both at the periphery and summit. The latter possess no bony shell, but numerous spicules of bone extend into the growth from the site of its attachment. On palpation these growths give the impression of a bony capsule, and this leads to mistaking an osteo-sarcoma for a central sarcoma. The most certain indication of the origin of a new growth in the diploe is the presence of the bony wall rising above the level of the surface of the skull and extending towards the summit of the growth. Sarcoma of the dura mater is recognized in exceptional cases only by the above-mentioned peculiarities of the gap in the skull, its situation within the plane of the surface of the bone, and its sharp outline. It may be diagnosed earlier by other symptoms. " If previously existing symptoms, especially those of intracranial pressure, disappear as soon, or soon after, a tumour appears at the surface of the skull, the surgeon is safe in assuming that the growth originated in the dura. Such a tumour begins to develop within the cranial cavity, and brings about symptoms due to encroachment on the intracranial cavity. As soon as the tumour makes its exit from the interior of the skull the diminution of space and the combination of symptoms resulting therefrom cease. In the second place, perforating dural sarcoma usually palsates as a result of the pulsation of the brain being transmitted to it. In the third place, such a tumour may be forced by pressure into the cranial cavity, causing temporary headache, slowing of the pulse, and loss of consciousness. If these three symptoms be present the surgeon can with certainty diagnose sarcoma of dural origin which has perforated the skull and continued to proliferate out- side. Conversely, he cannot, however, exclude the dural origin of a growth in which the characteristic symptoms are absent. A tumour may be so closely adherent to the edge of the defect in the skull that no pulsation of the brain can be transmitted to it, or that pressure cannot force the growth into the cranial cavity. The presence of cerebral symptoms accompanying a tumour on the surface of the skull has no bearing on the differential diagnosis under discussion, for periosteal, as well as myelogenous, growths may proliferate inwardly as well as outwardly. The diagnostic importance of cerebral symptoms depends OPERATIONS ON THE SCAT.P 247 upon the fact that tliey occur before the tumour becomes noticeable, and disappear after it has ur.uU^ its ap])earance on the surface. As soon as the tumour reaches the surface of the skull it spreads out to an extraordinary dej^ree, the defect in the skull completely covered, and there is no longer anything to distinguish it from periosteal and myelogenous sarcomata, which similarly proliferate and attain an enormous size." TrcdliHcnf. It remains to be seen what operative attacks, aided by modern surgery, may avail in these cases, but for the present, unless an opportunity arise for attacking such growths quite early — e.g. while they are oidy of small size — it will be wiser not to inferfere.^ And this warning is especially true of those cases in which sarcomata of a specially malignant kind appear, often after an injury, on the crania on children,'^ where the swellings of the scalp are nudtiple, or where they are travelling out of the skull by any of the apertures, ('.(/. the orbit. Large size, any evidence of fixity, duration of any length will cause any operation to be set aside, owing to the dangers of the operation, the possibility of its being incomplete, especially where the brain is involved, and the risk of its being impossible to close the gap. In addition to the question of metastases in such cases, the frequent presence of minute local secondary nodules {.see p. 245) must be remembered. The necessary difficulty and tediousness in isolating the affected bone, if of any size, by sufficient trephine-crowns, and joining these with a Gigli's saw {see p. 314), or the forceps of De Vilbiss {.see p. 312), or a chisel.^ It must be remembered that the overlying soft parts were extremely vascular and perhaps (from the enlarged gland) already involved in the growth. The position of these growths will not always admit of the use of an india-rubber band round the head. In isolating and going wide of the affected bone, it was uncertain whether one or more sutures would not be crossed, and sinuses, such as the superior longitudinal, met with and need securing (this, whether by underrunning or otherwise, not being always an easy matter), thus leading to profuse hgemorrhage. In addition to this source of hsemorrhage there is that certain to be met with in dealing with the soft parts and with the diploe around the affected bone, unless this be extensively sclerosed, when another difficulty presents itself. Tlien. supposing the bone sufficiently removed, wide of the growth, in many pieces, either because of its involvement in the disease, or to allow of further investigation in the case of a growth of doubtful origin, if this be found to arise from the dura mater, this membrane must certainly be dealt with, and the same would very likely be the case if, originating in the diploe, the growth had crept inwards. In further isolating the disease, if it had merely pressed upon the brain and not involved it most delicate w^ork would be required ; enlarged branches 1 An interesting case is published by Sir. H. Morris {Path. Soc. Tra?^., vol. xxxi, p. 259). The disease hei'e certainly took six years in running its course ; other deposits were present. The patient died away from London. The growth is stated to have begun in the diploe, and to have compressed, not involved, the brain. Dr. Drummond of New- castle, published three interesting cases {Brit. Med. Journ., 1883, vol. ii, p. 762). In none of them was operation possible. Other instances of sarcomata of the cranial bones or the dura mater are figured by Tilmanns {Text-book of Surg., vol. ii). 2 A good instance of such traumatic sarcomata is recorded, with illustrations by Mr. Hewetson, of York {Lancet, 189,3, vol. i, p. 1441). ' The] best means of removing bone from the skull on a large scale are given at pp. 311-313. 248 OPERATIONS ON THE HEAD AND NECK of the middle meningeal and, ven' likely, dilated sinuses would require to be dealt with. If the disease had involved, instead of merely displacing, the brain, new and special risks would have to be encountered just when the patient's condition, after an already prolonged operation, was least fitted to bear them. Thus the operator may find that he is dealing ^^ith a non-encapsuled growth of the brain itself, and all that he can do is to try and shell it out with the finger or sharp spoon. Lastly, the arrest of all hsemorrhage and the possibility of closing the wound and gap in the skull, usually by a second operation, if the patient survive, have to be remembered. Such are among the chief diflSculties and dangers which are very likely, if not certain, to be met with. Moreover, in these and in other prolonged operations which deal with the brain and its membranes, the fact must never be lost sight of that, with all the necessary interference with vital organs, and what with the ansesthetic, the margin left to the patient between hfe and death may be a ver\' narrow one. Even if the growth is small and circumscribed, and there is good reason to beheve that it is single, it will probably be wiser to dixade the operation into two stages if the dura mater be involved. The results given by von Bergmann.^ especially when due weight is given to his unusual experience and operative skill, do not seem encouraging. The last sentence referring to " cases apparently per- manently cured*' is too vague to be of any real value. ' The author has done extensive resections in four cases of cranial sarcoma ; in one of these the patient died. The tumour had prohferated a considerable depth into the occipital lobe, and the profuse bleeding which resulted caused collapse. The three other patients recovered. Two died at the end of one and a half and two years, respectively, as a result of recurrence of the growth. Regarding the fate of the third, he was not able to obtain any information. Grunberg investigated the histories of all operations published during the last two decades. Twent^'-two operations were performed on seventeen patients. In three cases two or more attempts at interference were made necessary by recurrence of the growths. The operation was completed in seventeen cases. Three of the patients died as a result of the operation, death being caused by entrance of air into sinuses, thrombosis of sinuses, and cerebral abscess. In seven cases recurrence took place soon after the operation. In two no information was obtainable. Of seventeen cases five were apparently permanently cured, which is a good result, considering the fatal termination otherwise." (3) Another similar, but distinct, class of these growths is formed by those epitheliomata of the scalp which have extended through the cranium to the dura mater or even the brain. Tillmanns ' gives good illiLstrations of two such epitheliomata invohnng the frontal region : one. in a girl of 14. which perforated the skull, was successfully removed by Braun ; the other, in a man of 56, was operated on by Tillmanns. Here recurrence rapidly took place. A xevy instructive case of carcinoma of the frontal region, invohdng the skull, was successfully operated on by Mr. Battle and is fully described in the Clin. Soc. Trans., 1899. vol. xxxii; p. 127. Mr. Shattock pronounced the growth to be a spheroidal- celled carcinoma, probably originating in the glandular structures of 1 Loc. supra cit.. p. 148. * Surg., vol. ii. OPERATIONS ON THE SCALP 249 tli(' skill. Mr. Battle's remarks on the mode chosen for removal of the cranial hone arc \'crv noteworthy : " Of the priiic;ij)al methods of removing large portions of the skull, the one whieh was brought to my notice by Messrs. Down — that of a circular saw worked by a motor — appeared the most likely to fulfil the object in a satisfactory manner. There was, however, much difHcuitj' in guitling the saw along the line which I had selected, and it travelled slowly through the dense bone, whilst the cable attached to it was cumbrous and difficult to hold. Were I again called upon to perform a similar operation, or one requiring the excision of much bone, 1 should use the method, since suggested, of the wire saw, worked across from one trcpine opening to another, and applied from witliiii outwards." CHAPTER XIV TREPHINING OPERATIVE INTERFERENCE IMMEDIATE OR LATERE IN FRACTURES OF THE SKULL Indications. The chief are : (1) Compound depressed fractures. Whether symptoms of com- pression are present or no these fractures should, as a rule, be explored by reflecting adequate flaps, then elevating any depressed fragments and remo\ang any which are quite loose. At the same time the surface of the dura mater, where exposed, should be carefully scrutinized and, together with the rest of the wound, thoroughly cleansed. Operative interference is indicated in tliese cases for two reasons : (a) Even if no symptoms of compression are present at first, secondary inflammation is very likely to follow in a few days, it not ha\ang been possible by expectant treatment completely to cleanse the wound. If, now, some minute fragment of the brittle inner table has pricked the dura mater, fatal infective meningitis is almost certain. Should, therefore, the surgeon, in these cases, wait for evidence of compression as a justification of operative interference, he will too often wait till it is too late. E\'idence of the presence of dirt, especially of dirt ground down to, or into, the bone, is a reason for exploring the wound, even if no symptoms of compression are present, (b) If the patient recover from the immediate effects of the fracture, injury to the inner table, insufficient to cause symptoms at the time, and not detectable save by an operation, may be present all the time and cause serious future trouble. In the words of Professor Xancrede : - " Undoubtedly many patients recover in whom the bone is not elevated, but in too many epilepsy, insanity, chronic cerebral irritation, &c., render life a burden, and operations are then required, which often prove useless.^ Operations for traumatic epilepsy show at times that in the effort to unite the irregular fragments, and from constant irritation due to the cerebral ^ By these terms it is intended to make a distinction between those cases in which operative interference is made use of within a few days after a fracture, and those in which it is only employed a long time after the injury. {See " Trephining for Traumatic Epilepsy.") 2 Intern. Encycl. of Surg., toI. v, p. 24. 3 Dr. Gunn {Trans. Amer. Surg. Assoc, vol. i, p. 89), speaking of later trephining for the relief of old depressed fractures, says "Although results of these secondary- opera- tions do not show a flattering percentage of success, I think that the reason may be looked for in the late period at which the operation is performed. It is rare that the patient submits to the operation till years have been wasted in the vain endeavour to effect a cure by medication. In the meantime, the constant irritation has begotten a permanent impression upon the brain and nervous system which remains after the offending point of irritation has been removed." 2.50 THKPIIINIXG 251 pulsation (liiviiit^ 10, was admitted, July 21, into the London Hospital -ndth extensive laceration of the scalp on the left side, laying bare the parietal bone. During the first few days he seemed to be doing well. July 26 : Bone as large as a crowi piece is exposed white and dry above the left ear. July 29 : A strong rigor ; wound not granulating. July 31 : Very restless. Uses all his limbs at times, but the left ones better than the right. August 1 : The skull was trephined in the middle of the exposed bone two inches above the left ear. The dura mater was covered with yellow lymph, but pulsated freely. On cutting through it about 3j of thin purulent fluid escaped. The arachnoid was seen to be covered with Ipnph. August 2 : There is still paralysis of the right hand. When the brain, which bulged, pulsating, into the wound was pressed back, pus in considerable quantity escaped from the arachnoid cavity. Death took place on August 3. The bone around the trephine aperture was dry and green. On the left side the arachnoid was covered with a thick deposit of purulent lymph, while on the right side it was normal. The superior longitudinal sinus contained puriform fluid. The skull at the seat of injury was discoloured over an extent almost as large as the palm of the hand ; adjacent to it were other patches, greenish-yellow, and non-vascular. There were no pyaemic abscesses in any of the viscera. E. S., aet. 40, was admitted into Guy's Hospital under Sir H. Howse on January 22, 1877, with a scalp wound four inches long, exposing the right parietal bone. The discharge became offensive and eiysipelas of the scalp set in. At this time almost the entire right parietal bone was exposed owing to sloughing of the ^ In these cases, and in fact, in any trephining cases where the discharges are infected, hot boracic fomentations, frequently changed, are preferable to dry dressings changed less frequently. 262 OPERATIONS ON THE HEAD AND NECK pericranium. Incisions were made where needful, drainage tubes introduced, and in a few days the erysipelas had subsided and the wound was sweet. February 1 1 : She had a rigor for the first time. February 13 : The temperature was 104 ; there was some paralysis of the left side of the face and the left limbs. February 15 : The hemiplegia becoming more marked the skull was trephined about one inch above the right parietal eminence. Pus was found in the diploe. On removing the disc of bone, abovit 5J of thick, foul, greenish pus welled up. The inner surface of the bone was rough, the dura mater, which corresponded to it, being covered with velvety granulations. As the dura mater did not pulsate it was punctured but without result. The patient became more conscious after the opera- tion, but soon relapsed into a semi-conscious state. Convulsive seizures of all the limbs, with twitchings of both sides of the face, then set in, and continued until the patient's death on February 17. The parietal bone was in a necrotic condition for a considerable area, the diploe being green and offensive. The pus seemed to have drained from the extra-dural space, but there was suppurative arachnitis over the right hemisphere, reaching to the falx in one direction and towards the base in the other. There were numerous pya?mic abscesses in the lungs and liver. In the following case Sir W. MacEwen^ was more fortunate. The case was one of extra-dural suppuration with pachymeningitis, exhibiting Pott's " puffy tumour," and originating in infective bruising of the scalp and deeper tissues, but here the pachymeningitis was fortunately limited and pygemia absent. I. R., set. 45, received from the shaft of a cart, a severe blow on the left side of the vertex, about an inch from the mid line. He was subsequently able to work for a week without feeling anything wrong except slight pain at the seat of injury. Later on he felt feverish, the pain, which was of a dull character, increased, and was accompanied by occasional sharp stabs over the vertex. He also had great head- ache and prostration. There was a distinct puffy tumour over the seat of the injury. The swelling, the patient declared, appeared three weeks after the accident and after it formed he had some relief from the pain. The primary swelling f rom- the bruising had subsided some weeks before the puffy swelling appeared. On incision the skull was found bare, a small quantity of semi-purulent exudation bathing the bone. The diploe was filled with granulation tissue, which could be traced in small portions penetrating the bone, both through the external and almost through the internal table of the skull, which was dark in colour. Between the internal plate and the dura there was a considerable layer of freshly formed granula- tion tissue, bathed in purulent exudation. The patient's symptoms quickly cleared up after the operation. TREPHINING FOR MIDDLE MENINGEAL HiEMORRHAGE (Figs. 121, 122) Indications. When a patient, after receiving an injury to the head, has shown some of the symptoms given below. . It is noteworthy that the injury and amount of violence vary extremely. While most frequently serious, as in falls on the head, the violence may be extremely slight, for example, a patient slipping while going downstairs and striking his head against the wall, a boy receiving a blow from a cricket ball, or a child having a trifling fall from a swing. From this the following conclusions may be drawn : (ft) That in cases of severer violence, laceration or contusion of the brain are only too frequently complications. (6) Where the violence has been slighter, either no fracture may be present or, if one be present, it is often only a mere fissure, and may involve the internal table only. It is a point of practical importance that the slighter the injury the less likely are the soft parts to show any damage. This has led, in some cases, to the injury being overlooked. (1) Interval of consciousness or lucidity. Typically the injury to the ^ Pyogenic Diseai^es of the Brain and Spinal Co'd, p. 289. MENINGEAL HAEMORRHAGE 263 head is followed by the symptoms of concussion : These may be but slightly marked and quickly disappear. Then, after an interval, during which symptoms may be slight or even absent, the patient gradually passes into a condition of deep coma. This interval between the con- cussion and the onset of compression varies, when present, from a few minutes to several hours. In about half the cases it is well marked. In a second group it is but little marked and may be easily overlooked. In a third and last set of cases this interval is never present at all owing to (1) the presence of a very large haemorrhage, producing compression symptoms at once ; (2) co-existing depression of bone ; (3) co-existing injury to the brain ; (4) drunkenness of the patient. (2) Condition of the limbs as to hemiplegia, paralysis, rigidity, &,c. Hemiplegia, though well marked in a large proportion of cases, must not be looked upon as essential, and middle meningeal haemorrhage must not be overlooked because hemiplegia is absent, ill-marked, or replaced by some other condition of the limbs. At least the following seven conditions of the limbs may be met with in middle meningeal haemorrhage : (a) Hemiplegia present and well marked, the leg or arm, and usually both, when taken up and let go, dropping without any resistance. This condition is present in probably one-third of the cases. It is note- worthy that occasionally the hemiplegia is on the same side as that injured, the extravasation taking place on the side opposite to that struck. (6) Hemiplegia present, but little marked. In these cases, which are not uncommon, the extravasation may be overlooked. They fall into at least two di\asions. In one the hemiplegia is little marked throughout, due, perhaps, to some power of accommodation on the part of the brain or to the circulation remaining feeble owang to co- existing shock from the time of injury to the moment of death. In another group of cases the hemiplegia is ill-marked because of brief duration, coming on as it does in these cases towards the close, together with coma, giving but little warning and leaving but short time for interference. When there is any doubt as to the existence or degree of hemiplegia, the following tests should be carefully made use of : whether the patient resists on the surgeon attempting to move the limbs ; the power of the grasp ; the result of a needle prick ; whether the patient moves either of his hands, or which of them, when the cornea is carefully touched, or the cilia gently pulled. (c) Hemiplegia present, but temporary. A very rare condition, produced probably by the brain being able to accommodate itself to the pressure of the efEused blood. (d) Monoplegia, or the paralysis more marked in one limb than the other. While a large haemorrhage generally makes pressure upon all the motor area, von Bergmann and Kronlein point out that the opposite arm is the part affected first and most, the branches of the artery having become quite small by the time they reach the centre for the leg. (e) General paralysis. Another rare condition, the existence of which may be explained by a very large clot — e.g. on the left side rapidly 'effused and making pressure through the left side of the brain, upon the right as well — or by co- existing extravasation into the^brain substance itself. PUP/LS S.QUAL PUPil^ UfitQU/il. 264 OPERATIONS ON THE HEAD AND NECK (/) Absence of any paralysis. A very rare condition and one which is, perhaps, due to the blood effused finding its way through a fracture in the skull beneath the scalp (see footnote, p. 2G5). Another explana- tion may be that the clot is posterior to the motor area, of the rarer pari eto- occipital and not the more frequent tempero-parietal variety. [g) Limbs rigid, convulsed, or twitching. It is only too probable here that, in addition to middle meningeal extravasation, contusion or laceration of the brain substance will be found at more spots than one. (3) Condition of the pwpils. Whilst this may vary, there are at least three conditions which are most important. (a) In an uncomplicated case of compression from middle meningeal haemorrhage the pupil on the injured side, after an initial transitory contraction, becomes dilated and fixed, i.e. does not react to light. The pupil of the opposite side, which at first is normal in size and reacts to light, also becomes dilated and fixed in the later stages. When present, this condition of the pupils is a most valuable sign of the existence of compression, and also affords important information as to the side affected. Its value and explanation were first pointed out by Sir Jonathan Hutchinson.^ (b) If the pupils are natural as regards reaction to light, the compression of the brain is probably recoverable if trephining be immediately performed. Further, it is more likely to be a case of com- pression of the brain only without other injury. (c) If the pupils are insensitive, often at the same time dilated, the compression is probably extreme, and, while trephining is urgently called Fig. 121. Typical condi- ^^r, it is less likely that in these cases the brain tion of pupils in left middle will recover itself after removal of the clot, meningeal hjemorrhage. (4) j^j^^ ^^Ise. This will vary according as the case is one of well-marked, ujicomplicated extravasation, or complicated with contusion or laceration of the brain ; and, if the concussion stage has been severe, according to the degree to which the heart has recovered from this. In well-marked uncomplicated compression the pulse will be slower than normal, e.g. 66, 52, or even slower, and usually full and labouring. If, later, a pulse which has been typically slow becomes very rapid it means that the final stage of paralysis of the vagus has set in and that a fatal termination is imminent. (5) Coma. With regard to this the following points should be borne in mind : (a) The degree of unconsciousness will vary with the size of the branch injured, and the rapidity with which the blood is effused. Where the effusion is rapid and the compression great, the coma may be as deep and complete as in apoplexy. But, in other cases, it will be found that though the coma is apparently deep, this is not really so ; thus the patient may moan constantly or may move his limbs feebly when disturbed. (6) The commencing coma may be taken for natural sleep or ^ London Hospital Reports, 1867, vol. iv, p. 29. SOTM PuPii^ fvu.y i MENINGEAL HAEMORRHAGE 265 drunkenness, in which condition the patient may be allowed to lie until it is too late. {c) In a few cases the onset of the coma is deferred till late ; its onset is here sudden, its course rapid, and it generally ends in death. (6) Respiration. This, in well-marked cases, is often stertorous and somewhat slow. In cases where stertor has not supervened to call attention to the existence of compression, other and still graver altera- tions in the breathing may be present, alterations which are warnings that the end is not far ofE and that, in the case of intended trephining, there is no time to lose, viz. catchy, short respirations, cyanosis, and gasping, irregular breathing, ceasing for intervals of ten or fifteen seconds and then repeated. (7) State of the scalp. When the history is deficient, or when the signs of compression are not well marked, ecchymosis or contusion of the parietal and temporary regions, giving rise to a pulpy or puffy feel, are of great value. This condition will be especially marked when the haemorrhage from the middle meningeal artery is finding its way through some fissure into the tissues of the scalp. ^ Treatment. Early trephining should be performed as follows : The scalp should be shaved widely as much bone may require removal. No anaesthetic should be given if the patient is unconscious or the respiration failing. If any be employed the greatest care must be taken on account of the risk of vomiting and aspiration-pneumonia. The head being supported on sand bags or a firm pillow, the middle meningeal area^ on the side which is bruised, and on the side opposite to the hemi- plegia, is explored by turning down a semilunar flap, the centre of which is one and a half inches behind the external angular process and one inch above the zygoma — roughly speaking, two fingers' breadth above the zygoma and about the same behind the external angular process (Fig. 122, p. 273). Kronlein distinguishes, according to the point of rupture, three haematomata — an anterior, fronto-temporal ; middle, temporo- parietal ; and posterior, or parieto-occipital. He advises trephining first at the usual place ; if no haematoma be found here, a second per- foration should be made further back, a little above and behind the ear, or, more accurately, at the inter-section of a line drawn backwards from the upper margin of the orbit with a vertical one carried up directly behind the mastoid process. Enlargement of either of these openings ^ There is a good specimen of this in the St. George's Hospital Museum, figured by Mr. Holmes in his Surgery, 4th ed., p. 140. It shows the parietal bone of a child, in which a gaping fissure crosses the middle meningeal artery, producing considerable extravasation inside the skull and still more externally. ^ L. B. Rawlings (surface markings) gives the following useful account of the surface anatomy of the middle meningeal artery. " The middle meningeal artery enters the skull through the foramen spinosum, and divides after a short and variable course across the middle fossa into two main trunks. The seat of bifi],rcation usually corresponds to a point just above the centre of the zygorna^^ The anterior branch is not only the larger of the two, but it is also more liable to injury, since it is protected in the temporal region only by a thin osseous barrier. The danger zone in the course of this may be mapped out by taking three points. ( 1 ) One inch behind the external angular process of the frontal bone and one inch above the zygoma. (2) One and a half inches behind the external angular process and one and a half inches above the zygoma. (3) Two inches behind the external angular process and two inches above the zygoma. A line uniting these three points indicates therefore, that part of the anterior branch which is most liable to injury. The anterior division of the vessel will be exposed by trephining over any of these three points, but it is generally preferable to choose the highest point, as in this way the posterior border of the great wing of the sphenoid is avoided ; as an additional reason it should be added that, in the position of points 1 and 2, the artery frequently runs in an osseous canal." 266 OPERATIONS ON THE HEAD AND NECK will enable the surgeon to deal with a middle or parietal-temporal haematoma. The brisk hsemorrhage which takes place from the scalp may be controlled by the use of Spencer-Wells forceps and Lane's tissue forceps, the latter acting as retractors also : Makka's clamps may also be employed for compressing the base of the flap. The pericranium is then carefully separated, and any fissure or fracture looked for in the bone. Whether one be found or no, a disc of bone is next removed with a full-sized trephine. When this has been exposed the clot,^ hsemorrhage may still be going on, warning of which will, perhaps, be given by the pulsation of the clot. This having been removed by a small scoop, by one of Volkmann's spoons, or better still by irrigation with sterile saline solution, the hsemorrhage may cease, or it may continue profusely, welling up from a point quite out of reach. In such cases the surgeon may, after saving his patient from the dangers of compression, have to face those of most serious hsemorrhage. In such a contingency much will depend on the accessibility of the bleeding-point, whether it is in the wall of the skull or in the foramen at the base ; the following steps may be made use of after the free exposure of the interior of the cranium by the removal of sufficient bone by Hoffman's forceps (p. 312). A good light is essential, an electric head lamp being often of the greatest use. (1) Ligature of the artery after removal of sufficient bone to expose the site of injury. (2) Crushing together with forceps the edge of the bone from which bleeding comes. (3) Underrunning the artery in the dura mater with a fine curved needle. (4) The use of Horsley's wax. This is a mixture of beeswax 7 parts, almond oil 1 part, and carbolic acid or salicylic acid 1 part. Its use is especially indicated when the artery is ruptured in the bony canal, the wax being forced into the opening wdth a probe. (5) Another method of checking the bleeding when the vessel is damaged in a bony canal is to plug this canal with a tiny boiled and aseptic wooden peg.^ (6) Forcipressure by means of a pair of Spencer-Wells forceps left in situ for twelve hours. (7) The above means failing, which is unlikely, ligature of the external or common carotid had better be resorted to.^ If such a step be really needful, a temporary closure of the common carotid (q.v.) will perhaps suffice. It is always to be remembered that local hsemostasis is greatly to be ^ Perhaps more bone must be removed by skull forceps satisfactorily to expose the clot. 2 This was suggested by Sir T. Smith, and used successfully by Mi". Willett and Mr. H. Marsh, at St. Bartholomew's Hospital in cases of haemorrhage from the descending palatine artery {Clin. Soc. Trans., vol. xi, p. 71. ^ Ligature of the common carotid is justified by a successful case by Dr. Liddell (Amer. Journ. Med. Sci., vol. Ixxxi, p. 344), in which secondary hsemorrhage from the middle meningeal artery, three weeks after a shell wound in the temporal region, was successfully arrested by ligature of the common carotid. If the condition of the patient be very grave, ligature of the common and not the external carotid will generally be resorted to, as being more quickly done. More recently Dr. E. L. Robinson, of Guernsey (Brit. Med. Journ., Dec. 31, 1904) reports a successful case with several points of interest. The patient, a woman set. 20, had, in falling from a shop counter, struck her head against a shelf. She had walked home and there vomited blood. While telling her story to a medical man, an hour later, she suddenly became unconscious with left hemiplegia, and widely dilated right pupil. A fracture was found in the anterior third of the temporal fossa, running down to the base. The bone when trephined was very thin. Fresh arterial blood and clot welled up into the opening as soon as this was made, and as it was impossible to see the source of the bleeding, the right common carotid was tied. This was successful at once. As the patient came round from the anaesthetic it was seen that the hemiplegia had disappeared. Save for rather tardy disappearance of paralysis of the third^nerve the recovery was uneventful. ^lEXIXCiKAL H/EMORRHAGE 267 preferred, and that, of the methods given above, ligature of the middle meningeal artery itself is the safest. Dr. 8h('])herd, of Montreal, records ^ an instructive case of middle meningeal luemorrhage in which ligature of the common carotid was successfully resorted to. That the ha-morrhage was not severe at first, and pressure symptoms from the slowly spreading clot were not marked until the day after the accident, is explained in Dr. Shepherd's opinion, by the fact that the rupture of the artery was low down, where the dura mater was closely attached to the base of the skull, and where it needed considerable force to separate it from the bone. A large and very tliick clot having been exposed by the removal of two trcpliine crowiis in tlie line of a fissured fracture in the anterior part of the left parietal, the empty meningeal artery could be seen ramifying on the dura mater, while blood was freely welling up from below. A large piece of bone, three inches long by two inches wide, was chiselled away in the hope of reaching the bleeding-point. After a large amount of clot had been removed there was furious bleeding from below. The brain and dura mater being held aside by a broad retractor it was seen that the fracture ran through the foramen spinosum, and then across the body of the sphenoid. The artery was evidently torn in the foramen. It was decided to tie the common carotid which immediately stopped the free haemorrhage. All the blood clot ha\nng been washed out, the space at the base of the skull was packed with iodoform gauze. The patient soon recovered consciousness. Two days later as the gauze was being removed, there was a tremendous spurt of blood as the last piece came away. The wound was therefore again packed. Three days after, the patient had a rigor, a temperature of l()2-5 , and paralysis of the left side and motor aphasia. These gradually disappeared and the gauze was removed without any bleeding ten days after the second plugging. The patient made an excellent recovery. Dr. Shepherd considered that the paral}'sis and aphasia were due to the compression affected by the large quantity of firmly packed iodoform gauze, and not to ligature of the carotid, for these signs came on only after the second packing and were veiy temporary in duration. The compression would have been rendered still greater w^hen the gauze became soaked w4th blood. Dr. Shepherd resorted to ligature of the common carotid instead of plugging the foramen, because this might have separated the fracture in the base of the skull. As in all operations on the head and brain, where the patient's condition is a grave one, infusion of saline fluid should be resorted to when the artery has been secured. How far the surgeon should remain satisfied with partial removal of the clot, or proceed to remove the skull freely, and then the clot, more extensively, must depend partly on the conditions under which the operation is carried out, but chiefly on the state of the patient, the size of the clot, and w'hether the depression in the dura mater begins quickly to pulsate and to rise up. If these last points are in doubt, there should be no hesitation, the condition of the patient admitting it. in removing more bone, and any clot which seems firm and dense, till all cause of depression in the membrane is removed. Prognosis. With reference to this point, the following remarks from a paper by Mr. Jacobson in the Guy's Hospital Reports, vol. xliii, maybe quoted : " The chief points on which this depends are whether the middle meningeal extravasation is probably complicated with such injuries as extensive fractures and brain injury and, secondly, upon the date of trephining, and whether, at this time, the brain recovers itself quickly or not. With regard to the former, or the existence of complications, the 1 Brit. Med. Journ., 1896, vol. i, p. 905. 268 OPERATIONS ON THE HEAD AND NECK surgeon will, if asked to state the probable result, base his opinion on the history of the case, the severity of the violence, e.cj. height of fall, whether any interval of lucidity has been present and, if so, for how long and how far has this been well marked, how far the symptoms of compression, well-defined hemiplegia, the failing pulse, the stertorous breathing, &c., are present or replaced by, or complicated with, those symptoms which are believed to point rather to laceration or contusion of the brain or its membranes, viz. restlessness, convulsive movements or twitchings, pulse quick and sharp, or pyrexia, which show that inflammation of the brain has probably supervened upon the injury to its substance." The seventy cases upon which the above paper was based appeared to fall into the three following groups : A. The most hopeful cases for trephining. Violence comparatively slight ; laceration of the middle meningeal artery or its branches ; fracture of skull, if present, slight and localized to one side, i.e. not implicating the base ; compression present, but little or no contusion or laceration of brain. Twenty-seven cases. B. Less hopeful cases. Violence greater ; laceration of middle meningeal or its branches ; fracture implicating middle fossa ; some injury to brain, but this only trivial. Twenty cases. C. Cases probably hopeless from the first. Violence very great ; lacera- tion of the middle meningeal or its branches ; fracture of skull extensive ; perhaps implicating several bones and sutures both in the vault and base ; injury to brain very severe. Twenty-three cases. Sub-dural haemorrhage. This obscure and difficult subject has had much light thrown upon it by a paper by Mr. W. H. Bowen.^ The differential diagnosis of extra-dural haemorrhage, intracranial suppura- tion, uraemia, idiopathic epilepsy, cerebral haemorrhage, and meningeal haemorrhage is carefully considered. Mr. Bowen is inclined to rely upon (1) the long duration of lucid intervals. (2) The presence of a scalp wound, or bruise, recent or remote. (3) The presence of Hutchin- son's pupil {see p. 264), which is however rarely present. The only treatment is early trephining. The following points of practical import- ance are brought out by Mr. Bowen in his paper : («) No fracture may be present in these cases of sub-dural haemorrhage. Operators who may be inclined on exploring a case to close the wound because the bones are found uninjured, should bear this in mind. (6) If, on opening the dura at more than one place, no clot is found and the brain bulges through, pulsating, the following possibilities must be borne in mind : (1) The diagnosis may be wrong and a cerebral abscess be present. If this is excluded, and if the passage of a curved director into the arachnoid cavity for the purpose of exploring neighbouring areas proves negative, the opposite side of the skull should be trephined and a careful search made there. (2) As in the case of middle meningeal haemorrhage it may be a case of contre-coup. (3) Where sub-dural haemorrhage is present, tenseness and non-pulsation of the dura mater are far more valuable than the colour of this membrane. " If colour be relied upon, two conditions at least may lead to error, one being that the compressing agent is not always blood, but may be blood and serum, or serum alone, when there will be no discoloration, notwithstanding the presence of pronounced compression ; the other that a thin layer of blood over the surface of the brain, associated with severe contusion, yet incapable ^ Gtiy's Hospital Reports, vol. lix. TRAUMATIC CEREBRAL ABSCESS 269 of compression, may cause discoloration, and this may also appear to be present when caused by the very distended veins on the surface of the brain pressed against the membrane." (4) With regard to the removal of the clot tliere is nothing to be added to the account given at p. 2()G. (5) Ha'morrhage may be difficult to stop and may recur dangerously. In such cases it is possible that a sinus has been opened by a fracture running into the base. Cerebral vessels may require ligature. (()) As to the advisability of drainage no rule can be laid down. Only when it is certain that all clot has been removed and that the field of operation is sterile, should the w^ound be entirely closed. The following case, under the care of the late Mr. H. W. Allingham,^ is a most interesting one, the bleeding having apparently come from a laceration of the frontal lobe. The length of the " latent " interval will be noted. A man, set. 40, was admitted to the Great Northern Hospital, having fallen off a tramcar while half drunk. He complained of pain in the left shoulder ; there was no evidence of injury to the head. The next four days the patient was very drowsy and irritable when disturbed. There was no jiaralysis. A week later the patient was seized with convulsions. These began in the left side of the face, the mouth being drawn up, and the eyelids moved in clonic spasm. The muscles of the neck were next affected, and subsequently the left arm and leg. The breatliing was stertorous. A large flap was turned down in the right parietal region and a disc of bone was removed over the right fissure of Rolando — i.e. about two and a half inches behind and one and a half inches above the external angle of the orbit. The posterior branch of the middle meningeal ran across the exposed dura mater. This mem- brane did not pulsate, and showed a black mass beneath it ; the artery being secured, the dura mater was incised and a large clot exposed. About three ounces of this having been removed chiefly by irrigation, a large cavity could be felt as far as the finger could reach ; the brain appeared to be much lacerated over the frontal lobe. The patient made a good recovery. TREPHINING AND EXPLORATION OF CEREBRAL ABSCESS DUE TO INJURY Indications for exploring ; symptoms and diagnosis of traumatic cerebral abscess. Many of these are given at somewhat fuller length in reference to that form of cerebral abscess which, as one of the results of otitis media, is discussed at p. 352. To begin with there is often the history of an injury. ^ This may have been a stab- with a knife, a graze of the head with brief concussion, a fracture, especially a compomid one, a blow with a stone or a glancing bullet. Occasionally an abscess may follow a trifling superficial septic injury, such as the bite of an insect, the infection reaching the brain through some of the emissary veins. Again the nasal fossae must not be forgotten, as shown by the case mentioned at p. 461. Dr. Carson^ mentions the case of a- child where the infection, starting in a nasal catarrh the result of an injury, extended through the cribriform plate to the brain and led to an abscess which terminated fatally. Often, but not always, follows a latent period devoid of brain symptoms, which may last from a few — e.g. four- days to three or four weeks or much longer. This latent period is succeeded by brain symptoms increasing in severity and going on to ^ Clin. Soc. Trans., vol. xxii, p. 220. * But the help which a history of injury gives is not always present, and this is an indication for always examining for any wound or scar, and exploring it, however un- important it may seem to be, in these cases. * New York Med. Journ., April 27, 1905. 270 OPERATIONS OX THE HEAD AND NECK those of compression, viz. headache felt over the side injured, but not necessarily most intense at the injured spot ; nausea or vomiting ; some pyrexia, although the temperature usually rises slowly, if it rises above the normal at all.^ Optic neuritis may be present. Other symptoms are mental dulness (the answers long delayed, but intelligent when they come), a slow pulse, perhaps rigors, progressive emaciation, perhaps accompanied by vomiting. Whether local nerve symptoms — e.g. disturbances of sensation and motion — are present must depend on the position of the abscess. If the injury has been over the motor area (Figs. 122 and 123) nerve symptoms may be clearly marked, but if over the anterior part of the frontal or temporo-sphenoidal ^ lobes, they may be entirely absent. Thus hemiplegia, a paralysis limited — e.g. of upper limb and, later on, gradually increasing — epileptic seizures, spasms, spastic rigidity, all have been met with, but must by no means be relied upon ; and even when paralysis is present it may escape observation, as when there is slight paralysis of the muscles of the lower half of the left side of the face, and some loss of power in the left hand and arm, but only temporary.^ Here, as in otitis media, there is but one rule, and that is, that in all cases where an abscess of the brain may be present, exploration should be undertaken, and that this step should not be deferred. For the surgeon, who is watching what he believes to be a cerebral abscess, must always remember that after a period of latency, which may last weeks or more, acute symptoms may set in suddenly and quickly close in death. Operation of trephining Jor traumatic cerebral abscess. As the fatality of cerebral abscess, if left to itself, is so high — 90 to 100 per cent. — trephining is abundantly justified. The chief difficulty is, of course, hitting off the seat of the abscess, especially in cases where there are no definite nerve symptoms to guide and where the history of the part of the head injured is indefinite also. To ob\'iate the neces.sity of multiple trephining, Dr. Fenger and Dr. Lee, of Chicago, have recommended,* as easier and safer, exploratory puncture and aspira- ^ On this and other points reference may be made to p. 352, Prof. Xancrede (loc. supra cit., p. 9.j) writes thus : '• I beheve that an abscess involvmg the cerebral tissue alone will be accompanied, in most cases, by a subnormal or, at least, a normal tempera- ture. Where a high temperature is noted, either the pus collection is a locahsed suppura- tive arachnitis limited by adhesions, or there is a meningitis in addition to the abscess." 2 With regard to the large collection of pus found here, Dr. Yeo (loc. supra cit., p. 885) quotes as follows from Huguenin {Ziemssen'-s Cyclopedia, vol. xii) : '' The difficulty of diagnosis is increased by the circumstance that no bands of fibres, which are direct conductors of sensibihty or motion," pass through this lobe ; and, therefore an abscess here •• may attain a considerable size, and may cause general symptoms of compression, before any distinct symptoms of local disease arouse the suspicion of a localised affection of the brain." 3 The value of accurately noting symptoms which, though of but brief duration, may be very important guides in treatment, is weU shown by a case of Sir. W. Macewen's (Lancet, 1881, vol. ii, p. 582). A boy, aged 11, was admitted into the Glasgow Royal Infirmary, two weeks after a fall upon his head, with a partially healed wound and bare bone over the left e\-ebrow. A week later he had a rigor. Five days later, or twenty-.six days after the injury, the patient had a convulsion confined to the right side ; when this had passed ofE, he was distinctly aphasic. The seat of the abscess now seemed to be the third left frontal convolution, and trephining was proposed. The friends, however, refused to permit this, as the patient had recovered consciousness, though they were warned that the improvement would only be temporary. Thirty hours later, the convulsions of the right side recurred, the temperature rose quickly from 101' to 104^, and the patient died before the operation could be performed. The situation of the abscess was verified after death. * Trans. Amc. Surg. Assoc, vol. ii, j). 78. TRAUMATIC CEREBRAL ABSCESS 271 tion. Tliis must b(> done mothodically, witli a needle, four inches long, set in an exploring syringe. The needle shonki not be too tine, and the gauge should be powerfulenough to make suffieient suction, as a tine needle is readily plugged with brain substance. This may be easily taken for pus. The needle, sterilised, is pushed tlu-ough a trepliine-hole, straiglit in, in a definite direction, for half an inch or one inch ; the piston is then withdra\vn a little and, if no pus follows, the needle is pushed half an inch further and the piston again withdrawn. The depth to which it will be permissible finally to push the needle will, of course, vary with the position of the trephine-opening and the direction of the pimcturc, the surgeon being guided by the anatomy of the brain. The ])unctures are to be repeated at intervals of half an inch or one inch, the utmost care being taken to push the needle in straight and to avoid all lateral movements. The loss of resistance and the sensation tliat the point moves in a cavity are to be carefully watched for. If, after a reasonable number of punctures, no pus is withdrawn, the operator may feel convinced that none is preseiit. Ail abscess in the brain is usually as large as a walnut, often much larger. More details are given at p. 357. Puncturing healthy brain tissue with a fine, perfectly aseptic needle can do but little mischief. The needle should be kept as a guide till the abscess-cavity is definitely opened either by inserting a pair of Lister's sinus-forceps or a sharp straight bistom-y. The abscess must be thoroughly drained and made to close from the bottom. A drainage tube should be used and should be kept in position by stitch securing it to the margin of the skin. The following cases of traumatic cerebral abscess, in addition to those given at p. 261 and in the footnotes to p. 270, are good instances of the disease and also of its successful treatment : A labourer, aged 60, was admitted into the ]\Iiddlesex Hospital, under the care of the late Mr. J. W. Hulke. a fortnight after being struck a glancing blow on the right temple by a falling ladder, which stunned him for a few minutes and caused consider- able bruise. He continued, nevertheless, to work as usual imtil the middle of the third day, when headache, which he had from the time of the accident, became very severe — -so severe that his wife feared that he would go out of his mind. On admission the pulse was 56, and the temperature slightly below the normal. The patient's mind was unclouded. About one week later, in the night, he became insensible, and in the morning the right upper and lower limbs were found absolutely palsied as regards motion, and nearly so as regards sensation. When the arm or thigh was severely pinched, he gave scarce any sign of consciousness of it, but shrank slightly when the left limbs were pinched similarly. Two days later, spastic rigidity of the left arm supervened. A small disc of bone cut out beneath the bruised bone on the right temple appeared uninjured. The dura mater bulged up so tensely that pulsation could neither be seen nor felt ; its exposed sturface appeared healthy. A needle connected with an exhausting syringe was pushed through it to a depth of one and a quarter inches. A brownish turbid fluid rose up into the receiver, and continued to flow after the needle was withdrawn. The minute opening was enlarged with a scalpel, and a considerable quantity of fluid escaped. The flaps, which had been reflected, were replaced. Next morning the spastic rigidity of the left arm had gone. On the second day slight return of power was noticed in the right Hmbs, and before the end of a week their palsy had disappeared. For a very few days after the operation the dressing was wetted and discoloured by the fluid which continued to ooze, but the wound soon healed, and two months after the operation the patient appeared quite well. It is interesting to note in the following case that the hemiplegia which followed the operation was only transitory. It also shows that grave symptoms may be latent for as long as five months if a skull wound remains unhealed. A child, aged 4i, had sustained a severe compound fracture of the right frontal bone. The removal of some portions of necrosed bone led subsequently to a slight hernia cerebri. The sinus persisted, but the child seemed well in other respects until about five months after the accident, when left-sided convulsions (chiefly of the muscles of the face and arm) came on, and an alarming condition rapidly developed. The sinus was opened up and a director passed for a distance of one inch 272 OPERATIONS ON THE HEAD AND NECK into the right frontal lobe downwards and backwards. A free flow of fetid pus occurred, and after the cavity had been washed out ^vith carbolic lotion (1 in 40), a drainage-tube was inserted. The latter was removed at the end of a fortnight. Left hemiplegia followed the operation, but it passed oflE some twenty-four hours subsequently. Recoveri- was rapid and complete. TREPHINING FOR EPILEPSY AND OTHER LATER RESULTS OF A CRANIAL INJURY This is one of the advances in cranial surgery, the results of which have not come up to the expectations formed of it. The operation — one of the most ancient in the history of surgery — after being almost abandoned for centuries,, has been again taken up in recent years, wdth all the advantages of modern surgery, especially in those cases where, after an injury, epileptiform con\^ilsions beginning in the leg, arm, or face are due to lesions of the corresponding parts of the motor area. This form of con\"ulsion forms a large part of the epilepsy which bears Dr. Hughhngs Jackson's name. It is to be feared that any candid inquirer, weighing fairly, unsuccessful as well as successful cases, and attaching due importance to the facts that many of the latter have been pubhshed prematurely as to final result — -i.e. before they have been sub- mitted to the time test — will come to the conclusion that the result of trephining for traumatic epilepsy is a disappointing one. It "^411 be worth while to go a little into detail with regard to the grounds which lead to these conclusions : Results of operation. Later collections of cases and (what is of paramount importance) keeping cases more carefuUy under after- observation, have shown that the operation for traumatic epilepsy has not come up to the expectations formed of it.^ One of the most exten- sive of cases with careful analysis of results is by Graf.- Graf ha.s collected 146 cases. Of these 71 were trephined, and though the dura was incised in some of these, the brain was not incised. In the remaining 75 the operative procedure was extended to the cortex cerebri. In 56 of the latter group there was removal of spicules or fragments of bone, or incision or excision of a cyst or removal of a cicatrix, while in the remaining 19 the cortical centre was excised. Of the total number there was an operation mortality of 6-1 per cent. Fifty- three of the cases were imder observation for too short a period to estimate the result of the operation. Of the remainder. 35, or 29-9 per cent, were free from recur- rence at the end of six months, 22, or 15-1 per cent, were improved, while 36, or 27 "6 per cent, were failures. Graf found that successful cases without recurrence at the end of three years were at the most only 6-5 per cent. This want of success can be readily understood from a consideration of the possible pathological conditions {see p. 274). It is of course quite possible to remove spicules or depressed portions of bone, or to remove any cyst or mass of connective tissue. As the result of the ^ Agnew {Trans. Amer. Surg. Assoc, 1891) gives results in 57 cases operated upon at Philadelphia. Of these 4 died, 4 were cured, 4 were operated upon too recently to venture an opinion, 4 passed out of observation, 32 experienced temporary benefit, and 9 obtained no relief. Of those reported as cured 2 had been under observation for only 10 months — too short a period to be sure of a permanent cure. Dr. E. G. Mason, of New York, tabulates {Med. News, vol. i, 1896, p. 313) 70 cases in a paper which is especially valuable because he refuses to accept any cases as " cures " unless the patients have been under observation for three years, and have had no return of fits. Starting with this sound proviso he finds 8 cases, or 6'3 per cent, can be accepted as cures; 6 (or 4*2 percent.) showed improvement of more than a year's duration ; in 14 (20 per cent.) there was no improvement ; in three cases death was due to the operation. 2 Arch. J. Klin. Chir., Bd. Ivi, quoted by Oppenheim, Textbook of Nervous Diseases, p. 1229. TRAUMATIC EPILKPiSY 273 operation, however, some scarring or adhesion is certain to take place which too frequently keeps up the cerebral irritation. Still more is it useless to break down adhesions between the dura and pia or between the pia and brain, because they will inevitably re-form after the opera- tion. Even excision of a portion of the cortex is certain to be followed by a cicatrix, which, in turn, will act as an irritant. It is usually im- possible to determine the exact pathological condition present before- hand, and it must be remembered that in some cases an injury to the head may cause contusion of the brain and subsequent sclerotic changes in the cortex without any fracture or depression of the bone. In some Fig. 122. of these cases, even when the initial lesion or portions of the cortex are removed, the slowly established habit, created by years of excitation, will remain.^ The treatment of traumatic epilepsy should, to a certain extent, be preventive. All depressed fractures, however small, should be elevated, for though no symptoms may be present at the time, such injuries are apt at a later date to produce epileptic convulsions. The surgical treatment of epilepsy is thus summed up by Professor Oppenheim : ^ (1) The operative treatment of non- traumatic true epilepsy is not justifiable. (2) The operative treatment of Jacksonian epilepsy of non-traumatic origin is admissible under certain conditions, e.g. if an operable cortical affection (cyst, tumour, or abscess) is probably ^ See the remarks of Prof. Nancrede {Ann. of Surg., 1896, vol. ii, p. 122). Also Sachs and Gerster {Amer. Journ. Med. Sci., Oct. 1896). For an expression of the opinion of German surgeons see the proceedings of the German Surgical Congress {Ann. of Surg., December 1903). 2 Textbook of Nervous Diseases, -p. \22Q. SURGERY I 1 8 274 OPERATIONS ON THE HEAD AND NECK present. Should this not be so the prospects of a successful operation are slight. (3) Operation is indicated in cases of cortical epilepsy following injury, especially if the cicatrix practically corresponds to a motor area. If at a distance from the Rolandic area the point for trephining should be that indicated by the attack. (4) In all cases scars, spicules of bone, &c., should be removed. In many cases it is advisable also to excise the cortical centre. But while it is authoritatively proved that the value of trephining for traumatic epilepsy has been greatly exaggerated, owing to many operations ha^^ng been ill-advised, and also, what is less excusable, to premature reporting of " successes," it by no means follows that this operation is to be abandoned. It is to be employed on careful and scientific hnes. We should be more careful in promising success save in cases of recent date, where there has not been time for the changes to occur which, as we have seen, must render recurrence of the con- vulsions after a time a matter almost of certainty. In other cases it will be only honest not to hold out much hope of cure, but to explain to the patient and his friends that the operation more or less must be uncertain ; that its dangers are slight in experienced hands ; that while cure in the truthful sense of the word is unlikely, some relief will almost certainly be granted in the number and severity of the fits ; that as to any headache, &c., from which the patient suffers, it is impossible to state what the amount of relief will be till the parts have been explored ; and, ha^^ng said this, we shall be wise if we leave the decision in the hands of the patient or his friends. For as we know nothing of the actual causation of epilepsy in these cases, so we must rest uncertain as to the relief which a trephine- opening on wide hnes may give. If headache or optic nemitis is present, these will be relieved. As to convulsions, we may hope that, in cases which are not of too long standing, the relief to tension may help towards recovery the impaired A^itaUty of cells so delicately constituted as those of the brain. In other cases the opening may allow of the intracranial circulation undergoing fluctuations, to which it is inevitably exposed, without the imstable cortical centres becoming congested and irritated and prone to explosions, as would otherwise be the case. Condition of the parts which may be met with during the operation and which may have originally caused the epilepsy. (1) The scalp. Shaving often reveals scars known or undiscovered. When operation was again resorted to in this disease, some years ago, it was hoped that tenderness of such scars would be a valuable guide and characteristic of cases to be benefited by operation. Thus Mr. Walsham^ found that, of eighty-two cases, the scar or spot was sensitive, tender, or painful in forty-two. Pressure in some caused vertigo, convulsions, rigidity, or spasmodic twitchings of certain groups of muscles.- Larger col- lections of cases have shown that these instances are fewer than was hoped, the share taken in epilepsy by tender scalp scars being a small one. In eight out of the forty-two cases collected by Mr. Walsham a sinus was present leading down to bare bone. (2) The 'periosteum. This may be found extremely thickened, and very closely adherent to the bone. Excess of vascularity may also be met with. Osteophytic deposits have not been observed. ^ St. Bartholomew's Hospital Heports, 1883, vol. xix, p. 127. ^ It is especially in those cases in ■which pressure on a tender scar produces convulsive movements on the same side, that the surgeon may be content with removing the scar. TRAUMATIC EPILEPSY 275 (3) The skull. Lesions of all kinds have been present. Depressions, fractures, fissures, are common. From the inner table a spicule ^ may- project inwards. With regard to these last conditions it is very note- worthy that in one of the cases collected by Mr. Walsham, though nothing was detected at the operation, a spicule was found, at the necropsy, not far from the trephine- hole. Another point which is of great importance with regard to the indications for trephining as given by the state of the skull is <;his. Several cases have been recorded which prove that it is not always safe in trephining for epilepsy to rely on the position of a fracture, unless that fracture coincides very closely with the spot selected for trephining from the character of the fit. Thus, in two cases related by Dr. Starr, depressed fractures existed, epileptic attacks had developed subse- quently to them, but the fit, which in both patients began in the arm, indicated disease in the middle third of the motor area, while the position of the fracture was upwards of two inches away from this spot.'^ In another case where the surgical indication or position of the fracture was put aside in favour of the medical one, or the evidence given by the fits, the latter proved to be the correct one, as on raising the button of bone a splinter from the internal table was found penetrating the dura mater and brain, though at the spot selected there was no evidence of fracture. (4) The membranes. Before opening the membranes the surgeon should remember that it is at this stage that danger begins. Aseptic trephining in experienced hands entails no risk, but it is another matter when the membranes are opened and the brain itself is interfered with. The risks of hsemorrhage, sudden cessation of breathing, shock, infec- tion, hernia cerebri, have now to be faced. Both the dura and pia mater may be found much thickened, blended with each other, and adherent to the cortex. In some cases they form respectively the outer and inner wall of a cyst. (5) The brain. When pathological changes are present in the part explored, the cortex may be found compressed or indented, stained, sclerosed or softened. Cysts in the cortex, perhaps the result of old hsemorrhage, are not uncommon lesions, and are amongst the most hopeful for treatment. If removal of the cyst is impracticable incision and drainage should be employed. Any blood clot must be removed by curetting or carefully cut away. If old, it may resemble yellowish scar tissue. If the dura has been opened to get at it, the edges of this ^ The term exostosis is soirietimes applied to the depressed bone ; this, when circum- scribed, is easily dealt with. An allied condition rarer, and one much more difficult to deal with, is described by Dr. Echeverria {Arch. Gen. de Med., 1878, t. ii, p. 5.33). A conical, irregular projection of bone, measuring 2 x 2i inches, here compressed the dura mater and brain, being situated very close to the superior longitudinal sinus, just to the left of the occipital protuberance. In trephining, the crown entered into this exostosi.s, the removal of it proving most laborious, the operation lasting three and a haK hours. The patient recovered. A case of Kochler's, of Berhn {Deutsche Med. Woch., No. 46, 1889), illustrates a less localised condition. A sword-cut had injured the bone, without depression. Epileptic fits followed in six weeks. About a year later trephining was successfully performed. The dura mater was adherent, the bone much thickened and covered with thorn-like processes pressing on, but not perforating, the dura. Before deciding whether any diffuse thickening of the bone is really morbid the varying thickness of the skuU in different parts must be remembered. Good illustrations of a blunt spicule from the internal table are given by Dr. Williamson and Mr. Jones {Brit. Med. Journ., vol. ii, 1899, p. 919). 2 Such cases emphasise the need of sweeping a probe around the margins of the trephine-hole, so as to explore the neighbourhood thoroughly. 276 OPERATIONS ON THE HEAD AND NECK " membrane must be drawn together with sutures, drainage being employed if needful. Before cutting through thickened membranes, especially if adherent to the brain, the surgeon should remember the following case, which occurred in the experienced hands of Dr. Gerster himself : The patient, set. 17, had been operated on twice before. The epilepsy continuing and the patient being anxious for a third operation, an attempt was made to lessen the tension caused by a scar at the site of the first operation, over the left arm- centre. Cutting through this scar, the surgeon found an enormously thickened membrane between the dura and the scalp. In the attempts to separate adhesions and cut through thickened membrane, excessive ha?morrhage occurred, which it was impossible to check for some time. The patient did not recover from the shock of the operation, and died in collapse three days later. If nothing be found when the dura is opened, the surgeon may, before deciding to interfere with the brain itself, explore the neighbour- hood of the wound within the dura with a blunt-pointed instrument, e.g. a curved, flexible, sterilized director. By this means a clot or cyst, which would otherwise have been missed, may be detected, and dealt with by enlarging the opening. But even when clots and cysts may seem to have been satisfactorily dealt with, and the fits cease at once, mischief in the brain may co-exist (especially if the case be one of long standing) and lead to their recurrence {vide infra). The majority of lesions of the brain will however be found to be much less amenable to treatment. How varied they are is shown by the following list enumerated by Dr. Starr : ^ " Any affection of the meninges, whether pachymeningitis or leptomeningitis, of traumatic or syphilitic or tubercular origin ; or new growths upon or in the cortex of the brain ; or cysts formed as the result of small circumscribed haemorrhages, or of spots of softening from embolism or thrombosis of a cerebral artery ; or circumscribed encephalitis or sclerotic patches, may act as centres of irritation in the cortex of the brain. The majority of these forms of disease, when exactly localised in a small area, appear to be traceable to traumatism, either to a blow, a fall on the head, or to a fracture with or without depression." But it is not only the variety of the lesions of the brain which may, after an injury, produce Jacksonian epilepsy, that is worthy of careful note ; it is their nature which makes the majority of cases recurrent after any operation, however skilfully performed. At first sight haemor- rhage and cysts would appear capable of being dealt with by careful curetting, drainage, &c. {vide supra). But going with these coarser lesions there is almost always present some meningo-encephalitis, circum- scribed or diffuse. Coen,^ van Gieson,^ Starr {vide supra) — the latter especially — have shown the frequency of the occurrence of adhesions between the pia and the cortex, of a chronic degeneration of the pyramidal cells, and of an increase in neuroglia. The bearing of this on excision of the cortex will be alluded to later (see p. 280). Operation. To begin with, a painful cicatrix^ may be freely excised. This may be done with some hope that nothing further in the way of 1 Brain Surg., p. 25. ^ Zieghfs Beitr. z. Path. Anat. u. Physiol., 1888, Bd. ii, s. 107. 3 New York Med. Record, April 24, 1893. 4 In one of Dr. Echeverria's cases (loc. supra cit.), convulsions, vertigo, &c., were cured by the removal of a small fibroma adherent to the frontal periosteum and supra-orbital nerve, Dr. Starr's opinion, on the other hand, is much less favourable : " From my TRAUMATIC EPILEPSY 277 operation will be required in cases where the scar is constantly painful, tender, or hot ; where it corresponds to the course of some known nerve ; and in any case where the original wound lacerated, or contused, and slow in healing, and where there is any chance of a splinter of wood or metal being embedded in the scar.^ If it be necessary, as it usually is, to remove a crown of bone, an appropriate semiluniir flap {see p. 309) must be reflected, with the aseptic and other precautions already given. Haemorrhage is next arrested, and the flap retracted by Spencer-Wells forceps, the pericranium being carefully turned off the bone, and its condition noted as to thickening and other evidence of old inflannnation. The bone being thoroughly exposed, the surgeon must be prepared for the following conditions, viz. the line of an old fracture, necrosis (indicated by a sinus with prominent granulations), hypertrophic sclerosis, depressed fragments of the internal table, spurs, or nodules of bone. Any sequestrum will, of course, be removed. For dealing with the bone the surgeon will select out of those methods described at p. 310 the one with wdiich he is most familiar. In trephining the surgeon will use the precautions given at p. 256, remembering that here he is especially likely to be dealing with a disc of bone of varying density at different points of its circumference. 2 It must be elevated with particular caution, as a spicule may have made its way through the dura mater and be pressing on the brain, or be in close contact with one of the sinuses. If the first crown show nothing abnormal, a probe should be gently inserted between the bone and dura mater and carefully swept around, so as to give information of the condition of the inner surface of the surrounding bone. If the crown show changes which are, however, not localised to it, more bone must be taken away, by one of the methods described at p. 312, till all that is thickened and capable of exerting pressure on the brain and its membranes is removed. If no change can be found in the crown removed, or in the sur- rounding bone, what more should be done on this occasion ? If there be reason to suspect the presence of an excess of cerebro- spinal fluid or of an abscess in the brain, because the symptoms of this condition (pp. 269 and 352) are present, or because the dura mater bulges up w^ithout pulsation into the trephine- hole, the treatment should be as directed at p. 356. Directions as to dealing with any cysts, and how far it is wise to go in attacking the thickened membranes, have been given at p. 275. These details of the operation would not be complete wdthout some reference to the question of excising fortions of the cortex tohere no lesion sufficient to account for tfie epilepsy lias been found more super jiciallij . This is not to be lightly undertaken. Professor Nancrede, of Michigan,-'* has with great candour recorded three cases in which he took this step ; experience I consider that true reflex epilepsy from scars in the scalp is a very rare occurrence." ^ Dr. Johnson {Clin. Soc. Trans., vol. vi, p. 35) records a case where trismus, facial neuralgia, and paralysis, with a recurrence of epilepsy (the patient, aged 44, had been free from fits for twelve years), were caused by a sharp, angular piece of flint embedded in a painful cicatrix of the cheek, the removal of which was followed by complete recovery. 2 Free and most embarrassing hiemorrhage may be met with in sawing through altered diploe traversed by large sinus-like venous channels, requiring firm pressure during and after the operation, plugging with a tiny sterilised wooden peg, or crushing the bone together with forceps at the bleeding- point. 3 Ann. of Surg., 1896, vol. ii, p. 122. 278 OPERATIONS ON THE HEAD AND NECK in all the fits recurred, though in one case not for two and a half years, while in another " somewhat over three years " had elapsed. And this candour is the greater, as Professor Nancrede allows that formerly he thought well of this procedure.. Dr. Sachs and Dr. Gerster ^ have given this a full trial, having employed it in five cases. Their experience leads them to the conclusion that, in epilepsy of long standing, the excision of cortical tissue does no good, and such excision is hereafter to be restricted to epilepsies of short duration. And again : " Since such cortical lesions are often of a microscopical character, excision should be practised even if the tissue appears to be perfectly normal at the time of operation ; but the greatest caution should be exercised to make sure that the proper area is removed." Not only may this step cause severe haemorrhage, shock, and open the door to infection, but is impossible to see how it can do otherwise than lead to fusing of the scalp membranes and cortex in a scar which will become increasingly dense wath time, and bring about " anchoring of the brain," with its grave disadvantages {see p. 276) and sclerosis of the cortex, leading inevitably to a recurrence of the trouble. To put it briefly, it seems certain that when taking this step the surgeon is almost sure to replace one traumatic epilepsy by another, which, supervening somewhat later, is traumatic also, but in addition, unhappily, surgical as well.^ What is needed is to prevent the adhesion of brain, membranes, and scalp, and at present none of the methods are reliable. Possibly trans- planting a flap of scalp, bone, and membrane might succeed, but such a step is too severe to be undertaken at the close of an operation already severe and prolonged, and if deferred for some days its object would probably be defeated. The use of gold and other pliable metal plates between the dura and the skull will not prevent the formation of adhesions between the dura and the brain. A case of Dr. Gerster's proves this. Having removed a cerebral cyst, this surgeon placed a gold plate between the dura and the skull. Two years and nine months after the first operation it was necessary to perform a second, and, while the gold plate was found lying exactly as it had been introduced, the best result attained was " that the surrounding tissue had undergone fewer changes than would have been the case if the ordinary scar had formed." Other materials have been suggested by the ingenuity of American surgeons.^ Another objection to the removal of motor centres (except, of course, in cases where they are involved by a growth) is that this step may merely replace one inconvenience by another. It is true that in most cases the loss of power has been temporary, but in some this has not been the case. Certainly not every patient would choose to lose his ^ Loc. supra cit. 2 After mere incision of the dura or meninges, the cicatrix left will no doubt, be linear and small, and the inner surface of the skull smooth and adhesions absent, but the condition present after removal of one or more centres will be very different. 3 Beach has used gold-foil. Abbe rubber tissue ; but these substances have been proved to have the disadvantages of causing formation of adhesions and scar tissue, of disintegra- ting, and of causing suppuration. Dr. L. Freeman, of Denver (Ann. Surg. October 1898), having tried gold-foil in a case of trcphming for cerebellar tumour, and found, three months later, that '• considerable new connective tissue had formed," recommends the use of egg-membrane, as being inexpensive, readily obtainable, strong in spite of its thinness, and durable, and not, in the full sense of the word, a foreign bod3\ The above claims are based upon two experiments on animals. TRAUMATIC EPILEPSY 279 epilepsy at the cost of having a right arm or leg permanently paralysed. Furtlierinore, it is easy to understand that in inexperienced hands permanent damage may be readily inflicted on the centres grouped about the motor area, bringing about a condition by which one form of distress will merely be exchanged for another. If it be decided, owing to the gravity and frequency of the attacks — especially where the condition amounts to the patient being practically in what is a status epilepticus — their limitation to one or two centres, the absence of any other extra-cerebral cause, and perhaps also the failure of a previous operation, to remove one of the motor centres, this should be accurately localised by electricity. To trust to measure- ments of the skull is not enough. Sufficient of the motor area having been exposed, the dura-arachnoid is opened and all hemorrhage is arrested. By means of two aseptic platinum electrodes, different parts of the motor area are examined,- the results most carefully noted, and when that spot is reached which causes motion in that particular part of the body first affected in the fit, that particular spot, and that only, should be excised (Keen). Its limits having been determined, any large veins which enter the field of operation are first tied with fine sterilized catgut passed under them by Sir V. Horsley's needle-director. The area of the centre is then marked out by a sharp knife held vertically to the surface and penetrating to the white matter. The centre is then excised by a sharp knife or scissors going to the same depth, about three millimetres, or a quarter of an inch. Haemorrhage is best arrested by ligature of any bleeding-points if possible, hot aseptic lotions, or compression with gauze wrung out of hot lotion, or sterihsed adrenalin chloride. The cautery should never be resorted to if it can possibly be avoided. It introduces sepsis and suppuration, and may lead to a hernia cerebri. It prevents the surgeon bringing together the flaps of dura mater over the excised centre. Drainage will usually be required on account of the oozing. After the removal of the centre, to make sure that this has been effectual, it will be well to again make use of the electric test (Keen). The strictest aseptic precautions should be taken before and during the operation ; sufficient drainage should be provided and, in bringing the wound together, the drainage-tube must not be pressed upon or closed. Great care must be taken to keep the wound sterile later on, infection leading to infective softening and hernia of the brain. Only if it has been needful to remove much bone should any of this be preserved and replaced, with the precautions given at p. 258.^ In cases where during the operation there has been any escape of cerebro-spinal fluid, th£ dressings will soon need to be repacked or changed. Causes of failure after trephining for traumatic epilepsy. These may be summed up as follows : ^ Prof. Kocher, of Bern {La Sem. Med., April 12, 1899, p. 121), is of opinion that not only should the bone disc not be replaced, but that the dura mater itself should be widely excised. He holds that one of the chief causes of epilepsy consists in an exaggeration, local or general, of the intracranial pressure. He believes that, in a number of cases of excision of cerebral centres, except in those where the excision has been sufficiently com- plete to bring about a definite paralysis, the success should be attributed rather to the opening of the dura mater, which estabhshes a sort of safety-valve susceptible of regulating the intracranial pressure. Kocher would, therefore, only put back the di&c where a very definite lesion, such as an exostosis or growth, has been removed ; in aU others the skull should be left open. 280 OPERATIONS ON THE HEAD AND NECK (1) Not hitting off the right spot. A bony spicule, undetected at the operation, has been found, at the necropsy, not far from the trephine- hole. To meet this contingency, or to find a clot, it has been ad\ased to sweep a probe or wire-loop carefully round the ^^cinity of the trephine- opening. (2) A general and diffuse thickening of the bone round the site of injury. (3) Membranes too much thickened and too adherent to the cortex to admit of their being safely detached. (4) Owing to the long continuance or to the amount of the irritation, the brain may be permanently affected. Thus, in Dr. Gunn's words already quoted {see p. 2.50). there are cases of depressed fracture in which " the constant irritation has begotten a permanent impression upon the brain and nervous system which remains after the offending point of bone has been removed." The grosser and more localised the lesion the more speedy will be the rehef. As long as the fits are diminished in number and severity, the prognosis is still hopeful. The fits may be very slow in disappearing. (.5) While marked relief has been given in some cases of violent temper, delusions, and melancholia, whether associated or not with local epilepsy, the same rule holds with the former as with the latter, i.e. if the interval between the injury and trephining has been a long one, the cure is very likely to be imperfect. (6) Neglect of after-treatment, both medical and surgical, but chiefly the former. Professor Xancredes words ^ are worthy of remembrance : " The operation, indeed, removes the most important cause of the epilepsy, but only one cause. The disturbed circulation in the nervous centres, and the excessive mobility of the nervous system, can only disappear with time ; and if all other sources of peripheral irritation are not most carefully guarded against, the patient may be slightly, if at all, benefited, whereas judicious after-treatment will sometimes relieve an apparent operative failure." Judicious after-treatment should especially refer to alcohol, exposure to the sun, overheated small rooms, and, generally speaking, the patient should lead a healthy fife. (7) TreiDhining for fits not belonging to traumatic epilepsy in character. There is no doubt that the glamour of a new operation and " the chance of finding something " have led to this operation being performed in unsuitable cases, which have not been published. It cannot be too strongly laid down that no operation is justifiable in other epilepsies save the Jacksonian, of which so many are traumatic in origin. That is to say, that in ordinary idiopathic epilepsy the conditions justifsdng operation must be of the very rarest. They would be something of this kind : Epilepsy with intense local headache ; epilepsy in which, after the general con\T.ilsions, paralysis or paresis of any group of muscles follows. Those who trephine an idiopathic epilepsy because it is impossible always to exclude traumatism in idiopathic cases, or because there is a bare possibility that a haemorrhage, the origin of irritation, may be met with on the surface of the brain, are likely to meet with disappointment. (8) An infected condition of the wound, almost invariably occurring during the operation, and bringing about (a) meningitis ; (b) hernia cerebri ; (c) cerebral abscess. (9) Shock. ^ Inter. Enc. Surg., vol. v, p. 102. BULLET WOUNDS OF BRAIN 281 Finally, in cases of honest doubt, and in those where a well-considered operation has failed, the interference of the surgeon will be justified by the fact that traumatic epilepsy tends to grow worse, and is little affected by medical treatment. In the words of Echeverria,^ once declared, traumatic epilepsy, due to injury to the head, leads to early insanity or to feebleness of intellect. OPERATIVE INTERFERENCE IN THE CASE OF FOREIGN BODIES IN THE BRAIN Under the above heading such bodies as bullets, knife-points, &c., are included. Depressed and isolated fragments of bone may come within the meaning of foreign bodies, but have already been considered [see p. 253). A. Bullets. The following questions will suggest themselves when a surgeon is called to a case of bullet wound of the skull : (1) Has the bullet penetrated the skull at all ? (2) It may have 'passed between the bone and the dura mater, ivithout penetrating the latter, and reached a spot quite out of sight. Probably in most hands a second application of the trephine, if needful, at some distance from the wound, so as to extract the bullet there, would be preferable to attempts at removing it from the original wound. (3) Has the ball split into two or more pieces ? Balls elongated as well as round are liable to split when impinging on sharp angles of bone. Thus, when the ball splits upon the outer table, part may pass beneath the scalp, while the rest may drive on before it some of the internal table, causing pressure on the dura mater, or even reach the brain. (4) Has the bullet penetrated the brain ? If so, where does it lie ? (5) Ought any exj>loration to be performed at once and if so, how far is the surgeon to go ? If the last question be answered in the affirmative, an answer will be given to most of the others. While, owing to the rarity of gunshot injuries of the head in civil practice in this country, it is very difficult to give a dogmatic answer, the following reasons are in favour of exploring in all cases in which it is clear that the injury is not going to be quickly fatal : (a) The fact that only by exploring will the surgeon be able to answer the question certain to be put to him by the friends, whether the brain is injured or no ? (b) Whether the bullet has split, whether the internal table is shattered and, if so, how far it resembles a punctured^ fracture, are points which alone can be cleared up by trephining. (c) Disinfection of the wound and good drainage are almost hopeless unless this be opened up and explored by trephining if needful. The following case is not only a good instance of the kind of gunshot injury to the head w^hich may be met with in civil practice, but it shows how slight may be the injury which actually originates the fatal mischief. It was brought before the Clinical Society ^ by Mr. Lucas : The patient, aged 21, had shot himself with a small revolver. " Almost in the centre of his forehead were two small circular holes, with slightly inverted edges. The surrounding skin was raised into a rounded prominence. There was some bleeding from the nose as well as from the womids. On turning back flaps, a ^ Loc. supra cit., p. 277. ^ Trans., vol. xii, p. 5. 282 OPERATIONS ON THE HEAD AND NECK blackened cavity was opened beneath the skin, formed by the expansion of the powder after it had penetrated the integument. At the bottom of this cavity, a somewhat cruciform aperture was seen in the bone, and lying upon the internal table were two flattened bullets. The internal table was driven back so as to give the appearance of a sinus, in which the bullets were lying loose ; and at the time we were under the impression that the man had very large frontal sinuses, which had been opened by the bullets. After removing numerous fragments belonging to the external table and diploe, the splintered internal table forming the posterior wall of the cavity was also removed. This came away in large, sharp-edged, angular fragments, two of which were grooved by the longitudinal sinus. When the internal table had been removed, the dura mater was seen at the bottom of the wound and pulsating. The membrane was entire except at one spot, where there was a small aperture just such as might be made by stabbing the point of a penknife into a sheet of paper. But for that small puncture it is not improbable that he would have recovered. Infective meningitis came on in about forty-eight hours, followed by death early on the sixth day. If the surgeon decides to explore the wound he does so with the intention of rendering the wound as sterile as possible, removing all dirt, hair, and splinters in the cortex, if accessible, \vithout making the condition of the patient worse than it already is. He will have warned the friends that removal of the bullet may be found impracticable on this occasion owing to the patient's condition. We will suppose that no cerebral symptoms are present, either focal ones to guide him, or such grave ones as coma, stertor, paralysis of the sphincters, which would lead him to stay his hand. Lastly, the injury is not of that destructive character, so shattering the skull and ploughing up the brain, especially in a direction towards the basal ganglia, as is certain to prove quickly fatal. Localisation. This can be accurately ascertained by a radiographic examination. Surgeon- General Stevenson^ thus sums up the question of localisation : It is not the bullet so much as the fragments of bone driven in which will cause infection. This is borne out by the military experience in South Africa. Here also while suppuration was rare after bullet injuries, it was the rule in womids due to fragments of shell. "All exploring instruments, electrical and other, for the detection of lodged missiles may nowadays be set aside as out of date, and dependence placed entirely on the use of X-rays for this purpose. By their means, using Mackenzie Davidson's cross-thread localiser, the exact position of any foreign body within the tissue can be ascertained to a millimetre, or stereoscopic photographs may be taken which will afford means of sufficiently exact estimation of the position of an object as large as a bullet to warrant the surgeon in operating for its removal without more accurate localisation. When using this method, small pieces of wire should be fastened on to the skin above and below the bullet, so that its relative position to known points on the skin may be shown in the stereoscope, and thus a clear indication obtained for the operative procedure to be carried out. Before proceeding to locahse the bullet, or to skiagraph it stereoscopically, its general position should be ascertained by means of the fluorescent screen or by a single skiagraph so that part of the limb or body in which it is situated may be placed in the proper position over the photograj^hic plate while these methods are being carried out." Mr. E. W. H. Shenton, Surgical Radiographer to Guy's Hospital, writes as follows : " It is possible by means of the Rontgen Rays to estimate the size of, and to exactly locate bullets or other bocUes which have become lodged in the cranial cavity. The simplest method, perhaps, is that where two radiograms are taken — one in an antero-posterior direction, and the other in the lateral. Another system, and a far more accurate one, is that now in common use at Guy's Hospital. It is a system whereby the exact distance from any given point may be fomid, and the principle upon which it is based as follows : When an image is being viewed upon the screen and the tube moved, the shadows of the various parts of the object viewed will move iipon the screen at different rates according to their distance fiora the screen ; that is, the nearer to the screen the less their shadows will travel in a ^ Report on Surgical Cases noted in the South African War. BULLET WOUNDS OF BRAIN 283 given time. Quite superficial objects, those almost touching the screen, will hardly move at all. By a suitable mechanism exact measurements are easily obtaiiied and, in all cases where the foreign body can be seen upon the screen, this can bo aceom{)lished without the em|)loyment of any photographic process. If considered desirable in the ease of bullets in the head, a skull may be taken and a bullet arranged in it, by the aid of the measurements obtained, to correspond in situation to the original bullet. Such a device will prove of great value to the surgeon at an operation for the removal of the foreign body. When exact localisation has been obtained, radiogia])hy can go no further, miless the practice of operating with the rays to hand is adopted. By such a metliod the surgeon is enabled to see the position of the fori'ign body from time to time, and any metal instrument he may be using. Until tubes of greater power are forthcoming this method cannot be advised for cases of bullet in the head." Though probes should not be used for localising the position of the bullet unless it is very superficially situated, they are of use in identifying it when its position has been determined by a radiographic examination. Some blunt instrument should be employed, such as Nelaton's, which is provided with a rounded porcelain knob at its extremity. Treatment. This may be considered under two headings. (1) The opening up of the wound for the purpose of removing fragments of bone and bruised tissues, and for cleaning the wound and providing drainage. (2) The removal of the bullet. This may be immediate or late and will depend on the condition of the patient and the situation of the bullet. The following remarks by Mr. G. H. Makins^ are of twofold interest, first from their recent date and their bearing on the effect of modern small projectiles of high velocity and, secondly, from the wide practical experience and weight with which the writer speaks. " Operative interference is necessary in every case in which recovery is judged possible. The injuries are, without exception, of the nature of punctured wounds of the skull, and the ordinary rule of surgery should under no circumstances be deviated from. An expectant attitude, although it often appears immediately satisfactory, exposes the patient to future risks wliich are incalculable. . . . Cases of a general character,^ or in which the base has been directly fractured other than in the frontal region, are seldom suitable for operation, since surgical skill is in these of no avail ; but in all others an exjjloration is indicated. I use the word ' explora- tion,' since what may be called the formal operation of trephining is seldom neces- sary except in the case of the small openings due to wounds received from a very long range of fire ; in all others there is no difficulty in making such enlargement of the bone opening as is necessary with Hoffmann's forceps. " The scalp should be first shaved and cleansed ; if for any reason an operation is impossible, this procedure at least should be carried out, with a view to ensuring as far as possible, future asepsis, infection in head injiu-ies being almost the only danger to be feared. The scalp having been cleaned with all care, a flap is raised, of which the bullet opening forms the central point, and the wound explored. In slight cases the entry wound is the one of chief importance, and the exit may be simply cleansed and dressed. The flap having been raised, if the wound be a small perforation, a half -inch trephine crown may be taken from one side ; but it is rare for the opening to be so small that the tip of a pair of Hoffman's forceps cannot be inserted. The trephine is more often useful in cases of non -penetrating gutter fractures where space is needed for exploration, and the elevation or removal of fragments of the inner table. Loose fragments may have to be removed from beneath the scalp, but the important ones are those within the cranium. These may either be of some size, or fine comminuted splinters of either table, often at as ^ Surgical Experiences in South Africa, 1899-1900. 2 Under this heading are included extensive sagittal tracts passing deeply through the brain, and vertical wounds passing from base to vertex or vice versa, in the posterior two-thirds of the skull. For their production the retention of a considerable degree of velocity on the part of the bullet was always necessary, and the results were consei^uently both extensive and severe. 284 OPERATIONS ON THE HEAD AND NECK great a distance as two inches or more from the surface. The cavity must be thoroughly explored and all splinters removed. I have seen more than fifty ex- tracted in one case of open gutter fracture. The brain pulp and clot should then be gently removed or washed away, and the wound closed without drainage. Frag- ments of bone, as a rule, are better not replaced, but complete suture of the skin flap is always advisable in view of the great importance of primary union, and the fact that a drainage opening exists at the original wound of entry, and that the wound is readily reopened to its whole extent, should such a steji become desirable. " The detection of fragments is most satisfactorily done with the finger, and in all but simple punctures the opening should be large enough to allow thoroughly effective digital exploration. The determination of the amount of brain pulp which should be removed is somewhat more difficult ; all that washes away readily should be removed, and its place is usually taken up by blood. " Few fractures of the base are suitable for operative treatment ; the only ones I saw were those of direct fractures of the roof of the orbit or nose, produced by bullets passing across the orbits. Here the advisability of interfering with the injured eye led to opening of the orbit, and sometimes exposed the fracture. " As to the most satisfactory time for the performance of these operations ... in head injuries the advantages of early interference were more evident than in any other region. This depended on the fact that, as in civil practice, the scalp is one of the most dangerous regions as far as the auto-infection of the wound is concerned, and one of the most difficult to cleanse except by thorough shaving." With regard to the treatment of retained bullets which are stated to have been distinctly rare, Mr. Makins advises that the ojjeration should not be undei'taken until " the patient can be placed under the best conditions which can be secured. . . . Sucli operations need the infliction of an additional wound, require great delicacy, and may be very prolonged in performance." Earlier interference is only indicated where the bullet has tried to escape or secondary symptoms develop pointing to irritation. Operation. A. The position of the bullet has not been determined, either on account of the condition of the patient or the radiographic exami- nation may have been inconclusive. While the head is being shaved and preparations for the operation made, the surgeon will take note of any superficial lesions, such as blackening of the skin, burning, the presence of grains of powder, and the original characters of the external wound, both for medico-legal purposes and for future guidance, all these lesions being soon liable to alteration. It is rare, supposing the patient to have recovered consciousness, that any localiisng symptoms are present, which can point to the lodgment of the bullet in a definite part of the cortex, e.g. the motor or the speech area.^ In a few cases, as soon as the whole head is shaved, the surgeon may gain evidence of the position of the bullet by finding on the opposite side of the skull a contusion of the scalp, an elevation of the bone, or even a tender spot, beneath which, after incision, some fine fissures may be detected (Phelps). 2 The surgeon, having raised an appropriate flap, enlarges the wound in the skull with Hoffmann's forceps and removes any dirt, soft parts which will certainly die, and superficially lying splinters. In order thoroughly to remove any powder, dirt, or lead splashes from the external wound in the skull, even after this has been enlarged with Hoffmann's or other forceps {see p. -'312), it may be needful to resort to rubbing with sterilised gauze, or even to use the gouge. The wound in the dura should be sufficiently enlarged to give exit to any blood or cerebral debris. If uninjured, or very slightly injured, the bullet having been deflected, the dura should be most carefully examined ^ Any such lesions, which may be noted immediately, are due to the passage of the bullet ; if occurring later on they will mark certain secondary morbid conditions. 2 -. % a stream of weak perchloride lotion. A •: drainage-tube was inserted. On the evening Fig. 125. of the same day the aphasia was much im- proved. Next morning the patient was again more aphasic, and it was found that the tube had become blocked. On freeing it, much fluid with broken-down clot escaped, and the power of speech improved. The patient recovered uninterruptedly, regaining completely Ms power of writing, reading and speaking. Sir C. Ball believed that the knife had penetrated the superior temporo-sphenoidal gyrus, traversed the Sylvian fissure, and probably injured Broca's convolution. (6) Cerebral Localisation iii the Diagnosis and Removal of Cerebral Groivtlis. The following case, trephined by Sir R. Godlee for Dr. Hughes Bennett in 1884,3 is of great interest, partly because it was one of the first cases of removal of a tumour from the brain in this country, and also on account of the completeness of the details and the accuracy of his reasoning. A man, aged twenty-five, had four years before suffered from slight concussion from a blow on the left side of the head. A year later there first set in twitchings in the left side of the mouth and tongue, paroxysmal and irregular in occurrence. Some months after fits began, with loss of consciousness and general convulsions. This condition lasted two and a half years ; and six months before admission, twitchings of the left hand, followed shortly by weakness of the left fingers, hand and forearm, were noticed. For three months these had prevented his using his tools. During this last period there had been twitchings of the left leg, which had also been getting weak. There was nothing abnormal in the skull or scalp Vision was normal, but optic neuritis was present on both sides, most marked on the right. Hearing was less acute in the right ear. There was now complete paralysis of the left fingers, thumb, and hand, the elbow movements were very ^ Convulsions in themselves are only an indication for interference when they are localised and persist, and especially if they alternate with paralysis of the same muscles, ^ Sir C. B. Ball, Trans. Roy. Acad, of Med., Ireland, vol. vi, p. 155. ^ Med. Chir. Trans., vol. Ixviii, p. 244. 294 OPERATIONS ON THE HEAD AND NECK limited, those of the shoulder impaired. There was no rigidity or wasting of muscles. The toes of the left leg did not clear the ground in walking. There was persistent vomiting and retching, with attacks of lancinating headache, rendering life intolerable. Large doses of the iodides were fruitless. An operation being decided on, the motor area and the fissure of Rolando were mapped out. Theoretically, in order to hit the middle of the fissure of Eolando, the centre of the trejjhine should have been placed about half an inch behind the diagonal line and about an inch and a half from the median longitudinal line. As, however, there was a tender sjwt on the scalp two inches anterior to this, the first trephine opening was made between the two. The dura mater was normal ; after a crucial incision was made in it, the brain was thought to bulge abnormally, and to be rather more yellow than usual. A second disc was removed with the trephine, overlapping the first, external to and slightly in front of it, and tlie angles of bone uere rounded off with a gouge. These two openings were then joined by one posterior to them, so that an aperture measuring two inches by an inch and three-quarters was made. The dura mater was opened and a sm-face of brain exposed nearly equal in size to that of the skull-opening. Occupying most of this space and crossing it obliquely from above and behind, clownwards and forwards, was a convolution, into the centre of which an incision was made. From an eighth to a c^uarter of an inch below the surface lay a transparent, lobulated, solid tumour, thinly encajisuled but quite isolated from the surrounding brain substance. The incision into the cortex being prolonged, the sides of the growth were easily separated by a steel spatula. The superficial sm-face of the growth being thus isolated, this portion was removed with the finger. As part now broke away, the deeper part was enucleated with a sharp six)on, the scraping being continued till apparently only healthy brain matter remained. The ca\-ity. about the size of a pigeon's egg, filled up -with blood, and sponge pressme failing, the haemorrhage was eventually checked by the electro cautery. A di-ainage tube was inserted beneath the dura mater, which elsewhere was ckawn together by sutvires. The skin wound was closed and an antiseptic dressing applied. The wound was not dressed till the third day, when the scalp near the wound was somewhat cedematous. The next day wet boracic di-essings were applied, but a hernia cerebri as large as half an orange was protruding through the lips of the wound. There were no twitchings of limbs or face, no headache. The patient was bright and cheerful, with a good appetite. The hernia cerebri, however, increased, and on the eighth day, having reached the size of half a cricket ball, was snipped away with scissors, the parts removed consisting chiefly of granular matter and clot,' with, apparently, little true cerebral structure. The hernia cerebri again increased somewhat, but all seemed to be doing well, when, on the twentj^-first day, a rigor occurred, headache and vomiting followed, then restlessness, sleeplessness, and gradual sinking about four weeks after the operation. At the autopsy extensive araclmitis was found. The parietal area appeared to have fallen in ; in its centre, and occupying the position of the fissure of Rolando, was the wound in the brain. The destruction of the cerebral cortex involved nearly all the ascending parietal convolution, the upper part of the ascending frontal, and the anterior tliird of the supramarginal g^Tus. The extent of softening was not great, but it was difficult to tell this accurately, as the brain had undergone the proce-ss of hardening. The growth was a glioma, of the size of a walnut. In the comments on the case, most interesting remarks are grouped mider the following heads: (1) diagnosis, (2) sm-gical treatment, (3) chni- cal phenomena after the operation, (4) revelations of the necropsy physiologically and pathologically considered. These will repay most carefiil perusal ; only the chief points can be given here. (1) Diagnosis. A brain growth on the right side was diagnosed in this case on the following grounds : slow progress, uncontrollable vomiting, violent pains, double optic neuritis. It was thought to occupy the cortex because certain motor tracts were imphcated in definite order, because paralysis was present without loss of sensibility, and above all because of certain paroxysmal seizures of local con\nilsions occurring without loss of consciousness, eminently suggestive of irritation of the grey matter. GROWTTTS OF THE BRAIN 205 Til this case tlioro was coinplete paralysis of tho fingers and hand, with inahiHtvto proiiate and supinate tlie forearm; there was partial paresis of tlie luovements of tiie elhow, and weakness of those of the shouhU'r joint. There was also shght paresis of the leg and one sich; of the face. Accom- panying all these there were paroxysmal convulsions in all these regions, occm'ring either singly or in definite order one after the other. These phenomena were to be accounted for by an extensive but not absolutely complete destruction of the motor centres of the fingers, hand, and fore- arm, with slight encroachment on and irritation of those of the face, upper arm, and leg. A very definite localisation was thus permitted, and the tumour was pronounced to have occupied the whole thickness of the middle two-fourths of the ascending parietal convolution, and a portion of the adjoining upper half of the ascending frontal convolution. The growth was })r()verl to be limited by the fact that the centres of the leg above, of the face and tongue below, of sight behind, and of the movement of the eyeballs in front, were not seriously involved. As to the probable nature of the tumour, the age of the patient, the absence of syphilis, and the slow progress, suggested glioma. (2) The Operation. One convolution only being exposed during the operation, there w^as at the time some question as to whether it w^as the ascending frontal or parietal. This doubt arose from the circumstance that in the attempt to approach the tender spot the theoretical position had been slightly departed from. After death, however, it was apparent that the convolution which had been incised was that in which from the first the disease had been diagnosed to exist, viz. the ascending parietal. There was no external appearance of disease about this part except that it seemed sw^ollen, less glossy, and less vascular than natural. An incision into it showed the morbid growth to be immediately under the surface, and almost completely involving the entire thickness of the cortex. It may be questioned whether it w^as advisable to arrest the haemor- rhage from the interior of the W'Ouncl by means of the galvano-cautery, as the bleeding was not severe and would no doubt have become arrested by natural means. The use of this instrument appears to have brought about the sloughing which was the cause of the inflammation and conse- quent hernia cerebri. It was remarkable that the discharge continued for so long to be so copious and so watery, as to suggest the idea of its being cerebro-spinal fluid. ^ (3) Clinical Phenomena following the Operation. The patient lost his headache, vomitings, and violent twitchings in the Kmbs ; even the double optic neuritis markedly diminished. The only change which followed the operation w'as completion of the paresis of the upper extremity, evidently due to the unavoidable destruction of the remaining arm-centres in the removal of the tumour. Coincident also with the formation of the hernia cerebri came fresh symptoms, in the shape of paresis of the left leg and partial angesthesia of one half of the body. These were probably due to the effects of simple pressure, and possibly to the subsequent secondary softening of the conducting fibres caused by it. (4) Revelations of the Necropsy. The brain was, practically, every- where healthy except over the area injured by the operation and in the 1 It was not conclusively shown at the necroi^sy if tho lateral ventricle had been opened. 296 OPERATIONS ON THE HEAD AND NECK membranes in the immediate neighbourhood. The meningitis was due to irritating matter from the interior of the womid flo^^'ing doAMiwards between the layers of the arachnoid, and accumulating at the base of the brain. The local inflammation of the wound had opened out the parts, and separated the adhesions so as to allow the discharge to make its way into the cranial cavity, but not till three weeks after the operation. The following case, quoted from a paper by Dr. Risien Russel, read before the British Medical Association in 1907,^ is an example of a case in •which the position of the tumour could be ascertained with practical certainty, and in which it was successfully removed by operation. M. B., a woman aged 40, complained of increasing weakness of the right foot of two months" duration. She next noticed twitchings of the right toes in attacks which lasted for a minute or two and which occm-red once or twice in the twenty- foiu' hours. These clonic movements and the motor weakness gradually ascended the limb, until six weeks after the commencement of her illness they culminated in a Jacksonian fit, which, commencing in the foot, subsequently involved the right arm and face, without loss of consciousness. A similar fit occurred three days later. Seven weeks from the onset of the illness she began to notice progressive loss of power in the right upper limb. She had been entirely free from headache, and at no time did she become aphasic. When she came under observation there was hemiparesis of the right side : the face was only slightly affected, the arm much more so, and the leg most of all. Indeed, no movement of the ankle or toes was possible. A diagnosis of a tumour in the leg area of the left motor region was made. Sir Victor Horslej' operated, with the result that a tumour the size of a walnut was removed from about half an inch beneath the cortex of the leg area. As an immediate effect of the operation there was marked increase of the hemiplegia, but the paralysis subsequently improved so that before the patient left the hospital, seven weeks after her operation, feeble movements could be made in the right toes and at the ankle, in which parts no movements had been possible before the operation. QUESTIONS ARISING BEFORE OPERATION ON A CEREBRAL GROWTH The chief of these are : (A) The existence of a growth ; (B) The site of the growth ; (C) The depth of the growth ; (D) Is it single or multiple ? (E) Its nature ; (F) The conditions which justify operative interference and the probable results of this step. The above points, and the five first especially, must be decided ^vith the help of a physician ; and it is to be hoped that in futm-e physicians will invoke, at least, the opinion of the surgeon at an early stage of the disease. In too many cases of cerebral growth the operation has only been resorted to as a forlorn hope, a fact Avhich is always to be considered when the mortahty from operation in these cases is estimated. Information with regard to questions (A) to (D) -^-ill be obtained by referring to some standard work on medicine. The surgical aspect and treatment of these cases necessitate the discussion here of questions (E) and (F) at some length. (E) The nature o£ the growth. Before deahng with growths of the brain itself it will be necessary to allude to those springing from the dura mater {see also p. 245). Prof. Keen- published a case of fibroma weighing over three ounces, attached to the dura mater, which he removed successfully in a patient aged 27 in 1887. The growth dated probably from an injury in childhood. It caused epilepsy, aphasia, ^ See Brit. Med. Journ., 1907, vol. ii, p. 1122. This paper and the discussion which followed contain much useful information as to the localisation of cerebral tumours, and of its practical value as regards operative treatment. ^ Armr. Journ. Med. Sci., 1888. GROWTHS OF THE BRAIN 297 conipk'te hoiniplogia, intense neuralgia, deafness, and great inipairnient of vision. After tlie operation, save for the eye and ear symptoms, all the otliers had passed away exeept slowness of speeeli and the epilepsy, and the last was much improved. In the same periodieal for 189G (vol. cxii, p. 5G3), I'rof. Keen gives the state of this patient nine years after the operation: "Eyesight still imperfect. Epilejrtiform attacks recur now at intervals of about a year. Patient still very nervous and unable to do any work." Sir W. Macewen 1 has ]iul)lished a case in -which a growth of the dura mater caused irritative lesions of the left frontal lobe. The patient was restored to perfect health after the operation, and died eight years later of Bright's disease. In the above-mentioned case the growth was Hniited to the dura. A detailed account of a case in which a growth originating in the dura involved the cortex of the brain is recorded by Dr. Bremer and Dr. Carson, of St. Louis. ^ The growth was an endothelioma. Owing to the characteristic spread of the paralysis from one. the shoulder centre, to the others of the upper extremity, the diagnosis of growth in the brain was made, though headache, vertigo, nausea and optic neuritis were absent. At the operation alarming haemorrhage took place during the removal of the bone owing to the immense size of some branches of the posterior meningeal vein. This was checked by packing while the opening was enlarged. The dura w'as dark, covered with large vessels, and did not pulsate. It was adherent to a growth beneath, which, though friable, was easily lifted from its bed between the dura and the apparently healthy brain. The patient died on the twelfth day with p^Tcxia and delirium. At the necropsy a portion of the growth was found to have escaped removal, and the microscope showed that the sm-face of the brain was itself invaded. It ^^'i^ now be necessary to consider growths of the brain itself. Almost every form of neoplasm may be found ^^^thin the cranial cavity. The most common forms are sarcoma, glioma, tuberculoiLS tumour, syphihtic tumour, endothelioma, and cysts. Less common are fibroma and osteoma, while rarer forms are hydatid cysts, psammoma, hpoma, large aneurysms of the arteries at the base of the brain, and tumours of the pituitary body. Some help as to the varieties of growth most likely to be met with, and the relative frequency of each, will be gained from the following table. ^ The interval since the publication of this paper may make it appear out of date. Owing to the care with which it was drawn up, and the sound pathological basis on which it rests, this is not so. The paper remains one of great value and is still quoted and relied upon by different authorities. It will be noticed that Dr. W. Hale White's conclusion that 10 per cent, of the cerebral growths collected by him could certainly have been operated on is distinctly higher than is shown to be the case now in the light of the experience of twenty years later. Of one hundred cases of cerebral growth the proportions were as follows : Tubercle . Glioma Glio-sarcoma Sarcoma . Carcinoma Lymphoma Myxoma . Cyst Gumma . Doubtful . 45 24 2 10 5 1 1 4 5 3 100 Lancet, August 11, 1888. p. 304. ^ Aimr. Journ. Med. ScL, February 1895. Dr. W. Hale ^^^lite, Guy's Hospital Reports, 1886. 298 OPERATIONS ON THE HEAD AND NECK Of the forty-five cases of tubercle, the cerebrum was affected in twenty- two, the cerebellum in twenty cases. The growth was multiple in nine- teen, and single in twenty-four cases. In all the forty-five cases one or more other structures than the brain were affected. Dr. W. Hale White concludes that not more than three tuberculous cases were likely to be benefited by operation, and even in these the other organs were tuberculous. Ot the twenty-four cases of glioma, of ten only could it be said that they were not infiltrating. The cerebrum was the seat of the disease in thirteen cases, the cerebellum in four. In one case there were multiple gliomata in the brain, and in two others there were growths in other parts of the body. Of the ten cases of sarcomata several afiected the dura mater in inac- cessible positions ; of the five cases which attacked the brain only, one alone could have been removed T\ith any prospect of success. Of the remaining growths none of the carcinomata or glio-sarcomata were amen- able to treatment. Of the four cases of cyst one could certainly, and another possibly, have been operated upon ; the myxoma was, and the lymphoma was not, amenable to operation ; and of the three doubtful cases, two could have been operated upon. Dr. W. Hale White's summing up is as follows : " Thus we see that out of one hundred cases of tumour of the brain, ten might certainly have been operated upon, and four additional ones might possibly have been ; so that in 10 per cent, of our cases we can hold out some hope of operative relief to our patients, pro- vided that a correct diagnosis of the position of the growth be made, even so late as shortly before their death, whilst, of course, earher in their histories many others might have been operated upon ^"ith a good prospect of success." The following are the conclusions of another physician of great clinical and pathological experience — -Dr. Byi'om Bramwell, well known as an authority on this subject, the conclusions having been given at a debate on Intracranial Surgery, at the Medico-Chirurgical Society of Edinburgh.^ Dr. Bramwell considered that the cases in which intracranial tumours can be successfully removed by the surgeon are rare, a consideration of the conditions present making it easy to understand why this must necessarily be the case. (1) In a certain but very small number of cases an intracranial tumour is not charac- terised by any symptoms during fife which enable a positive diagnosis to be arrived at. (2) In some of the cases of intracranial tumour in which the symptoms — e.g. headache, vomiting, giddiness, and double optic neuritis — distinctly show the presence of an intracranial tumour, there are no locahsing symptoms which enable the physician to determine in what part of the cranial cavity the tumour is situated. These cases constitute a not inconsiderable proportion of the whole. It is by no means uncommon to meet with large tumours in the temporo-sphenoidal and frontal ^ lobes, the " silent areas " of the brain, which are unattended 1 Trans., vol. xiii, 1894, p. 180. ^ There is increasing evidence to show that the frontal lobes can no longer be regarded as " silent areas "as has hitherto been the case. Sir D. Ferrier (Allbutt and Rolleston's System of Medicine, vol. viii, p. 50) comes to the following conclusions vnih. regard to the frontal lobe : (i) Lesions of the frontal lobe may be said to be not infrequently latent. (ii) On the other hand, in some cases, especially if the lesion is bilateral, and even in the case of lesions which are not calculated to cause pressure or disturbance of the brain in general, there may be mental symptoms of which the chief characteristics are failure GROWTHS OF THE BRAIN 299 with any very definite and characteristic locahsing symptoms. The occipital lobe was formerly also thought to be a silent area, but it is now known that lesions in this situation produce homonymous hemianopsia, a most important localising symptom (p. 292). (3) In a few cases, in which there are localising symptoms, these give an erroneous impression as to the position of the tumour. In support of this statement an instructive case is <^iven in wiiich, in a syphilitic patient, the local i)ain and tenderness and the localised character of the s])asnis, wliicli connnenced in the left big toe, clearly indicated that the tumour would in all probability be found in the cortex in the region of the foot-centre. The necropsy showed a glioma involving the right o])tic thalanuis, the growth iuiving encroached upon the posterior division of the internal cajisule and a])parently implicated the fibres to the left leg. (4) In many of the cases in which the exact position of the tumour is clearly demonstrated, successful operative procedure is impossible or uncalled for. Thus, {a) in addition to tumours situated at the base, the basal ganglia, &c., Dr. Bramwell is inclined to include under this head a large proportion of tumours situated in the cerebellum, and for these reasons : The surgeon can hardly hope successfully to remove tumours which involve the middle lobe of the cerebellum. Tumours which are situated in the lateral lobes are with difficulty reached, and the operation required for their removal is a dangerous one ; the surgeon has to work in a very narrow^ space, and there is a risk of w^ounding the large venous sinuses, the medulla, the pons, &c. Further, it is often an extremely difficult or impossible thing to determine, during life, in which lobe of the cerebellum the tumour is situated. (6) In many cases the tumour is so extensive and infiltrates such a large area of brain tissue that its complete removal is impossible, (c) In others the tumour is multiple. (fZ) In others it is malignant and of a secondary nature, (e) In some the cerebral tumour is complicated by associated lesions in other organs which contra-indicate any operative interference. Thus, in not a few cases of tuberculous growth of the cerebellum the lungs are also affected, and in some syphiHtic cases the vessels either of the brain or other parts of the body are so extensively diseased that an operation is very hazardous. (/) Speaking of syphilitic tumours. Dr. Bramwell, while admitting the good results obtained by very active drug treatment, was disposed to think that in many of the syphihtic cases in which the gumma is large and of some standing — cases in which a cicatrix must necessarily remain on the surface of the brain — operative procedure is advisable after the acute symptoms have subsided under the vigorous use of specific remedies, as the termination of many of these cases (the of memory, hebetude, apathetic indifferent or tendency to sleep, vague restlessness, and inability to concentrate attention, or a silly jocularit}\ (iii) The regional diagnosis of lesion of the frontal lobe is rendered more probable if, in addition to the psychical symptoms, there occur convulsive or paralytic symjjtoms, mono- plegic or hemiplcgic, on the opposite side of the body. These symptoms are indicative of extension of the lesion backward into the Rolandic area. (iv) The diagnosis of lesions of the frontal lobe may be made with still greater cer- tainty if, in addition to the symptoms enumerated under paragraphs (ii) and (iii), there are signs of pressure in the anterior fossa ; consistmg in protrusion or displace- ment of the ej-eball, with perhaps unilateral loss of vision, anosmia, and paralysis of one or other of the oculomotor nerves. (v) The diagnosis is confirmed if, in addition to some, or a combination of several, of the above-mentioned sj-mptoms, there is pain on deep pressure on the frontal bone. This local pain may, however, be entirely absent if the lesion be subcortical, and is especially to be found in cases of tumour causing tension or irritation of the dura mater. 300 OPERATIONS ON THE HEAD AND NECK patients ultimately becoming useless members of society, or insane) is so deplorable.^ The above conclusions of Dr. B}Tom Bramwell were based on an analysis of eighty-two cases of intracranial tumour which he had seen dm'ing life and which he had examined post-mortem. In seventy-seven out of the eighty-two operative interference for removal of the tumour was contra-Lndicated. Of the five remaining cases he considered that in two the success of an operation would have been extremely doubtful ; in the remaining three an operation might, he thought, have probably been attended with success. But; while believing that there are comparatively few cases in which the surgeon can hope successfully to remove ^ an intracranial growth, Dr. Byrom Bramwell would very strongly advocate trephining as a palhative measure ^ in many of these cases. " Thus in not a few, the headache is intense, and it has been conclusively shown that in some of these cases sudden death takes place, apparently as a result of the pain and resulting inhibition of the heart, a point to which Dr. Hughlings Jackson has directed attention. Again, in other cases in which the intracranial pressure is -greatly increased, the patient dies either suddenly in an epi- leptic fit, or gradually as a result of failure of the respiration. Further, it must be remembered that in a large proportion of the cases of intra- cranial tumour the optic neuritis is intense, and that in not a few of them the optic neuritis, if allowed to contmue, passes on to optic atrophy, and produces more or less, and it may be complete, blindness. Now, it has been conclusively shown that in some cases' in which the operation of trephining has been performed both for tumour and abscess, the optic neuritis has speedily disappeared, in consequence, I beheve, of the sudden rehef of the increased intracranial pressure." It will thus be seen, in many cases, in spite of the aid derived from locahsation, that the operation must be exploratory. The surgeon will, however, so plan the operation that in the event of the impossibihty of the removal of the growth, he can proceed to the paUiative operation of decompression for the rehef of symptoms. These are the opinions of two well-known physicians in this country on the percentage of cerebral growths suitable for operation. To turn 1 While admitting the force of this opinion it is to be feared that if surgeons follow Dr. BramweU's advice they wUl sometimes find, if they publish the results of their eases after carefuly watching them, that they have merely substituted one cicatrix for another (p. 273). 2 Dr. W. J. Taylor has published an account (Ann. of Surg., 1912, vol. Ivi., p. 55) on the end results of 63 cases of operative treatment of cerebral tumour which have been under his personal care or observation extending over a period of twenty-five years. Of the 63 cases 1 lived for twenty years. 2 for about six years, while all the others died within three years of the operation. In 30 of the cases the tumour was localised and was found at "the operation : in 14 of these the tumour was completely removed, in 9 it was partly removed, while in the remaining 8 cysts were opened and drained. Six of the cases were tumours of the dura mater ; of these 3 died withim a few hours of haemor- rhage, one was alive five months after and was then lost sight of, another died with a recurrence after 108 days, while the other lived for twenty years. Eight of the cases were simple cys-ts of which 6 recovered from the operation and 1 was alive five and a half years after. The operation mortality was very heavy, 6 of the patients died in the first five days, and 13 in the first ten days, giving an operation mortality of 19 per cent. Dr. Taylor describes these end results" as " very bad indeed." In many of the 33 cases in which the tumour was not found, decompression was successful in relieving the symptoms for a variable time. A paper by v. Eiselsberg (Wien. Klin. Woch. 1912, p. 17), in which 100 cases are analysed, may also' be referred to. The operation ie two stages is recommended. ' Palliative measures are again referred to at p. 318. GROWTHS OF THE BRAIN 301 elsewhere, Oppenheim analysed twenty-three cases observed by himself and verified by necropsy. Only one could have been removed by opera- tion. Von Bergmann puts the percentage of suitable cases as at most 6 to 7 per cent., and, with very few exceptions, would limit the operation to growths of the motor region and to those parts of the brain ad- joining it. Having spoken in general terms of intracranial growths, it will now be necessary to consider, from a surgeon's point of view, the varieties most frequently calUng for operation. These are the tuberculous, the gliomata and sarcomata, gummata, and cysts. Tuberculous Tumours. As a rule these should only be attacked when there is good reason to believe that the growths are primary and single. The frequency with which the_y are multiple and present as well as elsewhere is alluded to above (p. 298). But where a tuberculous growth is threatening to cause blindness, severe headache, constant vomiting, &c., it should be explored, and removed if possible. Sir V. Horsley ^ expressed himself as strongly in favour of operation. Where a trial of medical treatment for four months, fails, such tuberculous nodules are probably densely fibrous with caseous centres. Age, no doubt, has an important effect here. Thus, in a child, owing to the yielding skull, the presence of a tuberculous mass may be long un- suspected. Ransohoff, of Cincinnati, whose personal experience is considerable, as he has operated on eight cases of cerebral growths, reports his two successes with very instructive comments.^ The nature of the growth in the first case is not stated. The second case, stated to have been a solitary tuberculous deposit, was operated on in two stages. At the first operation an opening three and a half inches long and three inches wide was made. When thi'ee days later the dui-a, which pulsated feebly, was opened no growth was found. The patient was now placed in the sitting position — local anaesthesia being now employed — a step which caused the brain to recede and allow of palpation far beyond the limits of the cranial opening. The growth was found half an inch below the surface in the ascending frontal convolution, and was easily removed. Thi-ee and a half months after the operation the patient had had no convulsions, but a decided weakness of the flexors of the thumb, index and middle fingers remained. In tins case the general symptoms of brain growths (headache, choked discs, and optic neuritis) were absent, the symptoms being altogether focal. This is explained by the fact that when the growth was removed it displaced 12 grammes of water, a pressure to which the brain accommodates itself. With the develoi)ment of symptoms of intracranial pressure the value of focal symptoms decreases. This explains the frequency of failure to find a growth when seemingly umnistakable localiumg symptoms are present. Ransohoff points out that in two-stage operations the second one can be done satisfactorily mider local anaesthesia. If it be needful to cut away more bone, chloroform must be administered. He thinks that adoption of the two-stage method will diminish the very high mortahty. This, due chiefly to shock and haemorrhage, is stated by Haas, from an examination of 122 operations for removal of growths, to be as high as 61 per cent. Ransohoff beheves that tuberculous deposits in the brain are tw^ce as common as any other tumours. He quotes from a paper by Preyer, who ^ collected the cases operated on up to that time, sixteen in number ; Ransohoff's case and one of Heidenhain made eighteen. Three died from the operation ; six survived several months, two several years ; one of Czerny's lived four years and two months, one of Sir V. Horsley's seven years 1 Brit. Med. Journ., 1893, vol. ii, p. 1365. 2 Journ. Amer. Med. Assn., October 11, 1902. ^ Rev. Med. de la Suisse, May and June 1900. 302 OPERATIONS ON THE HEAD AND NECK and eight months, dying then of tuberculous disease of the spine ; one operated on by Kronlein was believed to be alive, six years after operation. Von Bergmannsome years ago opposed operations on tuberculous deposits in the brain on the grounds, chiefly, of the risk of setting up tuberculous meningitis and the great difficulties of enucleating such a deposit here, compared with one in the skin or bones. He " has reported twelve cases of cerebral tuberculosis treated operatively. In seven of these the central convolutions were affected ; in four the cerebellum. In one, in addition to disseminated tuberculosis of the pia, there was an affection of the parietal lobe. Of the seven cases with affection of the motor region thi'ee were cured, two died from the effects of the operation, and two from an extension of the tuberculosis. The five cases of affection of the cerebellum all terminated fatally, three immediately after the operation. In eight cases the tubercles were not completely removed, and in each case death rapidly ensued." Caseating foci in the cerebellum, owing to their comparative frequency, need especial allusion. The very high mortahty of Von Bergmann's results — himself one of the chief pioneers on cerebral surery — and the cases alluded to below make it extremely doubtful if it is justifiable to continue attacks on tuberculous deposits in this situation (p. 322). Sir V. Horsley ^ has removed a tuberculous growth from the right lobe of the cerebellum. Death took place nineteen hours later, the patient having only partially recovered consciousness. Generalised chronic tubercle was found in the viscera. The opera- tion was here performed as a last resource. Mr. Bennett May - removed a similar growth from the right lobe of the cerebellum of a child. The extreme bulging of the dura mater gave evidence of great intracranial pressvire. The cortex appeared quite healthy, but at one spot palpation gave an ill-defined feeling of hardness. This spot being incised, the finger detected a hard mass nearly an inch below the surface. This was dug out with the handle of a small teaspoon. It was larger than a pigeon's egg, hard and horny outside and caseating in the centre. The haemorrhage was trifling, but the patient sank from shock a few hours later. No necropsy was permitted. Mr. Waterhouse ^ mentions with helpful candour three cases in which he had operated upon tuberculous tumours of the brain. In none was the tumour single. Two cases died -^ithin forty-eight hom's of the operation, while in the third partial recovery for four months ensued, followed by death, due to another tuberculous growth. Gliomata and Sarcomata. As several cases are referred to, some fully, in these pages, and as the important questions of appearance and in- filtration are dealt with in the section on "Operations on the Brain" (p. 321), I shall only refer to one more instance of these growths. It vnU be found reported by Dr. C. K. Mills ; ^ the following epitome is given in the British Medical Journal, Jan. 24, 1903, p. 13. It contains two special points of interest : (1) the use, successfully, of the Rontgen rays, as a means of diagnosis, and (2) the means adapted for meeting the haemor- rhage. The patient, a girl aged 21, had had symptoms for tlu-ee years, andpresented all the classical phenomena — oj^tic neiu-itis, headache, vomiting, &c., together with left hemiparesis. Skiagraphy showed an abnormal shadow of about tlu'ee inches in diameter and irregular in outline, hing directly upon the Rolandic area. Over its anterior portion the middle meningeal and its branches ran, and the inner table of the skull was seen to be disorganised over the region of the growth. The central fissm-e ha\ing been localised, the cranium was opened by Stellwagen's trephine 1 Brit. Med. Journ., April 1887. ^ Lancet, April 16, 1887. ' Brit. Jled. Journ., October 1, 1898, p. 968 * Phila. Med. Journ., September 27, 1902. GROWTHS OF THE RRAIN .303 (Fig. 135), but tlio lui'morrhage was so sevens that tlu; wound had to be packed, and further .stei)s postponed. The jiatient rallied well, and at the second o])eration owinj; to the severe lueniorrhage before, both eoiniuon carotids were clamped by Crile\s method.' An encapsuled ovoid growth, three inches in length, wliich proved to be a s])indle-cell sarcoma, was discovered and removed with hardly any bleeding. The i)atient tlied in a few hours from post-operative shock. Gummata. Some have expressed the opinion that here surgical inter- ference is uncalled for. While no one will operate on a gumma of the brain till a sufficient trial has been given to mercury and potassium iodide,' or possibly an injection of salvarsan, there is no doubt whatever that a syphilitic lesion may reach a stage here, e.g. from its density, as elsewhere, in which it has quite got beyond the reach of specific remedies. Such a lesion, if localisuble and to be got at, should be attacked, because, if left alone, it will go on causing trouble indefinitely, and further the compression and wasting of adjacent nerve tissue which it will set up will in time become irreparable. On this point the remarks of Dr. Byrom Bramwell (p. 299) bear strongly. Sir V. Horsley, who is of opinion ^ that cerebral gunmiata are not really cured by drugs, would certainly limit the trial of drugs to two months. He holds that gummata are here incurable, because there is always a certain degree of pachymeningitis around them, and that this is inevitably progressive. One of the most interesting instances of operation in these cases is one of Sir W. Macewen's.^ In a woman, aged 25, there was left-sided motor monoplegia of arm and leg, preceded by muscular twitchings and tingling sensations, without loss of sensation, due to syphilis, which resisted prolonged treatment. A cortical lesion of the right motor area, in the upper half of the ascending frontal and parietal convolutions, with probable involvement of the paracentral lobule, was diagnosed. A crown of bone over an inch in diameter, with its anterior border reaching to a point about half an inch behind the auriculo-bregmatic line, and its uj^per margin reacliing to within half an inch from the centre of the superior longitudinal sinus, was removed. Its inner sm-face showed osteophytes. The dura mater was tliickened and rough. Crucial flaps of this being reflected, a yellowish opaque effusion covered the brain, obscuring the convolutions and bridging the fissure of Rolando. This was very friable and came away in minute portions. Towards the upper part of the opening the brain offered resistance on palpation. This sensation jjroceeded from the interior of the brain, in the direction of the paracentral lobule, a layer of brain tissue intervening between this more resistant structure and the finger. An incision being made tlirough the upper part of the ascending parietal towards this firm structure, about two drachms of grumous fluid escaped. The resistance now dis- appeared, and cerebral pulsation was for the first time feebly perceptible. The patient made a good recovery, and regained sufficient power over the left side to enable her to walk two miles, and to do her household work. Mr. Waterhouse ^ mentioned an interesting case of intracranial gumma, in which, in spite of the administration of potassium iodide and mercury for four weeks, and then potassium iodide in doses of 30 gr. t.d. for a further period of five weeks, the symptoms steadily increased. The patient became hemiplegic, then comatose. A large gurmna was ^ This is described, together with other methods of temporary closure of the common carotids, q.v. ^ The American method of pushing this drug in large doses at frequent intervals, in milk [Arch, of Medicine, New York, October 1884), is especially applicable here. A warning is needed now. ^\'hether this drug be used for gummata or in uncertain cases, its lowering effects must always be remembered. Some daj's should always be allowed to elapse between the discontinuing of the drug and the operation, otherwise the shock of a severe operation will be ncedlesslv increased. * Brit. Med. Journ., 1893, vol. ii, p. 1365. * Lancet, May 23, 1885. ^ Loc. supra, cit. 304 OPERATIONS ON THE HEAD AND NECK removed " from the left area of Rolando." Recovery was rapid and complete. A case of gmnma and localised meningitis of the motor region success- fully operated upon will be found reported by Dr. C. K. Mills.^ The patient, aged 27, had been twice previou.sly treated with success by large doses of pota.ssium iodide. On his third admission the prominent sjTnptoms were extreme pain in the left parietal region, frequent spasmodic seizures of right upper and, later, of right lower limb and right side of face. When the bone- flap was turned back — vStellwagen's trephine was used — the dura was adherent to the skull over a considerable portion of the bone-flap which had to be pulled away from the membrane. The latter was, in places, four or five times thicker than normal. The dura, pia and arachnoid were ahherent to each other and to an oblong flat mass, which corresponded almost exactly in its dimensions to the shadow furnished by the Rontgen rays. As it was impossible to dissect the mem- branes from the mass beneath, it was decided to remove them altogether. This was done with but little disturbance of the brain tissue. To replace the removed dura, advantage was taken of a suggestion by Prof. Keen, and an incision made in the scalp outside of the line of the main opening. The scalp was turned back, and a piece of the pericranium dissected loose and inserted into the opening left by removal of the dura. This piece of pericranium was turned upside down, so that the osteogenetic surface would be away from the brain and not next to it. The last note of this case, four weeks after the operation, runs as follows : " The patient had made a j)erfect surgical recovery ; his headache and epilepsy have disappeared." Cysts. There are three separate conditions under which these tumours especially occur, (i) One is in the cerebellum, particularly in childhood, and affords the only hopeful outlook for operations at this early age. Sir James Goodhart ^ says that cysts, " although not common, should be kept in mind. I must have seen some five or six cases, and one can never see a fatal ending in such as these without regretting that surgery was not allowed to attempt a cure." (ii) Cysts may also occur after injury over the motor area, as in the following case : ^ A man, aged 22, had eijileptiform convulsions, each lasting from two to three minutes, with an average of over one hundred in twenty-four hours. The con- vulsions were limited to the tongue, right facial muscles, and platysma. When they subsided the parts remained paralysed. Consciousness was retained. Eight years previously he received an injury to the head, after which his right arm became weak, though he was able to work. It was clear that an irritating focal lesion existed, confined to the base of the ascending convolutions, causing a Jacksonian epilepsy. At the operation, in the lower part of the ascending frontal a cyst about the size of a filbert was found, situated partly in the cortical and partly in the white substance of the brain, surrounded by a narrow zone of encephalitis. In manipulating the medullary substance dm-ing the removal of the cyst, the patient while under chloroform had a convulsion similar to those prior to the operation. The convulsion ceased with the removal of the cyst, and he never had another. The wound healed firmly under one dressing, the paralysis of the facial muscles soon disappeared, and the patient has since been constantly at work. The power of the right arm has also increased. Possibly the cyst might have caiLsed, indirectly, slight pressure on, or had set up inhibitory action of, the middle part of the. ascending frontal. Allusion has already been made (p. 275) to the difficulty which is sometimes met with in securing the obhteration of these cysts, and the need, here, of frequently prolonged drainage, (iii) While the two forms of cvsts mentioned above are those most frequently met with, the surgeon mus't be prepared to meet with a third in which the cyst is associated wdth a new growth. Such a case has been reported by Mr. Ballance.^ 1 Philn. 2Ied. Journ., November 29, 1902. ^ Diseases of Children. 3 Macewen, Brit. Med. Journ., Augxist 11, 1890. * Trans. Med. Chir. Soc, March 1896. GROWTHS OF THE JUIAIN ;3()5 A lioy, aged 1 1, liad, six moiitlis bi-foro adiiiissioii, received a severe Mow on tlio head. Fits, eoinmeiiein<^ witii twitehiiig of the riglit angle of the mouth, were followed by paralysis of llie right side of the faee, and right extremities. November 1891). The lower part of the left motor area having been exposed, a large subcortical cyst, lying tmder a])parentiy normal brain tissue, was found and evacuated. February ISid. — As the symj)toms returned, a tube was passed into the cyst, in order to drain it continuously. 'I'he symptoms then in most ])arl disaj)|)eared, and the boy remaineil in fairly good health until January ]S9:{, when his condition rather suddenly became exceedingly grave. At a third operation a growth three ounces in weight was removed from between the dura and tlu; left motor cortex. The boy left the hospital quite well save for a slight right liemi|)legia. June 1893. He was readmitted in September 1893 in an almost moribund condition, and died a few hours after another attem[)t to relieve the symptoms of pressure. At the necropsy an enormous growth was found in the left cerel)ral hemisphere. If it is right to say that cerebral surgery has not done as much as was expected of it fifteen years ago, and that surgeons no longer attack cerebral growths with the enthusiasm and frequency of that time^ this proves that the enthusiasm was not based on careful and reliable reasoning, that operations for cerebral growths were performed without sufficient discrimination, and that the risks inseparable from this path in surgery were under-estimated — surgeons forgetting that while aseptic surgery had removed certain risks, others, especially shock and collapse, remained inseparable from the pectiliar vitality of the part attacked. Any candid surgeon, acquainted with the history and progress of his profession, will allow that in two directions the progress of modern surgery has been less brilliant than might have been expected when its other triumpha are considered. The two referred to are : removal of cerebral growths compared with the other advances of cranial surgery, the surgery of the intra-thoracic viscera. The explanation of this is not far to seek. It lies in the fact, to which due weight has not been attached, that all the organs here concerned are peculiarly vital structures, and that, however great advances may be made, this fact will remain unchanged. Reference to the discussion on the " Treatment of Intracranial Tumoiu's," introduced by Sir D. Ferrier in a speech of great ability,^ in which he put the question of operation in the most favourable light possible, will support the above conclusions. Sir D. Ferrier mentioned, briefly, two cases in which the patients had survived the operation two years or more. Two surgeons only took part in the discussion, and two more successful cases of removal of cerebral growths were mentioned, but so briefly as to be of little value. Dr. Byrom Bramwell, the president of the section before which the paper was read, stated that his " experience in regard to the success of operative procedure differed notably from that of Prof. Ferrier, for in none of his fourteen cases in which an operation had been performed had a tumour been successfully removed by the surgeon. The additional experience of the past few years had entirely confirmed the conclusions which he had published in the Edinburgh MedicalJournal four years ago." Speaking of the proportion of operable cerebral tumours, Sir D. Ferrier •considered it a fair estimate to say that only 7 per cent, of cerebral tumours are capable of being surgically dealt with. As to the recent statistics of the results of operation, he considered that when cases were collected from* all sources, and therefore containing many factors not strictly -comparable with each other — of which one, the personal equation of the .operator, is exceedingly variable — such a collection of cases gave 13 per 1 Brit. Med. Journ., October 1, 1898. SURGERY I 20 306 OPERATIONS ON THE HEAD AND NECK cent, of complete recoveries, i.e. the patients were alive at least a vear, and in some cases several years, after the operation. Turning to the cases at the National Hospital for the Paralysed and Epileptic, where the operations were performed by Sir Victor Horsley and Mr. Ballance, men of special skill in this branch of surgery. Sir D. Ferrier pointed out that the cases operated on gave a percentage of 16-6 of complete recovery. Two well-known authorities on growths of the brain, Dr. Beevor and Mr. Ballance, thus reply to the question, " What do patients suffering from tumours of the brain gain from surgery ? " ^ " It appears to us that in the several following ways enormous benefit may be given by operation : " (I) The complete removal of a tumour, as in Sir V. Horsley's case, of a small tuberculous mass occupying the cortex in the region corresponding to movements of the thumb. " This patient, a man aged 20, suffered from frequent local fits, be- ginning in the thumb and forefinger, and from headache. From theye symptoms he was completely relieved by removal of the tumour and part of the cortex. 2 " (2) Partial removal of the tumour, as was probably done in the case on which the paper was founded. " The 02:)eration on this patient relieved her of headache, vomiting, double o])tic neuritis, and from the greater part of her paralysis. The mental condition, which was very much deteriorated, was restored, the patient regaining her former cheerful condition. " (3) The drainage of a cavity in a cerebral glioma or sarcoma which cannot be removed. This is well illustrated by a case under the care of Sir W. Gowers and Mr. Ballance. "The patient, aged 11, suffered from headache, vomiting, double optic neuritis, fits beginning in the thumb and followed by hemiplegia, and was practically relieved of all his symptoms, including moral deterioration (stealing), by this procedure. He lived for three years. " (4) The removal of bone and incision of the dura mater. The benefit resulting from this operation is well shown by a case which was under the care of Dr. Buzzard and Mr. Ballance. "A woman, aged 41, was admitted with symptoms pointing to tumour of the internal capsule, viz. hemiana?sthesia. nearly complete hemiplegia, double optic neuritis with failing sight, and severe headache with agonising paroxysms. In (me of these paroxysms she became comatose, and was evidently dying, it was thought, from haemorrhage into the tumour. The above operation was at once performed, and the relief of the urgent symptoms was immediale ; and in a month's time the report states that there was no headache, vomiting, or optic nem-itis, and some return of jjower and sensation had already occurred, with improvement of sight and restored mental condition. " (5) Removal of a considerable area of bone without opening the dura mater is, we believe, considered by some to be adequate to relieve the classical symptoms of tumour. It is true that the dura, bulging through the opening in the skull, indicates that there is a relief of pressure, but what we have to deal with is tension within a practically inelastic mem- brane, and the intra-dural space can hardly be materially increased while the dura is intact, and the opening in the skull is comparatively small. The sac of the dura cannot be distended to its full extent while the cranium is intact, and so when bone is removed its foldings are flattened out. A considerable fall in pressure can only be obtained by taking away a large area of bone, and in tumour cases when this is done the dura still bulges 1 Brit. Med. Journ., 1835, vol. i, p. 8. ^ ^rit. Med. Journ., 1887. GROWTHS OF THE BRAIN 807 uiuler much increased pressure. As we have known of no case in which the removal of bone alone has relieved the pressure symptoms, we should advise that the dura should always be opened ; another reason of great import being that the cortex might be involved without any of the typical signs being present. . . . " (0) We would conclude this paper with the question, ' How soon should one of the preceding operations be performed ? ' When the type symptoms are present, it is quite certain that no delay is desirable after a fair trial has been given to antisyphilitic remedies, and we should limit this time to six weeks or two months.^ The main difficulty arises when the symptoms are not typical ; and it is to be borne in mind that large slowlv-growing tumours may be present without any symptoms which are unequivocal. As an instance of this a case may be referred to which was under the case of Sir V. Horsley and Dr. Beevor. The patient had occasional fits, beginning in the corner of the mouth, with unconsciousness, six years before other symptoms arose which justified operation, and then the tumour was found to be so situated that it could not be removed without producing aphasia. It would be easy to mention other cases illustrating the same point. In any case where the typical signs of tumour are absent, and where the fits always begin with the same localised warning, and are attended with loss of consciousness, the question is, ' Are these fits due to idiopathic epilepsy, or are they due to a tumour ? ' And we should say that no operation is advisable, other signs of tumour- being absent, unless the paralysis which follows the fits is permanent — that is, not recovered from in the course of a few days — or unless the fits occur very frequently. While it is impossible to lay down absolute rules for the treatment of these cases, it would appear that occasional fits, be- ginning locally, followed by loss of consciousness, and attended only by headache, would not justify an operation ; but that any other combina- tion of the type symptoms — headache, purposeless vomiting, optic neuritis, especially with failing sight, localised fits, and permanent paralysis — would render surgical operation advisable." We come now to the last of the questions which arise before an oj)era- tion on a growth of the brain : (F) The conditions which justify operative interference, and the probable results of this step. These may be summed up as follows : (1) That as the most benign growths have proved ultimately fatal, operations are justifiable under certain conditions. But (2) for the re- moval of the growth the site of the growth must be known. At present, if locahsation be impossible, only a palliative operation should be at- tempted. The cases collected for Von Bergmann show this clearly. In one group, 116 cases, an accurate diagnosis was possible ; in all the growth was removed, and in only 7 per cent, was the operation fatal. In the second group, 257 cases, the diagnosis was imperfect, and 50 per cent, died as a direct result of the operation. At present growths of the motor area are the ones which most clearly justify attacks. Operations for the removal of growths of the cerebellum, except in the case of cysts, are rarely hkely to be successful (pp. 275, 304). (3) The growths which are most favourable for operation are fibromata, encapsuled sarcomata, and gummata. (4) The operation should be under- taken at an earUer stage than has hitherto been the case, before the patient is weakened by headache, vomiting, a long course of potassium 1 Sir V. Horsley, Brit. Med. Journ., 1893. 308 OPERATIONS ON THE HEAD AND NECK iodide, &c. (5) As a large opening in the skull is absolutely necessary, the operation should usually be performed in two stages. ^ (6) PalUative trephinings have been shown to be thoroughly justified (pp. 300, 306). This step, if not deferred till too late, may be trusted to remove for a time the headache and vomiting, to arrest the optic neuritis which will go on to bhndness, and to diminish, but probably not to arrest entirely, the epileptiform con\^lsions. The following case recorded by Sir A. Pearce Gould, shows that where a growth has been localised, but has not been found, and where its complete removal has not been possible, the symptoms have been materially relieved by the relief given to the pressure. The patient, aged 41, had, six weeks before, suffered from severe headache without vomiting, followed by aphasia, right facial paralysis, and stu]K)r deepening into coma (February 7, 1897). A two-inch trephine was used over the left face centre. When the dura mater, wliich bulged into the wound without pulsating, was divided the brain bulged still more. Puncture of this with a director in two or three directions proved negative. Four days after the operation the brain had receded below the trephine opening, over which the scalj) had been replaced ; three days later the patient was quite conscious and had lost his headache, paratysis, twitchings and aphasia. He was able to resume work in four months, but it was noted that six epileptiform fits had occurred : otherwise the health was good. The patient was able to earn his living as a market gardener, though still liable to epileptic tits, during one of which he was drowned in 1903. There was no necroj^sy. It will be noted that, in this ca.se, in addition to the trepliining, the dura m^ter was opened. Sir D. Ferrier ad\^sed, if no guide to the site of the trephining be present, that the palhative opening be made freely over the occipital or frontal region. A free opening may lead to the appearance of a hernia cerebri ; this must be treated by careful pressure and the strictest asepsis : of the other palhative measures, drainage of the lateral ventricles and lumbar punpture. it must suffice to say that our knowledge is, at present, scanty. As to the actual results, even in the cases where the growth has been successfully removed, complete recovery is the exception. The hfe of the patient is prolonged, and the pressure symptoms, headache, &c., are cured, but the epileptiform seizures are only diminished, though often markedly so. Much the same may be said of the paralysis in many cases. OPERATIVE PROCEDURES ON THE BRAIN. CHIEFLY FOR THE REMOVAL OR THE PALLIATIVE TREATMENT OF GROWTHS Preparation of the patient. The day before the operation the patient's head is shaved and thoroughly cleansed according to one of the methods described on p. 16. The patient has the usual purgative administered the evening before, followed by an enema on the morning of the operation. Anv course of iodides or bromides should be suspended for at least a week before the operation. Marking out the position of the lesion and the flap. Great attention must be paid to the exact localisation, and this step should not be left imtil just before the operation. Dr. C. K. Mills, a well-known American neurologist, whose papers are always practical and lucid, emphasises the following from an experience of twenty-two cases in which operations were performed for new growths. " A mistake of less than one inch in locating the fissure of Rolando or the height of the horizontal branch of the Sylvian 1 Dr. Howard Lilienthal has ixiblished a paper {Ann. Surg., 1910. vol. li, p. 30) on "Operations in two .stages" in which the advantages of this procedure in a number of other conditions, in addition to intracranial disease, are insisted upon. OPERATIONS ON THE BRAIN 309 fissure, may add considerably to tlie uncertainties and difficulties in an attempt at removal by makinfi; the opening so as to only partially include the neoplasm. Not only the limits but as nearly as possible the direction of the osteoplastic flap should be marked out, as well as the extent and direction of its base line, so that no loss of five or ten minutes takes place in attempts to localise it with chances that not even then is it in the best position or direction." The procedure advised by Dr. Mills, when it is intended to remove a growth limited to the motor area, is first of all to mark out the Sylvian point together with the stem and posterior horizontal branch of that fissure. The area supposed to include the underlying tumour is then exactly mapped out, and, finally, the base line of the flap which the surgeon is to make should also be indicated. The spot for the insertion of the Stellwagen trephine, the instrument employed by Dr. Mills {see p. 318), is next determined. As the arm of this trephine can be extended so as to give a radius of nearly two inches, the point selected for the pin should be about half an inch in front of the Rolandic fissure, at about its middle or a very little below this point. It is now known that the motor area is in front of the fissure of Rolando, and the circle outlined by the arm of the trephine, when the pin is placed in the position just stated, would be such as to include a little more than the motor region forwards and backwards, while it would nearly uncover it towards the median line and also in the direction of the Sylvian fissure. When the position for the pin and the extremities of the base line have been determined by careful measurement, they are marked on the scalp by small incisions.^ At the time of operation it is then only necessary for the pin to be inserted in the proper position in the scalp, and for the knife to be inserted at one end of the base line and swept around the circle until it reaches the other end. No time is then lost in determining the direction and length of this line. Anaesthetic. If not contra-indicated, a hypodermic injection of a quarter of a grain of morpliia- is given and then chloroform is administered. The object of giving the morphia is twofold : in the first place, it allows of the performance of a prolonged operation without the necessity of giving a large amount of chloroform, the amount actually used in an operation lasting two hours being very small. The second reason is perhaps the more important : that this drug causes well-marked contraction of the arterioles of the central nervous system, and that consequently an incision into the brain is accompanied by very little oozing if the patient be under its influence. Removal of bone and exposure of the brain. It will be taken for granted that for the present, at all events, operations for removal of ^ Or by nitrate of silver. A solution of silver nitrate (30 gr. to the ounce) is painted along the lines and allowed to dry. It is then brashed over lightly with a solution of pj^'ogaUic acid (5 gr. to the ounce). The stain thus produced is not washed away when the scalp is subsequently sterihsed. - In one case, a child of 4, one-twentieth of a grain was found amply sufficient. The advisability of a preliminary injection of morphia has been a good deal disputed. Sir F. W. Hewitt in his most careful work on anaesthetics, p. 422, says : " The ase of mor- phine before chloroform has been found to be advantageous in cerebral surgery, there being less vascularity of the brain and its membranes with this mixed narcosis than with chloroform alone. But as many of the patients requiring these operations may be at the time of the administration in a state of torpor or semi-coma, or may during the operation display symptoms of shock or respiratory depression, considerable discretion must be exercised in applying the method. Many surgeons, indeed, who at one time used this mixture narcosis, have now abandoned it in these operations." 310 OPERATIONS ON THE HEAD AND NECK growths of the brain will generally be performed in two stages : (a) Removal of the bone, (6) incision of the membranes and the brain with removal of the growth, an interval of a few days intervening between the two operations. Sir V. Horsley,. to whom as a pioneer at once most skilful and scientific we owe so much, having turned down the flap which bears his name and which obviated the risk of a hernia cerebri inseparable from the old crucial incision, removed the necessary amount of bone with a large trephine followed by the use of powerful bone forceps or saw. The objections to this procedure are : (a) For removal of a growth, and still more for the palliative operation of " decompression " a large amount of bone requires removal : {h) If a large amount of bone is taken away, the resulting gap in the cranial wall may itself be the cause of considerable trouble. To ob\'iate these objections the osteoplastic method of resection of the skull may be employed. This method, introduced by Wagner as long ago as 1889, has increasingly gained ground in recent years. Prof. Kronlein thus strongly advocates its use.^ The old opinion still holds that the power of regeneration in the convex bones of the skull following loss of substance is small, and that consequently defects of any extent are only filled with connective tissue and not with bone. In certain cases such defects have recently been observed to close through regeneration of bone. These are, however, conspicuous exceptions, and as such they only confirm the rule. Experience shows that the connective tissue scar, which usually clo.ses small defects of the cranial bones, maj' be so firm and dense as to lead one to believe that a production of new bone has taken place. The conditions are entireU' different in the case of more extensive defects of the skull which are only covered by skin and scar tissue. Such patients are not only extraordinarily vulnerable as regards any violence affecting the skull, but their infirmity frequently manifests itself in an entirely different manner. This is very clearly shown by an observation recently communicated by Konig. Konig's patient had an exteiLsive traumatic defect in the left parietal region. He manifested a degree of weak-mindedness bordering on idiocy, and suffered from epileptiform attacks. All the.se severe disturbances, which Konig very correctly, no doubt, referred to the displacement and distortion at the surface of the brain in the region of the defect, disappeared as soon as ho successfidly brought alx)ut bony closure of the defect. Based upon such experiences, it is altogether jastifiable to demand that extensive and permanent defects of bones should be avoided from the beginning in cases of operations upon the brain. We must not, however, attach too much importance to a single case, and it is by no means certain that where a large amount of bone has been removed and the healing of the wound has run an aseptic and rapid course that the defect left and the resulting scar are of the weak and perilous nature imphed by Prof. Kronlein. Anyone of large ho.spital experience is familiar with cases where, after a comminuted compound fracture of the skull, the patient comes from time to time with a thinly covered pulsating scar, for the renewal of some artificial covering. But owing to the widely different conditions under which the two scars have formed there is no comparison between the state of such a scar and that resulting from a wide removal of bone with strict attention to the rules of modern surgery. This is certainly true of the removal of bone in the temporal fossa. Mr. J. Hutchinson, jun., whose experience and success in the removal of the gasserian ganghon by the temporal route is well known, writes - that the large aperture left by trephining and bone forceps ^ Von Bergmann's Sysi. of Pract. Surgery, Aincr. Trans., vol. i, p. .330. 2 The Surgical Treatment of Facial Neuralgia, 1905, p. 91 ; Sir F. Treves's Manual of Operative Surgery, vol. i, p. 22.5. ()l>i:i{ATI()NS ON THE BRAIN 311 " becoiucs so completely lilled up with bone in a year or two that it can no longer be detected." Till recently the objections to the osteoplastic method were valid ones (1) that unless performed by complicated instruments not always at hand and involving special experience in technique the method was a prolonged one, especially in thick and com- pact skulls, save in specially experienced hands, and (2) if performed by the very simple mallet and chisel it entailed what has appeared to many to be an unnecessary violence and, perhaps, for there can scarcely be any proof here one w'ay or the other, a harmful degree of concussion of the brain. Now, however, Wagner's method has been so simplified, as will be seen below, that the above objections arc no longer valid. The course to be taken is, however, an open one. On the one hand if the surgeon pre- fers it, especially in his earlier cases, he is entirely justified in using the simpler method. Time and further experience alone ^vili show whether the advocates of the osteoplastic flap and this only have been premature in their claim that this method is essential for sound surgery. Before dealing in some detail with the different ways of removal of the skull a few words must be said about the haemorrhage. This in large incisions of the scalp must always be free ; in some cases it has been so profuse as to add gravely to the perils of the patient. The simplest methods of meeting are described at p. 255. Makka's clamps (Fig. 118), if available, may be used, or a fairly large drainage-tube sterilized and split longi- tudinally may be carried once round the forehead above the root of the nose and the ears and below the occipital protuberance and secured over a pad of gauze. There is no need to clamp the tubing very tightly, a step which is further objectionable from the risk which it entails of causing sloughing of soft parts in a prolonged operation. It must be remembered that the above step cannot always be relied upon to arrest the haemorrhage from the scalp. ^ If it fail, the surgeon must, if not intending to employ the osteoplastic method, raise the flap rapidly, including the periosteum, and seize each bleeding vessel, including the whole thickness of the scalp, with Spencer- Wells forceps. As soon as the flap is partly raised an assistant can compress its edge between his fingers, relaxing his pressure over different parts of this in turn, as the operator takes up the vessels. We will now suppose that the surgeon W'ho is not employing the osteo- plastic method has turned down his flap, wrapped this in sterile gauze, arrested the bleeding, and removed the tubing. In order to remove the bone freely — and a cramped opening is certain to defeat the object of the operation — the following courses are open to him : ( 1 ) He may make a large opening with a one or two-inch trephine in the centre of the area to be removed, and then complete the removal with bone forceps such as those of Hofimann (Fig. 126). This is, however, ^ Thus in a case of removal of a small spindle cell, encapsuled sarcoma of the brain and dura mater, in which the skull wall was hypertrophied and the diploe obliterated, reported by Dr. J. E. Owens, of Chicago (Ann. of Surg., May 1905, p. 695), " in spite of the fact that the head was encircled by an elastic band haemorrhage persisted even after a number of artery forceps had been employed. These, as well as digital compression here and there, were not sufficient to completely arrest the bleeding." After partial forma- tion of an osteoplastic flap the completion of the operation had to be deferred owing to the alarming prostration of the patient, chiefly from loss of blood. The operation was completed about a week later, and then the htemorrhage from the scalp was so free as to be only arrested by loosening the flap at the pedicle for the purpose of enclosing the latter in an elastic ligature. The patient recovered. 312 OPERATIONS ON THE HEAD AND NECK always a very slow process, increasing greatly the amount of anaesthetic necessary ; in thick or sclerosed skulls Hoffmann's forceps may prove in- C. FiG l^O Three useful skull-cutting forceps. A, Hoffmann's. B. Lane's. ^ " ' C, De Vilbiss. adequate and it is well to be provided with a pair of powerful forceps sS as those figured above or Lane's fulcrum cutting forceps (Fig. 126) To ) A quicktr method is to make four small trephine openings at the OPERATIONS ON THE BRAIN 813 angles of the area to be removed, and then to join these by the forceps shown in Fig. 12(5, or by the forceps of De Vilbiss (Fig. 12G), or by a Gigh's saw as described below. ^ If the ha3morrhage on division of the bone, now or with an osteoplastic flap, is severe — and this lias been perilously the case on several occasions — the following ways of controlling the hoenior- rhage suggest themselves, e.g., pressure with sterile gauze wrung out of hot sterile saline solution, or out of sterile adrenalin solution (1 in JOOO) ; the application of Horsley's wax ; crushing the cut edge of the bone with strong forceps — too much force must not be used or fresh channels are opened ; the use of sterile wooden pegs ; these faihng, temporary com- pression of one or both carotids may be tried. The bone being removed, the surgeon decides by the pulse and con- dition of his patient, the urgency of the case, and the report of the anaesthetist, whether he shall complete the operation or defer this to a later stage. In all doubtful cases this will be the wiser course. It was advocated some years ago by Sir W. Macewen and Sir V. Horsley, and their advice is now largely followed. It is no exaggeration to say that if it had been taken oftener the mortality of this operation would not have been so high. The step, as pointed out by Sir W. Macewen, not only diminishes shock, but also, if the dm'a be opened, by soldering the membranes at the margin of the exposed brain, shuts off the subdural space and so prevents the escape of blood into it. The objections must not be forgotten, viz., the double anaesthetic, the two operations, and the difficulty of keeping the wound aseptic. If the above course is taken, all haemorrhage is finally arrested, the flap is replaced, a few sutures inserted, and the usual dressings applied. The osteoplastic flap. The first point to consider is the position of the flap. If localising symptoms are present, and the removal of the tumour is considered feasible, the flap will naturally be cut so as to expose freely the site of the tumour. In those cases where the tumour cannot be localised, or where, though its situation is known, its removal is considered to be impossible and the operation is undertaken solely with the object of relieving symptoms, its situation must be carefully planned so as to minimise the chance of any untoward results, such as paralysis, following the operation. Many surgeons prefer to make a flap the centre of which is just above the ear. Others prefer one of the " silent " areas such as the frontal. Dr. Hudson [vide infra) advises the occipital region in these cases as less likely to cause damage, as he maintains that the brain can project in a backward direction without interfering with these centres. The following are among the many methods which may be actually employed. (1) The mallet and chisel and their disadvantages have been already mentioned (p. 311). Doyen's guarded chisel or guarded saw may be used (Fig. 127). A large horse-shoe shaped incision must first of all be made through the soft parts down to the bone. This flap is not dissected free and turned down, but by means of an elevator the soft parts are turned to one side so as to expose the bone throughout the line of the incision. The bone is then divided by one of the following methods : ^ Trephines and other instruments worked by an electric motor or surgical engine require much skill and care in avoiding injury to the dura mater. Their use is described on p. 316. 314 OPERATIONS OX THE HEAD AND NECK iSc Fig. 127. A, Doyen's guarded chisel. B, Doyen's guarded saw. (2) Four small perforations may be made by means of a small trephine at the angles of the flap. These holes are then joined (Fig. 134) by the De Vilbiss forceps, by Hey's saw, or by means of a Gigli's saw {vide infra). (3) The openings in the bone may be made with Doven's perforator and burrs (Figs. 130, 131). These small openings are then joined by one of the methods mentioned above. Marion, of Paris. ha\ang tried nearl^'all the different methods of. craniectomy, has come to the conclusion that much the most rapid is that by means of Gigli's saw.^ M. Marion employs Doyen's instru- ments for perforating the skull and uses a modification of the introducing director usually sold %\ith Gigli's saw. A small trephine may be used instead of Doyen's perforator. As to the introducer, the whalebone guide usually sold will not stand boihng and tends to fray and perish. A flexible strip of copper and a loop of silver wire will supply all the needs of an intro- ducer. The flap of soft parts having been out- lined by incision and the periosteum sepa- rated for about a quarter of an inch (Fig. 130), four or moreoriflces, according to the size of the bony flap to be raised, are made with M. Doyen's instruments. " The perforator is first fitted on, and the bone is perforated down to the inner table very rapidly. Owing to the tri- angular shape of the perforator, with an almost blunt extremity, one can scarcely injure the dura mater if care is taken when the inner table is reached. As the deeper layers are arrived at the centre of the perforation becomes depressible. A cha- racteristic sensation indicates that the skull is actually perforated. A burr (Fig. 131) being next substituted for the perforator — the burr should be sufficiently large, from 12 to 15 mm. in diameter — each orifice is enlarged until its dimen- sions, superficial and deep, are almost the same. The orifices are now joined by the saw. This is introduced by passing the director (Fig. 133) from one orifice to the next (Fig. 132), a step rendered easy by the elasticity of the director, and by giving a slight curve to its extremity. The saw is then passed along the groove, and if there be any difficulty in doing this a thread or a piece of fine silver wire is first attached to the saw and drawn through." The 1 Arch. Gen. de Med., 26, 1904, p. 1025. Fig. 12'8. Gigli's thread-saw. OPERATIONS ON THE BRAIN 31 5 Fi(i. 12!). Steel director and ■vvhalel)oncc;ui(l(> foruse witli(!if,di'.s saw. Hole.s are first made witli a small trepliiiie, tlien the director makes a way for the whalebone guide, threaded with silk. The guide is withdrawn, leaving the silk in situ ; the silk afterwards assists in the passage of the Gigli's saw. director is hold in position by an assistant to protect the dura mater. The first two holes are then joined by the saw. " The sawing is effected easily and rapidly (Fig. 134) if care is taken that the two ends of the saw are not held at too acute an angle, and the two hands and the angles of the saw kept in the same place. Fur- ther, the sec- tion of the bone should not be made perpendicular to its surface but a little obliquely from without inwards. When all the circumference of the flap has been thus treated, the saw is slipped down to the base of the flap, and this is partly sawn through, a step which greatly facilitates i ts fracture . ' ' The following ad- vantages are claimed by M. Marion for this method. (1) Only one special instrument, Gigli's saw, is re- quired. Unless a small trephine is used Doyen's instruments will also have to be added. (2) It is rapid and gentle. M.Marion claims that as large a flap as can be desired can be raised in less than five minutes. The vibra- tions of any elec- trical apparatus are avoided and the need of any installation dis- pensed with. (3) The surface of the section is very clean and per- mits of the most exact readjustment of the flap. (-4) There is no danger of womiding the dura mater. Fig. 130. The outline of the osteoplastic flap (5) By this means it having been marked out by incising the soft parts is easv to saw through ^"^^ slightly separating the periosteum, five open- ,11" J. ^ , „ 9 ings in the cranium are being completed with M. the base of the flap m Doyen's burr. (Marion.) 31 G OPERATIONS ON THE HEAD AND NECK part,^ a step which, if not indispensable, greatly facilitates the regu- larity of the line of fracture, a point which is not without importance in the readjustment of the flap. The only objection to the method is a small one. A saw may break, especially when used at too acute an angle or when the hands are worked in different planes. Several should always be at hand. (4) The bone may be divided by means of electrically driven burrs or saws. This method is both powerful and rapid. A large bone flap can be cut in a few minutes. There is usually less trouble from bleeding from the bone. The chief disadvantage is that the dura mater is imperfectly protected. (5) Stellwagen's Trephine (Fig. 135). This instrument, which com- bines the knife and trephine, is intended, while worked by hand, to supply, in great measure, the speed of craniectomy by the help of the electro- FiG. 131. M. Doyen's porforator and burr. (Marion.) Fig. 132. The cranium having been cut through up to the third opening, Gigli's saw is being passed from the third to the fourth opening with the aid of M. Marion's guide. (Marion.) motor. As in the case of all new inventions it has been promptly and largely tested by American surgeons, some of whom, but not all, speak very highly of it. 1 This method may be adopted, whatever method may have been employed to cut the flap. The base of the flap may also be partly divided by De Vilbiss forceps or by the cliisel : Gigli's saw is, however, simplest and most satisfactory. If the flap is forced back without partial division pf its base serious fracture of the skull may result. OPERATIONS ON THE BRAIN 317 Advantages of S(('llwagen\s trephine. A largo openiiij]f is rapidly made. P^roin accoiiiits of Anioricaii cases the time varied according to experience with the instrument, from thirty to eight minutes. It does away with the risky jarring inseparable from the use of mallet and chisel. ^ It makes the osteoplastic fiap so accurately that the reunion is ({uick and certain. One possible difticulty is that, when the flap is large, that it may be difficult to catch all the vessels that are divided as quickly as is desirable. FiLJ. 133. M. Marion's guide for digli's .saw. (Marion.) This may be avoided by carrying the kuife to a certain distance, the vessels are then secured, and the knife is next carried round another portion of the circle and so on. (0) Dr. Hudson 2 has described a new operation for decompression. A large osteo])liistic flap is made on tha-posterior aspect of the skull over the occipital lobes of the cerebrum so as to allow of the expansion of the brain in a Fig. 134. Division of the cranium by Gigli's saw. (Marion. backward direction. By means of special forceps designed by Dr. Hxidson, the bone is cut with a bevelled edge so as to allow of exact reposition. The Hap is replaced and kept in position by loosely twisted silver wires. As the tumour grows and the intra-cranial pressure increases, the wire loops untwist and the bone is displaced backwards. Should this not occur, a little cucaine may be injected and the bone is given a lift by a sharp-pointed stylet. ^ It is interesting to note that Prof. Keen has opened the skull with a chisel and mallet in 150 cases, and that he has yet to see the first instance of mischief from this method. 2 Ann. of Surg., 1912, vol. Iv, p. 744. 318 OPERATIONS ON THE HEAD AND NECK Cushing's Operation for Decompression (Fig. 136). Gushing insists on the importance of preserving the temporal muscle in the formation of an artificial hernia cerebri. He turns down a large flap on the lateral aspect of the skull, consisting of the soft parts down to the temporal fascia. When this flap has been turned down, the temporal muscle is divided parallel to its fibres, and the periosteum is exposed by retracting the edges. The periosteum is then separated and divided and the requisite amount of bone removed, preferably by a trephine and skull-cutting forceps. The divided temporal muscle is then, when the compression has been relieved, brought together by a few sutures. Gushing finds that in this way an enormous hernia cerebri may develop without sub- sequent ill effects. When the tumour cannot be localised, or if it should be of such a character as to render removal impossible, this operation is often remark- ably successful in relieving the distressing symptoms. Second Stage of the Operation. This is undertaken after an interval of five to seven days or more. If no more bone requires re- moval, and this should have been rendered unnecessary by the careful preliminary local- isation advised on p. 309, local ansesthesia, as recommended by Dr. Ransohoff, may be tried if a second general anaesthetic is thought undesirable. The sutures are removed and the flap turned down and wrapped in sterilised gauze. The next step is the opening of the dura mater. This stage is absolutely necessary for the relief of symptoms. If decompression alone is aimed at the dura should first be incised in the line of the vessels, a second incision being subsequently made at right angles to the first. The four pointed flaps thus formed are dissected up close to the margin of the bone and are then cut away. If it is thought that the removal of the tumour is possible, the dura is not cut away but a flap is turned down so as to expose the surface of the brain. Prof. Kocher advises that, when the convex border of the bony flap is situated near the middle line of the head, that the dural flap may be inverted, i.e., the base being placed upwards and the convexity downwards. He further points out that it is desirable that the line of incision in the dura should not coincide with the edge of the divided bone. The dura mater is best opened first by incision with a scalpel and then by bhmt-pointed curved scissors, great care being taken not to wound the parts beneath. The main branches of the middle meningeal are best secured by underrunning them with fine catgut by means of a small fully-curved needle before they are divided. The dura mater should be raised with much gentle- ness, as if any adhesions are torn, very free venous hgemorrhage may result.^ Fig. 135. Stellwagen's tre- phinC; with saw and knife blades. The latter arc used to incise the scalp. The arm can be adjusted to describe a circle of from 2^ to 4^ inches in diameter. ^ Any of the dura mater which is adherent to the growth is usually much altered. In a recent case, the membrane will simply be highly vascular. In advanced cases it may be yellowish, and in some instances, on separating it from the growth beneath it is found to be of a dirty reddish colour. In all cases where it is adherent the dura mater must be freely excised, if possible. OPERATIONS ON THE BRAIN 319 Treatment of the Brain. If this, after incision of the dura mater, bulges very proiniuently into the wound, it indicates pathological intra- cranial tci^sion, and probably a growth. C. H. Frazier,^ calling attention to the fact that this bulging of the brain may be one of the most embarrassing features of cerebral operations, distinguishes between " initial " bulging, that which follows immediately on reflecting the dura and is due to the increased tension caused by a growth, and " consecutive " bulging caused by the osdema set up in normal brain tissue by the exploratory manipulations. This far exceeds Fig. 136. Cushing's operation ot sub-temporal decompression. the " initial " form, and, as it is most embarrassing, exploration should be as expeditious as possible.^ Alterations in the density of the brain must next be observed, but it must be remembered that the softer cerebral growths situated beneath the cortex are scarcely to be detected, save by exploratory incision ; with tuberculous nodules it is different. A needle is of very little value in exploring for a growth. A tumour too soft to be detected by the finger will not be recognised by a needle : serious haemorrhage may follow its use. Careful search with one of the instruments shown in Fig. 137, or digital palpation and the insertion of ^ Amer. Journ. Med. Set., Feb. 1904. 2 In some cases where there is abundant evidence of increased intracranial tension a growth may be present, but out of range of the operation. This is especially likely to be the case where " false " localising symptoms are present. Thus, in a case in which Dr. \Yeir (Arm. of Surg., June 1887) trephined over the upper part of the right fissure of Rolando for spasms in the left limbs and loss of power in the left leg, no growth was found. Death took place ten weeks later, and a spindle-celled sarcoma, apparently originating in the pia mater, was found springing from the lower surface of the left cere- bellar lobe, displacing the medulla forwards to the right, and invading the fourth ventricle. In such a case the best course to pursue would be to complete the operation for decom- pression. 320 OPERATIONS ON THE HEAD AND NECK the finger-tip under the margin of the bony opening are preferable. The removal of a growth is best effected by one of Sir Victor Horsley's combined spatiilse and directors shown in Fig. 137. If a sarcoma be encapsuled it may be shelled out by one of these aided by the finger. Hsemorrhage. In removing a portion of the brain, or a growth, the bleeding which has been so much dreaded will usually cease if the wound be packed for a few minutes with strips of sterilised gauze. The value of a pre- liminary injection of morphine has already been alluded to. Other methods for arresting hsemorrhage are irrigation with sterile saline solution at a tempera- ture of 110° to 120°, fine catgut ligatures tied without jerking and not too tightly ; or if these fail the use of adrenalin solu- tion (1 in 1000). Should the bleeding be otherwise uncontrollable it may be necessary to leave the gauze packing in situ, the end of the strip being brought out at one end of the lower angles of the womid. Sir V. Horsley has invented a combination of fine dissector and small aneurysm needle well adapted to facili- tate underrunning and ligature of the vessels of the pia mater. If any bleeding vessel is not well within reach, the open- ing must be enlarged to get at it. When other methods fail — and careful plugging and firm pressure with firm bandages over the dressings has failed more than once — small Spencer- Wells forceps may be left on for thirty-six or forty-eight hours ; but the patient must be carefully watched, lest his restlessness cause the friable tissues to give way, or inflict damage on the brain. The treatment of haemorrhage from the meningeal or diploic vessels, or from any of the large venous sinuses, has been given at p. 266. Incision of the Brain. The cuts in the cortex must be made exactly vertical to the surface. If possible, portions of each centre should always be left, so that the cortical representation of the par- ticular group of movements may never be totally destroyed. A portion of brain removed does not leave, as might have been supposed, a per- manent gap mth vertical sides, for, in a very short time, the corona radiata forming the floor of the pit bulges almost to a level with the surroimding cortex. Difficulty in detecting the growth.^ This may arise from several causes (1) The want of distinctness in the growth — in other words, its ^ These remarks refer to gliomata. Fig. 137. Combined blunt dis- sectors and si:)atul{e used by Sir V. Horsley. I'hey are equally adapted for the protection of the dura mater under the saw, or for the separation of a growth from the surrounding brain. They also act as flat probes in testing the depth of trephine-holes. OI'KKATIONS ON THE BRAIN 321 close rosemblaiiLe to iiornuil brain substance.^ A glioma may have the appearance of hypertrophied convolutions. (2) The growth may be overlaid by normal brain tissue. (3) By change in the growth — viz., ha)morrhage from its thin-walled vessels, and later on, secondary changes in the clot. These conditions may be very ])uz;zling. Difficulty in isolating the growth. (1 ) This may be due to the absence of a capsule, aiul thus to the infiltiation of surrounding parts. This is of especial importance in the case of gliomata. A capsule would occasionally appear to have been present. Thus in Dr. Bennett and Sir R. J. Godlee's case the glioma was found to be " thinly encapsuled, but quite isolated from the surrounding brain substance." Not so, however, is it in many other cases. Indeed, the chief pathologists speak decisively on this point. Dr. Fagge thus wrote : " The substance of a glioma is always continuous with that of the surrounding cerebral tissue, for there is never a capsule as with some sarcomata.^ Indeed, it often assumes the form of the pai't in which it grows, so that one might imagine the corpus striatum or the thalanms or some particular convolution, to have become swollen to three or four times its usual size." Sir J. Bland Sutton ^ writes : " Virchow pointed out that when a glioma is situated near the surface of the cerebral cortex it appears like a colossal convolution." Sir D. Ferrier ^ says on this point : " It is unfortunately the case that a large proportion of the tumours which invade the brain are of an infiltra- ting character, and apt to recur in spite of apparently the most complete extirpation. One can scarcely hope for a cure, therefore, under such conditions ; but, nevertheless, there are many cases in which extirpation of such tumours has, for a time at least, rescued the patient from im- pending coma and death, and restored him for a time to clearness of intel- lect and a fair degree of comfort." A little later on we are advised that, " It is, on the whole, better not to attempt to remove a tumour which proves to be a soft infiltrating one without distinct demarcation from the healthy brain substance." The benefits to be obtained from partial removal of a cerebral tumour are at present doubtful. Sir V. Horsley ^ mentions several cases where partial removal was followed by considerable improvement; while Dr. Byrom Bramwell regards this as a very doubtful step. On the one hand partial removal may cause very serious haemorrhage when the patient is ill fitted to stand this. On the other hand the tension may be so great — the initial and consecutive bulging already spoken of — that unless some of the growth be removed it maybe impossible to draw the edges of the dura mater together. Further, Mr. Ballance's case mentioned at p. 306 shows how long life may be prolonged after incomplete removal. (2) Another source of doubt in telling when a glioma not encapsuled has been isolated, arises from the fact that, as pointed out by Dr. Fagge, these growths, in common with all the less circumscribed forms of cerebral tumours, are apt to set up morbid changes in their immediate vicinity, usually of the nature of softening, partly inflammatory, partly oedematous. ^ A glioma may be of a pinkish red colour, or it may look so exactly like the normal brain substance that a microscope is required to demonstrate its presence. (Fagge's Medicine, vol. i, p. 523.) 2 The glioma is distinguished by having no capsule, but merging indefinitely into the tissue around. (Wilks and Moxon, Path. Anat., p. 239.) ^ Tumours Innocent and Malignant, p. 174. * Brit. Med. Journ., 1898, vol. ii, p. 9G6. ^ Ibid. 1906, vol. ii, p. 411. SURGERY I 21 322 OPERATIONS ON THE HEAD AND NECK If a cyst be found it should be completely removed, if possible. If this be not feasible, all the more superficial part should be cut away, and the cavity packed with sterilised fjauze. Operation for Tumours of the Cerebellum. Unusual difficulties always attend these operations owing to the limited space, the numerous sinuses, and the proximity of the medulla and its centres. It must also be remem- bered that though it is often easy to diagnose a tumour in the cerebellum, it is often impossible to exactly localise it. Indeed, not infrequently it is not possible to be sure in which side of the cerebellum it is situated. Bone must therefore be freely removed so as to allow of a thorough exploration. An incision ^ should be made commencing just behind one mastoid process, and then curving a short distance above the superior curved line to terminate in the corresponding position behind the opposite mastoid process. There wdll be free bleeding which must be checked in one of the ways already described. The periosteum is then incised and together with the muscles attached to the occipitah is detached with the help of an elevator and the flap thus formed is turned down. The bone is best removed by making an opening with a large trephine and then to enlarge this by means of some convenient form of bone-cutting forceps. The cere- bellum may also be exposed by making two trephine openings as near the mid-line as possible and then cutting away the intervening bone. The external occipital protuberance should always be preserved on account of the torcula herophili which lies beneath it. The lateral sinus should, however, be exposed on each side of this. Bone may be removed down- wards to within one inch of the foramen magnum. An osteoplastic flap is unnecessary here owing to the thickness of the flap of soft parts. If, at this stage, the patient's condition continue good, the operation should be completed ; otherwise it is w^ell to defer this for some days. When sufficient bone has been removed the cerebellum is freely exposed by turning down a flap of dura mater. The occipital sinus is secured and ligatured above and below. If a growth is present the cerebellum will now bulge prominently into the wound. If the growth is in a lateral lobe it should be sought for and removed as recommended in the case of the cerebrum. If on the other hand there is reason to suspect the presence of growth at the cerebello-pontine angle, a favourite site, the subsequent steps are far more difficult. The shortest route to the cerebell-o-pontine angle is along a line parallel to the petrous part of the temporal bone. Provided the opening in the bone is extended as far outwards as possible, one may after retracting the cerebellum inwards obtain a view not only of the seventh and eighth nerves as they enter the internal auditory meatus, but also of the sensory root of the fifth nerve at the apex of the petrous. It is, however, extremely doubtful if a growth in this situation can be safely removed considering its surroundings. The need of the greatest care in all manipulations of the cerebellum, especially near its centre, is inculcated, owing to the risk of bruising the medulla and pons. Owing to the increased tension it will probably be impossible to displace the cerebellum sufficiently with a retractor to expose the growth. Either the ventricle must be punctured or part of one cerebellar hemisphere removed. Dr. Fraz'er considers puncture of the ventricles so often fatal ^ Harvey Gushing suggests a T-.shaped incision for exposing the cerebellum. OPERATIONS ON THE BRAIN 323 as to be unjustifiable.^ On the other liaud, removal of a hiige part of ojie cerebeHar lieniisphere has given marked rehef in several cases, though no growth was found. Thus blindness, headache, vertigo have all been greatly relieved. The following case, mentioned by Dr. R. W. Murray in the Medical Chronicle, June 1905, is a good instance of the way in which the situation of a growth, though producing well-marked symptoms, may cause insuperable difficulties in its removal. A woman had suffered from occi])ital headache, vomiting, failing sight, and tendency to fall to the left side. On the removal of the brain at the necropsy, the left half of the cerebellum appeared normal. It was only after making sections and a careful examination that a small growth was found in the left amygdala. It was a mixed cell sarcoma of the jjia mater of the cerebellum and the choroidal plexus of the fourth ventricle. Closure of the Wound. All bleeding having been stopped, the cut dura mater is sutured witli fine catgut. If the brain bulges much while the dura is being sutured, it should be depressed wuth a spatula, while the edges are, if possible, quickly brought together by a continuous suture. If necessary a flap of pericranium may be employed. Room must be left for drainage, and the flap adjusted with salmon-gut sutures. Sir V. Horsley removes the drainage tube which is to be inserted at the most dependent part of the incision (as the patient hes in bed), at the end of twenty-four hours, and makes firm but gentle pressure over the centre of the flap. The tube serves to drain the steady oozing of blood and serum from the cut surfaces, which takes place during the first day, and its removal at the end of this time is advised, in order to allow of a certain amount of tension from wound exudation to occur within the cavity ; this tension not interfering with primary union if kept within proper bomids, while it secures pressure on the bram which tends to extrude, and serves, when the wound is finally healed, to separate the skin flap from the brain beneath by a cushion of soft connective tissue. If, after the removal of the tube, there is much pain and throbbing in the wound, and the union threatens to break down, the edges must be sufficiently separated with a probe, gently used, in the track of the drainage tube and another drain inserted. Nothing has been said about the replacement of the bone in those cases where the osteoplastic method has not been employed, as the opera- tion wiU often be done in two stages, and, thus, the bone will not have survived the interval. As has been said before, exact evidence is required as to how far large gaps eventually become closed and to what extent artificial protection is needed. Needless to say every precaution for meeting and treating shock, both during and after the operation, must be taken (see p. 29). In these cases it is a mistake to wait for shock and to treat it : shock should be expected as a matter of course, not waited for. Excision of Cortex Centres for Epilepsy. This matter has been referred to at p. 279. Though cases have been pubhshed in which some rehef has followed this operation, ^ it is now recognised that the relief is only of a temporary nature. It is now generally regarded, that with the exception of suitable cases of traumatic epilepsy [q.v.), epilepsy is mihkely to be benefited by operative treatment. The follo\\dng words of Sir W. Macewen, though spoken many years ago, have still an important bearing ^ An authoritative account of the surgical aspects of growths of the cerebellum has been given by Dr. C. H. Frazier {New York Med. Jount., February 11, 1905. ^ See Prof. Keen, Amer. Journ. Med. Set., October and November 1888. 324 OPERATIONS ON THE HEAD AND NECK on this subject. " Can the motor area be removed in large pieces with immunity from serious consequences ? If this region be of such psychical importance to movement, and destructive cortical lesions in it are followed by secondary degeneration of the motor tracts, then excision of these areas will necessarily induce permanent paralysis, late rigidity, and ulti- mate structural contracture. The removal of large wedges from the brain, especially in the motor area, will produce serious effects upon the brain as a whole, causing during cicatrisation a dragging and displace- ment of the neighbouring parts, with final anchoring of the cerebrum to the cicatrix." ^ Causes of difficulty in cerebral operations and of their not doing well. Most of these have been fully alluded to. (1) The ancesthetic may not be well taken (pp. 248, 309). The possi- bility of employing local anaesthesia in the second stage of the operation has been pointed out at p. 318. (2) Hwmorrhage (p. 320). This has already been discussed. Dr. Ransohoff '^ records a case in which che haemorrhage met with during the removal of the bone proved actually fatal. " An osteoi^lastic resection had been commenced and about one inch of the bone cut through when profuse bleeding occurred, which was not arrested by phigging with Horsley's wax. The bone was rapidly removed with a trephine and bone forceps in order to get at the source of the haemorrhage, but death took place just as the dura was reached. A glio-sarcoma, the size of a small peach, not adherent to the dura was found just under the trephine opening. The diploic veins in the neighbourhood of the opening were much enlarged. There had been no unusual bleeding from the scalji. Raising the patient into the ujiright position was of no avail, and there was no time for ligature of the carotid." In two cases the haemorrhage has occurred some little time after the operation, and has then been due to the vomiting after the anaesthetic. (3, 4 and 5) Difficulties in sufficiently exposing the area occupied by the growth, in detecting, and in isolating it. (6) Shock. Many of the causes of this are sufficiently obvious. One may be mentioned which has not been already discussed, i.e. the inter- ference with subjacent parts of the brain, or the opening of a lateral ventricle in the removal of a deep-lying growth. (7) (Edema of the lungs. This is especially likely after prolonged operations, where it has been necessary to give ether, and in cases where, for some time before the operation, the patient has been practically bed- ridden, and the functions at a very low ebb. (8) Hernia Cerebri. This may occur in two ways : {a) Immediately, during the operation, in a case where there is much evidence of intra- cranial pressiu-e, and where it has not been possible to remove the cause. Thus, in a case of Dr. Pilcher's, the projecting cerebral mass was so great in volume and so tense that there was no possibility of returning ^ " Anchoring of the brain and some of its consequences. ^ — When injury has been in- flicted on the surface of the cerebrum, followed by plastic effusion and cicatricial forma- tion, the superficial substance is apt to become soldered to the membranes when these remain intact, which may in turn be fixed to the skull, or, in the event of their detach- ment, the brain may become directly adherent to the bone. Thus the surface of the brain becomes anchored to the rigid cranial wall. It has no longer the free play within its water bed fco expand and contract according to the varying state of the circulation. Each variation produces a dragging of the brain at the spot, and through it the whole hemisphere is affected. Any sudden physical effort jiulls on the brain, producing a slight shock, just as if the cerebrum had received a blow. Vertigo results. Following upon this, the grey matter of the cortex, immediately surrounding the cicatrix, by the incessant movement is apt to become unstable and produce fits. Some cases of traumatic epilepsy are thus caused." ^ Trans. Amer. Surg. Assoc, 1903. CRANIECTOMY FOR MICROCKPHALUS, IDIOCY, ETC. 325 it within the cranial cavity. It was, accordingly, sliced down to the level of the bone.^ (6) Later on it may point to unrelieved tension, (c) In other and more immerous cases a later hernia cerebri indicates infective changes, or may be the result of softening of the brain. (9) Impossibility of complete removal. (10) The liability of patients, with increased intracranial pressure due to the presence of a growth, to sudden and unexpected death, has already been mentioned. Sir D. Ferrier - gives two instances in which sudden death occurred. In one, a growth the size of a hen's egg was found at the necropsy, under the cortex in the area of Rolando ; while in the other the symptoms pointed to a growth in the upper part of the same area. (11) Septicaemia and allied conditions. (12) Reappearance of the growth. CRANIECTOMY FOR MICROCEPHALUS. IDIOCY. ETC. Lannelongue's suggestion of invoking the aid of surgery in the treat- ment of imbecility ^ aroused much interest, and in the immediately succeeding years a large number of cases were submitted to craniectomy, with a view of either removing some morbid condition or relieving pressure on the brain, or in some way stimulating its development. Like some other advances of modern surgery, it has not been based on the sound foundation of pathology or common sense. The disease is probably primarily due to defective cerebral development, the early ossification of the sutures being secondary to this. These hopeless pathological con- ditions, the poor vitality of the patients, and their mifitness for severe surgical operations, render the results, as might have been expected, very unsatisfactory. It is first necessary to consider what 'pathological conditions are likely to he met ivith and how far theij are remediable. These appear to be: (i) Microcephalus, whether due to premature closure of the cranial sutures (Virchow), or secondary to maldevelopment of the brain (Broca). In the following conditions the brain is at fault, with or without marked microcephalus, and sclerosis and atrophy are met with in a varying degree in nearly all. (ii) Porencephalits. By this is meant a localised atrophy, leaving a cavity in either cerebral hemisphere, which may be deep enough to open into a lateral ventricle, (iii) Maldevelopment and atrophy of the minute structure of the cortex of the hemispheres, without any gross defecte. (iv) Meningo-encephalitis, leading to thickening of the meninges and atrophy of the cortex, (v) Cysts, perhaps containing blood (q.v.). (vi) Hiemorrhages into or on the surface of the brain, (vii) Hydrocephalus. This last will be sei:)arately con- sidered. It is obvious, first, that many of the above are only to be recognised by exploration, and that most of them, if found, are hopeless of improvement. Thus it is clear that where sclerosis and atrophy are present to a marked degree, in cases of porencephalus. where one entire hemisphere is converted into a cystic cavity surrounded by slu-unken brain tissue and thickened arachnoid, interference will be futile. In the latter it may be fatal by the shock that will follow on the with- drawal of a relatively large amount of cerebro-spinal fluid. Dr. J. Griffiths, of Cambridge,^ showed that the skulls of microcephalic idiots may be classified in the following groups : (a) The skull is of normal shape and outline, but small, ill-developed, and ill-filled. There is no premature synostosis of the sutures. (6) The skull is not only small, but deformed from imequal growth. Whether this deformity is due to primary disease of the bones or to premature synostosis of several of the 1 Ann. of Surg., March 1889. ^ Brit. died. Joum.. October 1, 189S, p. 965. * Btdl. de VAcad. des Sciences, 1890, and Union Medicate, t. i, 1890, p. 42. ' * Proc. Med. Chir. Sac, March 8, 1898. 326 OPERATIONS ON THE HEAD AND NECK sutures, or whether it is due to disease as well as defective growth of the brain, is still an open question. As in one form of microcephaly the brain itself is generally defective in the power of growth, its development having been arrested at an early period of embryonic life, and as in the other there is, in addition to arrested development, disease of the brain substance, and as the existence of cases of microcephaly in which prema- ture synostosis has been able to impede or dwarf the growth of a normal brain is, as yet, quite hypothetical, craniectomy can be productive of no permanent good, the original fault being in the cerebrum and not in the skull. In recommending operative steps the wise surgeon will be careful not to be too sanguine, remembering the nature of many of the conditions which he may meet with, and the impossibility of improving some of them. Furthermore it must be remembered that here, as in trephining for epilepsy, cases have been reported much too soon to be looked upon as successes. The second point is, that we are here dealing with very vital parts in patients of poor vitality, and that, unless the surgeon is careful not to attempt too much, death from shock will be a very present danger. Thirdly, many fatal cases have not been published, and we do not know what the mortality of this operation really is. Before leaving the question of the advisability of operative interference in microcephaly the conclusions of Prof. Keen, of Philadelphia, may be quoted — conclusions which are most valuable on account of his long experience in operative surgery, and especially from his well-known skill in operations on the head and brain. Prof. Keen performed craniectomy in eighteen cases of microcephaly, the youngest patient being eighteen months and the eldest seven and a half years old. In five cases the opera- tion was fatal ; in six cases slight improvement followed ; in seven none at all. Prof. Keen's conclusions are as follows : No good can be expected from the operation in cases with average-sized heads, nor in those cases with extreme microcephaly, nor when the patient is over seven years old. In one case a restless, mischievous idiot was transformed into a " quiet, sleepful child " ; but the improvement, when there is any, is usually slight. Much depends upon special education after the operation. In some cases of moderate microcephaly the operation is justifiable, and in a small number a slight improvement will follow ; but in the majority there will be no result, good or bad ; while in a definite proportion (15 per cent.) " the operation will happily be followed by death." ^ Dr. J. Chalmers Da Costa adds the weight of his opinion to the above. " Microcephalus is not the result of premature sutural ossification. A micro- cephalic brain is not a more or less normal brain of very small size, the idiocy resulting from the smallness of the parts j^resent, but is always an abnormal and undeveloped and, in many cases, a diseased brain. If a strip of bone is removed from the skull, new normal brain cells will not be produced. Parts that are entirely absent cannot be created, and powers that do not exist cannot be called into being. The reported improvement, if continuous, is not due to the operation, but to proper instruction and care. The proper treatment for microcephalus is educa- tional, hygienic and disciplinary." ^ This writer puts the mortality as "nearer 15 than 2 per cent, as alleged." Operation. We will consider first a case in which there is marked microcephalus, in which, perhaps, premature ossification is the cause of the trouble. The operation should always be of the nature of a linear 1 Journal of Nervous and Mental Diseases, February 1898. 2 Ibid. June 1904. TREPHININC; IN (iENKUAL PARALYSIS 327 craniectomy, completed as speedily as possible. Every precaution should be taken against shock, and if the ha3morrhage has been severe it may be necessary to resort to infusion of saline fluid. Lannelongue ^ operated in his first case as follows : Having made an incision through the scalp and pericranium just to the left of the sagittal suture, a small circle of bone was removed with a trephine, a finger's breadth' from the' suture ; from this as a starting-point, a narrow strip of bone was cut out parallel with and to the left of the sagittal suture, extending from the coronal to the lambdoid suture. The periosteum was not replaced. Sir V. Horsley removes the periosteum over the bone to be excised. This last step he effects by making parallel saw-cuts backwards and forwards from the trepliine opening, and then removing the bone between the saw- cuts with bone forceps such as those of De Vilbiss. In some cases in addition to the removal of bqne parallel to the sagittal suture, a second narrow strip has been removed over the corresponding fissure of Rolando. The dura mater is not incised and the greatest care must be taken to avoid injury to it during the operation. Dr. Griffiths ^ and others have estab- lished artificial lambdoid sutures, operating at intervals, first on one side of the skull and then on the other. Numerous other incisions have been employed for the craniectomy, among which may be mentioned an elhptical or H -shaped craniectomy of the vertex, and a large horse-shoe- shaped division of the bone on the lateral aspect of the skull. Dangers of the Operation. These are chiefly : (1) Shock. (2) Haemor- rhage. Haemorrhage from the scalp may be met by drainage tubing passed round the head or by Makka's clamps, but other bleeding may be encountered. (3) Injury to the dura mater, especially adherent in children. (4) Infective changes in the wound ; these patients, restless and ill-regulated in their behaviour, may make the maintenance of asepsis very difficult, especially in older and thus less easily managed cases, by tearing off their bandages. (5) Hyperpyrexia of obscure origin. TREPHINING IN GENERAL PARALYSIS OF THE INSANE, AND IN OTHER FORMS OF INSANITY This operation has been recommended on the authority of Dr. Claye Shaw ^ and Dr. J. Batty Tuke,^ but the results have been such that it does not deserve encouragement even as a palliative step. It must not be forgotten that here is no morbid condition that can be cured ; that the excess of fluid^ — the removal of which, and so the relief of tension, is the object of trephining — is variable ; and while it is clear that in those cases which have improved after the operation the benefit has been only temporary, it must be remembered that temporary periods of spontaneous marked improvement are not uncommon. As the question of trephining occasionally arises in traumatic insanity, Dr. Da Costa's incisive remarks as to the principles which, should guide us may be quoted.^ Having condemned operation in cases of non-traumatic insanity, hypochon- driacal delusions and hallucinations, Da Costa divided cases of travsmatic insanity into two classes. To the first belong those cases in which the injury has caused no gross lesion and in which, on account of trivial shock, mental or physical, the ^ UUnion Medicnle, July 8, 1890. ^ Loc. supra cit. ^ Brit. Med. Joiirn., vol. ii, 1889, p. 1090 ; vol. ii, 1891, p. 581. * Ihid., vol. i, 1890, p. 8. * Journal of Nervous and Mental Diseases, June 1904. 328 OPERATIONS ON THE HEAD AND NECK patient has developed a distinct neurosis, on the basis of which a psychosis has supervened. In this group operation is not to be thought of. In the second group are found cases in which the injury is the direct and sufficient exciting cause of the condition. Here the insanity may develop at once or some time after the injury. Whether the insanity follows sooner or later, the chief indications are depression of bone, local tenderness, fixed headache, or some localising .symptom. When there are positive signs of increased pressm-e, trephining as a palliative measure may be considered proper. " One should not operate upon a case simply because there is a dubious record of an antecedent fall or blow, which merely suggests the possibility of a traumatic origin for the insanity." Da Costa believes that injury is the direct cause of insanity in only 2 per cent, of the cases. OPERATIVE TREATMENT OF HYDROCEPHALUS. DRAINAGE OP THE VENTRICLES In hydrocephalus there is distension of the ventricles with cerebro-spinal fluid. The condition may be congenital 'or it may commence during the first few years of life. As medical treatment is ineffective, surgical treatment may be called for. Unfortunately, in the majority of the cases, the distension of the ventricles is secondary to some disease in the cere- bellum, corpora quadrigemina, or crura cerebri obstructing the veins of Galen, or, as Mr. Hilton showed long ago,^ to occlusion of the cerebro spinal opening in the fourth ventricle — all equally hopeless forms of disease. In other cases the collection of fluid is due to meningitis, tuberculous, syphilitic, or cerebro-spinal. By others hydrocephalus is regarded as dependent upon an arrest of development of the brain. Simple tapping of the ventricle through a lateral angle of the anterior fontanelle has been often carried out, w^ith the result of often giving marked relief, obviously, from the nature of the cause, only temporary, convulsions and coma carrying off the patient after a varying interval. Withdrawal of the fluid slowly by a Southey's tube has been equally unsuccessful. Drainage of the Lateral Ventricles. Prof. Keen, of Philadelphia, was the first to formulate this operation, as distinguished from the ordinary puncture. The ventricle, in a boy aged 4 years, was exposed by trephining one inch and a quarter above and behind the external auditory meatus, and by puncturing the brain with a needle at this spot. At a depth of about an inch and three-cpiarters the ventricle was reached and cerebro-spinal fiuid escajjed. Three double horsehair sutm-es were then introduced and the needle withdrawn. Drainage thus estab- lished was kept up for fourteen days, when the horsehair was replaced by a drainage tube. On the twenty-eighth day after tlie operation, the symptoms returning, a corresponding operation was performed on the right side. The cliild died on the fort J'- fifth day. Intracranial Drainage o£ the Ventricles by making a communication between the ventricles and the subdural space. This method was brought before the Clinical Society by Dr. Sutherland and Sir W. Watson Cheyne.^ The operation is based upon the experiments of Dr. Leonard Hill.^ The child, aged G months, was markedly hydrocephalic, emaciated, anaemic, with intelligence undeveloiDcd, and quite blind. The condition was attributed to con- genital syphilis. The dura was exposed at the left lower angle of the anterior fontanelle. To form a drain a bundle of the iinest catgut, containing some sixteen strands and about two inches long, had been prepared, one end of the strands being tied. together, and the other end free. The dm-a mater was incised and the tied end ^ Rest and Pain, Lectures ii and iii. Mr. Hilton first noted this fact in 1844. * Trans., vol. xxxi, p. 166. ^ Physiology and Pathology of the Circulation, 1896. DRAINAGE OF THE VENTRICLES 329 of tlie huiuUe was ])ushed downwards and backwards between the brain and (lie dura, i.e. in the subihual space ; the other end was jnished through the thinned cerebral substance into the lateral ventricle. The incision in the dura was closed. On the Hfth day. when the wound was healed, it was noticed that the head was distinctly smaller in all dimensions. This diminution in size continued, but without any im- provement as regards the child's intelligence or vision. Symptoms of basal men- ingitis began to a])})ear nine weeks after the operation, and death followed three weeks later. At the necropsy, though the ventricles were not distended, a consider- able quantit3f of iluid remained in the subdural space. The best material for gradual drainage would appear to be strands of sterilised silk as used by Mr. W. S. Haudley in the operation of lymph- angioplasty. Mr. Pendlebury thus describes an operation in which this material is used.^ "A sharp pedicle needle with a good curve is threaded with No. 12 plaited silk, both having been carefully sterilised. The thread when doubled is at least thirty inches long. The head is shaved and made thoroughly aseptic. A spot about one inch to one side of the middle line is chosen as near the posterior part of the anterior fontanelle as ])ossible. With a tenotome make a tiny incision through the skin in this position. Push the threaded needle into the lateral ventricle, curve it through the falx cerebri into the opposite ventricle, and bring it through the skin in a corresponding position on the other side of the mid-line. Withdraw the pedicle needle, leaving the silk in situ. Thread the double silk of one side on to a long probe and push the probe beneath the skin backwards into the nape of the neck. Do the same with the silk on the other side. Cut off the superfluous silk and put a stitch into each of the small wounds that have been made in order to introduce the probe and the silk it carries beneath the skin. The doubled silk now connects both ventricles with each other and with the connective tissue of the neck." Drainage of the Fourth Ventricle. This was performed by Mr. Stiles in a case of acquired hydrocephalus due to basal meningitis.^ The patient, aged 13, with well-marked evidence of congenital syphilis, presented symptoms of chronic basal meningitis, viz. irregular pjTcxia, persistent head retraction, nystagmus, gradually increasing blindness, great weakness and emacia- tion. This condition becoming critical, with marked cyanosis and rigors, it was decided to open the fourth ventricle and drain the ventricular system. IVIr. Stiles trephined in the middle line over the lower part of the occipital bone, including the margin of the foramen magnum, and enlarged the opening by forceps. The dura mater was opened after the occipital sinus had been secured between two ligatures. Separation of the two tonsils of the cerebellum allowed of the escape of nuich cerebro-spinal fluid. Immediate improvement followed the operation and lasted for a week, when there was again a rise of temperature. Death occiu-red wath hyperpjTCxia nineteen daj's after the operation, much cerebro-spinal fluid having drained aw^ay in the interval. ^ St/stem of Treatment, Latham and English, vol. ii, p. 1193. * Bruce and StUe.s, Trans. Edin. Med.-Chir. Soc, 1898, vol. xvii, p. 73. CHAPTER XVI OPERATIONS ON THE EAR A. OPERATIONS ON THE EXTERNAL EAR These will require but a brief description. Growths, especially papillo- mata and epitheliomata, are occasionally met with. The latter require free removal. Rodent ulcers are not infrequently found invading the external ear : they should be treated on the hues recommended at p. 394. Boils or Furuncles in the external auditory meatus are often exceedingly troublesome. They are the source of much severe pain, and often, as one abscess subsides, others make their appearance. Treatment. Owing to the extreme tenderness a general anaesthetic is necessarv : a free incision is then made into the centre of the swelling which usually contains a small amount of thick pus. The ca\aty is then lightly plugged with sterilised gauze and a hot boracic fomentation is applied. The plug should be changed daily, and the meatus syringed with carbohc lotion (1 in -iO). A bacteriological examination of the pus should always be made, for, in recurring cases, a vaccine is often of the greatest service. Exostoses are occasionally found in the external auditory meatus. They may be sessile and composed of cancellous bone, or exceedingly hard (ivory exostosis). Should the growth be pedunculated it may be removed through the external auditory meatus. If sessile or diffuse the treatment will depend upon the symptoms present. Should there be suppuration in the middle ear they should always be removed, as the retention of discharge which is certain to occur is liable to favour an extension of the septic process to the mastoid or to the cranial cavity. In other cases operation will be indicated if there is a tendency to occlude the meatus, or if they are causing deafness. If the growth is situated near the external orifice of the canal it may be removed by a dental drill, or burr, through the external auditory meatus. If its attachment is more deeply situated it is best to make a curved incision immediately behind the auricle, to detach the cartilaginous meatus from the bone, and then to remove the tumour by one of the above means or by a chisel. The greatest care must be taken to avoid damage to the tympanic membrane and other important structures. When the operation is completed the wound is closed and the meatus hghtly packed with sterilised gauze. This must be changed daily and all blood and discharge washed away by gentle syringing with dilute carbolic lotion. Foreign Bodies in the Ear. These may usually be removed by syringing, or by the use of aural forceps, or a small ear hook. In rare cases where the foreign body is firmly impacted it will be necessary to make a curved incision behind the ear, detach the cartilaginous meatus, and, after incising this in the longitudinal direction, displace the foreign body by passing a small elevator beyond it and so levering it out through the wound. 330 OPERATIONS ON THE EAR 331 Removal of Aural Polypi. It is first necessary to point out that aural polypi are really niassesof granulation tissue,^ of inflammatory origin, and that their presence denotes the existence of suppuration. Treatment of the polypi nuist therefore be only a part of the treatment of the suppuration of which they are a complication. If of sufficient size to cause any obstruc- tion they should always be removed : indeed, not infrequently, the removal of a polypus, by allowing of free drainage, may lead to a termination of the suppuration. Before the operation the meatus should be cleansed as thoroughly as possible by careful syringing, e.g. by Lot. Hydrarg. Perchlor., 1 in 3000. It must be remembered that the discharge which is always present is very infective and that removal of a polypus may, by opening up some fresh channel for infection, be followed by some acute trouble in the mastoid or the middle ear. The operation may be carried out under local anaesthesia, induced by the application of a 20 per cent, solution of cocaine and a solution of adrenalin hydrochloride (1 in 1000) : in children or in nervous patients a general anaesthetic is desirable. The polypus is best removed by a small wire snare (Wilde's or Gruber's). The attachment of the polypus may be verified by a fine probe, after which the wire loop is pushed deeply into the meatus and pushed over the polypus till it encircles the latter. The snare is then tightened, and, as soon as the pedicle is gripped, a gentle pull brings the polypus away. If the polypus is presenting at the meatus no speculum will be required. The haemorrhage, which is sometimes severe, may be controlled by syringing with hot sahne solution. The meatus is then lightly packed with a little ribbon gauze and a pad of gauze is applied over the external ear. The gauze packing is removed at the end of twenty-four hours, and the meatus is syringed, daily. It may be necessary lightly to touch the point of attachment of the polypus with the galvano-cautery. Drops of rectified spirit are often of service in the after-treatment. Incision of the Tympanic Membrane. This operation is indicated under the following circumstances, (a) In acute suppurative otitis media, when spontaneous perforation of the drum has not taken place, and^when there is severe pain accompanied by pyrexia. (6) In acute otitis media where, though perforation has occurred, pain still continues, owing to the opening being too small to allow of free escape of the pus. Occasionally the pain and discharge cease after the escape of pus, only to be followed by a further abscess owing to the perforation being of insufficient size to secure free drainage. This process may be repeated a number of times, (c) In some cases of chronic catarrh where there is excessive secretion and the drum is bulged outwards. Operation. Owing to the extreme tenderness of the inflamed structures, and the necessity for deliberation on the part of the operator, a general anaesthetic such as nitrous oxide gas and oxygen, is desirable. The external meatus must be irrigated wdth some dilute antiseptic lotion to remove all cerumen or epitheHal debris, and is then dried with pledgets of cotton wool. The incision is made with a small, sharp triangular myringotome (Fig. 138 B). A large speculum is introduced and a strong light thrown on the membrane either from a forehead mirror or a head lamp. Generally speaking, the cut should be made below and behind ^ Hence after the removal of the polypus the treatment must be directed to the suppuration and its cause. 332 OPERATIONS ON THE HEAD AND NECK the handle of the malleus. The knife is pushed through the drum close to its inferior border, and then cuts in an upward and backward direction, passing midway between the malleus and the margin of the membrane. If cut in this direction the edges of the wound will retract and so ensure free drainage. Owing to the obhque position of the membrane, the knife, if it be made to cut downwards and forwards, must also be directed inwards ; otherwise a mere puncture instead of a free incision will be made. If there is already a perforation or if there is a locahsed bulging the incision must commence at this point. The inner wall of the tym- panum must be avoided. At the conclusion of the operation the meatus is again gently irrigated and then hghtly plugged with sterilised gauze. SMIZ/^P/^ELIS M£MBK/^f^E. PROCESS l/J BR£y*S M^^DLC O^ f^z-ilU^SuS Carf£ Of' L/OMT B. Fig. 138. A, The tympanic membrane, showing the line of incision in mj'^ringotomy. B, Politzcr's mj'ringotomc. B. OPERATIONS FOR THE COMPLICATIONS OF SUPPURATIVE OTITIS MEDIA. POINTS OF PRACTICAL IMPORTANCE TO THE SURGEON IN THE ANATOMY OF THE PARTS CONCERNED. ^ I. Tympanum, (a) Roof always thin, not more than a line and a half in thickness, often thinner ; indeed, the bony roof may be more or less deficient, when a thin membrane alone intervenes between the middle ear and the cranial cavity. Through this, inflammation in otitis media readily reaches the brain, causing meningitis, subdural or cerebral abscess. (6) Parts of the brain and cerebellum which are in relation ^^ath the middle ear. These are the middle and back part of the temporo-sphenoidal lobe, and the outer and front part of the lateral lobe of the cerebellum, (c) The mucous membrane and the endosteum lining the tympanum are in most intimate contact ; hence, in otitis media caries and necrosis readily occur, especially if the blood-supply to the tympanum from the dura mater is cut off. {d) The skin of the external auditory meatus is con- tinuous with the membrane tympani, and thus otitis media may be set up from without, as well as by mischief reaching the tympanum through (e) the Eustachian tube, which enters in front, and makes the mucous membrane of the throat continuous with that of the tympanum. (/) The outlet of the mastoid cells and antrum is inadequate for drainage through the cavity of the tympanum, partly because the greater part of the cavity ^ These should be studied together with a skull and one or two sections of a temporal bone. THE MASTOID ANTRUM AND MASTOID CELLS 333 of the antrum is situated below the level of the aditus, and partly because the attic of the tympanic cavity into which the channel opens contains the head of the malleus and the body and short process of the incus, which will hinder the free escape of pus. The floor of the tympanum is, in part, below the orifice of the Eustachian tube, which thus only imperfectly drains the cavity of the middle ear. TI. Mastoid Antrum and Mastoid Cells, (-^z) Their development varies Fig 139. A, Maccwcn's triangle. B, Posterior margin of the external audi- tory meatus. C, External auditory meatus. D, Posterior root of zygoma. E, Zygoma cut across. with age. In adults, if well marked, they may measure an inch and a half horizontally, two inches vertically, and reach quite up to, and even around, the lateral sinus. (6) Two groups of cells are present, and their relations are of the utmost importance — A. The upper, or antrum, present both in early and later life, horizontal in direction and closely adjacent to and communicating with the tympanum. B. The lower, or vertical. These cells are not present in early life, and vary much as regards their contents. In only about 20 per cent, do they contain air. The mastoid antrum is of far greater importance. This is a small chamber lying behind the tympanum, into the upper and back part of which (the tympanic attic) it opens. Its size varies, especially with age. Present at birth, it reaches its largest size, that of a pea, about the third or fourth year. After this it usually diminishes somewhat oA\'ing to the encroachments of the developing bone around it. Its roof, the tegmen antri, is merely the backward continuation of the tegmen tympani. The level of this is indicated by the horizontal root of the zygoma. " The level of the floor of the adult skull at the tegmen antri is, on an average, less than one-fourth of an inch above the roof of the 334 OPERATIONS ON THE HEAD AND NECK external osseous meatus ; in children and adolescents, from one- sixteenth to one-eighth of an inch " (Macewen). The outer wall of the antrum is formed by a plate of bone, descending from the squamous to join with the mastoid part of the temporal. This is very thin in early life ; but as it develops by deposit from the periosteum, the depth of the antrum from the surface increases. Macewen gives the average for this depth as varying from one-eighth to three-quarters of an inch. At Fig. 140. Oblique section through the right temporal bone passing through the carotid canal, the tympanic cavity, and the antrum. The two portions of the bone are oi>ened out so that on the left the outer boundaries of these structures are seen from within, while on the right the inner aspect is shown. J, the tegmen tympani. B, the attic. C, the carotid canal. D, the handle of the malleus. E, the tympanic membrane. F, the incus. G, the mastoid process. H, the mastoid cells. /, the stylo-mastoid foramen. K, inner wall of tympanic cavity. L, carotid canal. M, promontory. N, aque- ductus fallopii. O, antrum. P, additus. the junction of the two parts of the outer wall of the mastoid antrum is the squamo-mastoid suture, often still present at puberty. Through the floor, formed by the petro-mastoid, the antrum communicates with the lower or vertical cells of the mastoid. This floor is on a lower level than the opening into the tympanum, and thus drainage of an infected antrum is difl&cult, fluid finding its way more readily into the lower cells. Behind the mastoid antrum is the bend of the sigmoid part of the lateral sinus, with its short descending portion. ^ The sinus lies more superficially than the antrum, being usually one fourth of an inch, occa- 1 Korner, of Frankfort, has shown (Arch, of OtoL, vol. xviii, 1889, p. 311) that fatal intracranial diseases (meningitis, sinus-phlebitis, and abscess) more frequently occur with disease of the right petrous than the left. This is due to the fact that the right lateral sinus, and its sigmoid flexure, come more forward into the mastoid and base of the petrous than does the left, and therefore, with its dura mater, lies nearer to the primary disease. THE MASTOID ANTRUM AND MASTOID ( KIJ.S 335 sionally half an inch, I'loiii the surface. The iimer wall is formed partly by tlio petrous and i)artly by tlie mastoid ])ortions of the temporal bone. The exact position of the antrum, a little above and behind the bony external auditory meatus, is represented by Macewen's " suprameatal triangle." This is a triangle bounded by the posterior root of the zygoma ajbove, the ujiper and posterior segment of the bony external meatus below, and an imaginary line joining the above boundaries. " Roughly speaking, if the orifice of the external meatus be bisected horizontally, Fig. 141. The outer wall of the mastoid bone, the antrum, attic, and tym- panum, together with the posterior wall of the oseous meatus, have been re- moved here in order to show the field of operation in a case of chronic extensive disease. It will be noticed that the mastoid cells, both horizontal and vertical, are widely developed. (1) Posterior root of the zygoma, forming the upper boundary of Macewen's triangle. (2) Antrum and, in front of it, the attic. (3) Vertical cells of the mastoid. Where these are well developed and become infected, Bezold's mastoiditis (p. 338) will occur. (4) Ridge on the inner wall of the tympanum indicating the Fallopian ac[ueduct. (5) Fenestrae in the inner wall of the tympanum, indicated in shadow. (6) A natural deficiency in tegmen enlarged with a small osteotribe to remind my readers how thin is the roof of the antrum and tympanum. (7) Cells present in this case, even in the zygoma at its junction with the middle root. This will show how difficult it is in some cases to bring about complete asepsis. the upper half would be on a level with the mastoid antrum. If this segment be again bisected vertically, its posterior half would correspond to the junction of the antrum and middle ear, and immediately behind this lies the suprameatal fossa " (Macewen). When opening the antrum through this triangle the operator should work forwards and inwards, so as to avoid the sigmoid sinus, while to keep clear of the facial nerve (Figs. 140 and 141) he should hug the root of the zygoma and the upper part of the bony meatus as closely as possible, and not continue his perforation more forwards than is absolutely needful. The level of the base of the brain will be a few lines above the posterior root of the zygoma (Fig. 141) and about one-quarter of an inch above the root of the bony meatus. 336 OPERATIONS ON THE HEAD AND NECK In the first few years of life certain points of difference exist in the anatomy of the antrum, which are of practical importance. Speaking generally, the thinness of the outer wall and the presence of the squamo- mastoid suture favour the escape of infected material to the outside of the skull, while the small degree of development of the mastoid cells also helps to render less frequent intracranial complications at this age, especially thrombosis of the sigmoid sinus. Mr. H. Stiles ^ points out two more anatomical details which should be remembered. During early life the undeveloped condition of the mastoid process leaves the stylo-mastoid foramen exposed upon the lateral, not the under, surface of the base of the skull. In making the first incision, therefore, by which the soft parts are reflected from the bone, the surgeon should take care, below a point on a level with the middle of the meatus, to make his incision a superficial one only, to avoid injuring the facial nerve. Secondly, the posterior root of the zygoma, which in the adult forms a surface-guide to the level of the roof of the antrum, does not now exist. B. The lower, or vertical. These cells are not developed in early life, and vary much in their contents. The mastoid process begins to develop in the second year. As it increases in size, the mastoid air-cells make their appearance, but they do not reach their full development until puberty. They are developed as diverticula from the antrum and present a very varied arrangement. They may extend throughout the whole process, in which case they are only separated by very thin bony lamellae from one another and from the lateral sinus. In some cases they are small and numerous, while at other times the mastoid process may be solid. The air-cells may extend beyond the limit of the mastoid, over the roof of the meatus towards the zygoma and in other cases towards the jugular process of the occipital. Their mucous lining is continuous with the mucous membrane of the tympanum and the antrum. The following are the different ways by which infection may reach the interior of the skull from the ear : (1) Through the roof of the antrum, especially if the bone be naturally deficient here, into the middle fossa ; (2) Through the posterior wall of the antrum to the lateral sinus, the sigmoid groove and the posterior fossa ; (3) By the labyrinth and internal auditory meatus into the posterior fossa ; (4) By the different sutures with their contained processes of dura mater ; 2 (5) By the veins which drain the tympanum and the mastoid cells. These fall into three chief groups : (a) Those opening into the lateral sinus ; (b) Those passing through the mastoid foramen into the occipital vein and soft parts outside the skull ; (c) Those rmming through the petro-squamosal suture to the dura mater. All these veins carry sheaths of connective tissue, and thus inflammatory products may reach (a) the lateral sinus, causing septic phlebitis ; (6) the soft parts outside, causing periostitis, cellulitis, &c. ; (c) the dura mater and brain, causing meningitis and abscess. Five Results of Otitis Media which may come under the notice of the Surgeon. (1) Acute inflammation of mastoid cells : mastoid abscess ; (2) Chronic mastoid suppuration ; (3) Abscess in the brain or cerebellum ; 1 Brit. Med. Journ., vol. ii, 1891, p. 1142. ^ The sutures may be of fatal significance. Thus in cases where there is infective niii-cliief outside the bone, the infection having made its way there by an opening in the mastoid, or. where tliis is sclerosed, bj' dissectmg its way along the external auditory meatus, if it reach a suture and its contained process of dura mater, infection of the inner surface and meningitis may easily follow. MASTOID DISEASE AND OTITIS MEDIA 337 (4) Infective thrombosis of the sinuses and pyaemia ; (5) Meningitis ;' one or more of these often coexist, and thus the symptoms may be much bUMKhnl t(),t(eth(M- and confusing. Acute Mastoiditis and Acute Mastoid Abscess. This trouble usually arises in the course of chronic middle ear suppuration. It is a rare complication of acute otitis media, except when scarlet fever or influenza is the cause of the latter. The chief symptoms are pain, tenderness, redness and oedema over the mastoid process, with pyrexia and possibly rigors occurring in a patient suffering from middle ear suppuration. Fig. 142. A left temporal bone showing the antrum and the mastoid cells which have been opened up for an acute mastoid abscess. A, Posterior root of the zygoma. B, The antrum. C, The external auditory meatus. D, The mastoid cells which have been opened and which extend to the apex of the mastoid process. The auricle is commonly displaced forwards and outwards in adidts, and in a downward direction in children. This is due to pus having made its way through the thin sheath of compact tissue of the mastoid, thus giving rise to a subperiosteal abscess. Indications for Operation. In adults the presence of a subperiosteal abscess is always an indication for at once opening up the mastoid antrum and cells ; but in young children, if the swelling is but slight and if constitutional symptoms are absent, treatment by fomentations may lead to a spontaneous escape of the pus through the external ear. Occasionally the mastoid abscess bursts into the external auditory ^ According to Poulsen (^rc/i. of OtoL, July 1892, p. 346) the relative frequency of the three latter complications is about the same. Thus, out of thirty-six cases of complica- tions of otitis media, there were thirteen cases of abscess, twelve of sinus thrombosis, and eleven of meningitis. ^ It must be remembered that in these cases the appearance of the mastoid abscess may coincide with a diminution, or even entire cessation, of the discharge from the ear. SURGERY I 22 338 OPERATIONS ON THE HEAD AND NECK meatus, when there will be an opening on the posterior wall through which a probe can be passed into the mastoid cells. In some cases, where there are large air-cells extending to the apex of the mastoid process, the pus may make its way through the bone in this situation into the digastric fossa whence it will extend deeply among the muscles at the side of the neck : this variety of the disease is known as Bezold*s mastoiditis. In other rare cases, where the cells extend forward to the root of the zygoma, the pus may make its way in this direction and even extend into the squamous part of the temporal bone. There will be pain and swelling in the root of the zygoma and the temporal fossa, and probably oedema of the eyelids. In all these cases opening the antrum and mastoid cells is urgently called for. Antrectomy. Operations based on those of Schwartze and Stacke. The name of Schwartze, of Halle, is associated with the first attempt to put operations on the antrum on a satisfactory footing, he having published, in 1873, a series of cases in the Arch. f. Ohrenheilkunde, Bd. vii, u. ix. Replacing such very hmited opera- tions as that of Wilde's ^ incision and drilhng the bone, Schwartze opened up the mastoid cells and antrum, establishing drainage between these and the tympanum, and keeping the com- munication open by plugging or by a leaden nail. This pioneer operation, though excellent and based on correct principles, admitted of improvement. It was used extensively for many years, with the result that it was found admirably adapted for acute, but insufficient for some chronic cases where the mischief was 143. Automatic mastoid extensive. Stacke, in'1892, published ^ his oper- retractor. ation which modified that of Schwartze in the following important details — viz. the detach- ment of the auricle, the removal not only of the outer wall of the antrum but the upper and outer part of the bony meatus, the taking away of the ossicles and membrana tympani, and the replacing of the auricle, drainage being effected through the external auditory meatus. Generally speaking, in acute cases, an operation based on Schwartze's is called for, while in chronic cases, Stacke's operation, or some modifi- cation of this, is indicated. The Operation for Acute Mastoid Abscess. The hair must be shaved and the skin carefully cleansed for a distance of about three inches behind and above the ear. In the case of a woman the hair may be kept out of the way by a bandage round the head or by a rubber cap. Owing to the extreme tenderness the cleansing process will usually have to be carried out after the patient is anaesthetised. The position of the patient at the operation is of considerable import- ance : the head and shoulders should be slightly raised, and the head ^ In Wilde's operation an incision is made down to the bone about three-quarters behind the auricle. Drainage of a subperiosteal abscess is thus effected, but the antrum is not opened. ^ Arch, of Ohrenheilkunde, Bd. xxxi. YlG MASTOID DISEASE AND OTITIS MEDIA 3'M tunu'cl well over to the sound side so that the diseased ear is uppermost. A loosely-filled sand-bag beneath the head is often of great service in the maintenance of this position during the operation. The sterilizied towels should be arranged as follows : one towel is placed beneath the patient's head and shoulders, whih^ a second, folded diagonally, is fastened tightly rounil the head so as completely to cover the hair. The patient's body is then covered by one or more large towels, and finally, a small towel witti a central slit is arranged so as to cover the patient's face and the anaesthetist's hands and apparatus and to leave the ear and seat of operation alone exposed. A good light is absolutely essential, as the field of operation Fig. 144. A, Macewen's gouge. B, Osteotribes or burrs made for use with a trephine handle. is at the bottom of a deep wound, easily obscured by haemorrhage, and in close proximity to structures of the utmost importance. The most satisfactory illumination is obtained from an electric head-lamp, which is comfortable to wear and which throws a bright light into the depths of the wound without in any way obstructing the field of vision. A curved incision must be made parallel to, and from half to three- quarters of an inch behind, the attachment of the auricle ; it should commence above at the level of the top of the pinna and extend downwards to the apex of the mastoid process.^ It should at once be carried down to the bone. If a subperiosteal abscess is present it is in this way opened and an area of bone, bare and devoid of periosteum, of variable extent, will be felt. Free haemorrhage may follow, but this can be checked by picking up the cutaneous vessels with Spencer- Wells forceps. ^ In children the superficial position of the facial nerve must be remembered. 340 OPERATIONS ON THE HEAD AND NECK Whether a subperiosteal abscess is present or no the periosteum must be stripped with a raspatory from the mastoid process in a forward direction until the posterior wall of the external auditory meatus, the suprameatal spine, and Macewen's triangle are exposed. Care must be taken to avoid injury to the cartilaginous meatus and its cutaneous lining. In order to obtain a free view of the area involved the margins of the incision must be widely retracted. This is best effected by the retractor shown in Fig. 143. By tightening the screw it is automatically retained in the desired position, and also to a great extent checks the oozing from the cutaneous vessels. The surface of the bone is now dried and carefully inspected for a sinus or depression from which pus is oozing or for a discoloured patch of bone. Such an opening may, or may not, be present, and the next stage of the operation will depend to a certain extent upon the existence or non-existence of such a sinus. A. If a sinus is found this should be opened up and explored, for here the pus has made its way through the bone and consequently this sinus affords a direct track to the abscess cavity. The bone must be removed by some form of gouge or chisel. Most surgeons prefer gouges with curved cutting edges ; others, however, use flat chisels with slightly rounded corners to the cutting edge. In either case several sizes should be ready to hand. The gouge or chisel must in all cases be used so as to remove thin shavings of bone from the exposed surface. This is ensured by holding the gouge so that it makes an acute angle with the surface of the bone, and then giving it a few light taps vnih the mallet until a grip is obtained : the handle is then depressed and a few more blows will cut away a shaving of considerable extent. On no account is the gouge to be driven vertically into the bone so that it becomes locked ; this may lead to a fracture of the skull or to some serious injury to the brain or lateral sinus. The gouge or chisel must always be held so that it cuts from behind forwards and from above down- wards. In this way it is cutting from the lateral sinus and the fossae of the skull, and hence, even if these structures are exposed inadvertently, they will probably escape injury. If cutting in the reverse direction, however, the edge of the instrument may be driven into the lateral sinus or brain and inflict serious injury on these structures. The gouge should be lightly but firmly grasped by the thumb and the four fingers, while the WTist rests against the patient's head : in this way it may be kept under perfect control, and, even if it unexpectedly should penetrate any thin portion, can be prevented from damaging the under- lying structures. The best form of mallet is a small well-balanced metal hammer which can be easily sterilised. In many patients, especially children, the bone is so soft that the gouge can be quite easily used by the hand alone without the assistance of the mallet except perhaps for the first few cuts. The condition revealed when the sinus has been opened up in the way described above will vary a good deal in different cases. A large abscess cavity, the size of a hazel-nut, may be fomid, or, instead of a single abscess cavity, a number of cells containing pus and septic granulation tissue may be present. In either case the extent of the cavity should be investi- gated by a small blunt-ended probe. The compact tissue of the mastoid must now be gouged away so as to thoroughly expose the whole of the infected area. When there is a single large cavity bone nmst be removed so as to avoid any overhanging edge beneath which suppuration might MA.STOID DISEASE AND OTITIS MEDIA 341 still go on. When many septic cells are present each must be opened by gouging away the bony septa, and the various extensions of the cells mentioned on ]). 'A'M') must be remembered, those at the apex receiving special attention. The wound must be carefully inspected after each application of the chisel to make sure that the lateral sinus and the dura mater are not exposed. The former is especially likely to be injured as bone is removed to expose the posterior part of the cavity. Indeed, sometimes the bone has been destroyed by the backward extension of the suppuration to such a degree that the lateral sinus and dura of the posterior fossa form part of the boundary of the abscess cavity. The Fig. 14.5. Maccwon's combined small curette and seeker. 1'he latter will serve as an ossicle-hook. middle fossa, which very rarely extends below the level of the posterior root of the zygoma, is unlikely to be exposed at this stage of the operation. Directly the gouge opens up any new space it is advisable to explore this with the blunt probe as described above. If the space is an air-cell it will be felt to have a definite deep bony wall ; if it be a lateral sinus or cranial cavity the soft yielding dura mater will be felt. Haemorrhage is not often troublesome : blood is best mopped away by small strips of sterilised lint or gauze introduced into the depths of the wound by means of fine bayonet-shaped forceps. It is a not uncommon mistake for the surgeon to rest content with opening and draining the abscess cavity. This, however, is not sufficient : the mastoid antrum, which is the cause of the abscess and which is always infected, must also be opened and drained. If this is not done chronic inflammation with further caries and necrosis is bound to continue and will probably lead to a persistent sinus behind the ear as well as to a further extension of the septic process in the bone. In many cases the probe will readily pass along a channel leading in an upward and forward direction to the antrum, which is then easily opened up. In other cases, though it certainly exists, the channel may be so narrow and sinuous that it is not found by the probe. It will then be again necessary to identify Macewen's triangle and the posterior root of the zygoma. Bone must then be gouged away in a forward and upward direction and the antrum will soon be found beneath ^^^ '^^^ this spot. The antrum can be identified by the following tests : (a) In- vestigation by the probe shows that its deep wall is bony ; (6) A bent probe Fig. 146. Stacke's guide, can be made to pass in a forward and upward direction towards the tympanic cavity. The antrum must be thoroughly exposed by the removal of any over- hanging edges and must then be carefully curetted by a small Volkmann spoon to remove all septic granulation tissue and carious bone. The mastoid cells must be treated in the same manner. 342 OPERATIONS ON THE HEAD AND NECK B. If no opening or discoloured bone is seen, it is best at once to proceed to open the antrum. To effect this the operator should, after having first identified the superficial landmarks mentioned above, proceed to cut a shallow groove with a half-inch gouge. The upper limit of the groove is the root of the zygoma, while its posterior limit should be rather less than three-quarters of an inch behind the posterior wall of the meatus. When the depth of the groove is about a quarter of an inch a smaller gouge should be selected and bone now be taken from the region of the antrum, immediately above and behind the external auditory meatus. As this is done one or more cells, probably containing pus, may be opened : that they are air-cells and not the antrum may be determined by examination wdth the probe as described above. Any cavity which is opened must be carefully investigated, as the middle fossa does occasionally descend below the level of the root of the zygoma. The depth of the antrum varies within wide limits. It may be only a quarter of an inch from the surface or as much as three-quarters of an inch. In the latter case, if the bone is sclerosed, as does sometimes happen, the exposure of the antrum may be a matter of considerable difficulty. If the surface marking is remembered and is carefully followed, however, a small antrum a\411 be found even under these conditions. When it is opened its roof is examined both by direct inspection and by the probe for any carious patch or perforation which will open the middle fossa and expose the dura. The infected mastoid cells are then opened up as described above and the whole cavity is thoroughly curetted and scraped to remove all septic granulation tissue. All loose chips of bone are then sought for and removed by the curette or forceps and the whole cavity is irrigated with lot. hydrogen peroxide (5 per cent.), which probably will find its way through the tympanum to the external auditory meatus. In any case the meatus should also be washed out. The wound behind the ear is then lightly packed with a strip of sterilised ribbon gauze and a small length of the same material is intro- duced into the external auditory meatus. A few fishing-gut sutures may be used to close the upper part of the wound, but free drainage must be secured. A gauze pad is applied and a thick layer of absorbent wool, and the whole is firmly bandaged. After-treatment. The first dressing may remain unchanged for forty- eight hours : the gauze plugs are then removed, after moistening with hydrogen peroxide. The post-aural wound is then gently syringed with the same lotion, which will probably, in part, escape through the meatus. Should it not do so the meatus must be cleansed separately. The gauze plugs and the external dressings are then replaced. For a time the dressing will have to be changed daily, but as the discharge lessens, they may remain untouched for two and then three days. The wound soon shows healthy granulations with but little discharge, and the escape of pus from the meatus also soon ceases in most cases. Should this, however, continue, and should a fistulous opening behind the ear also persist, further treatment will be called for {see p. 344). Possible accidents and complications. (1) Injury to the Lateral Sinus. This may be brought about by the gouge or by the sharp spoon or curette during the removal of the septic granulations. In either case there is severe haemorrhage and the wound becomes at once flooded with blood. Fortunately this can at once be checked by pressure. While an assistant iMASTOID DISEASE AND OTITIS MEDIA tUii thus controls the bkuHliiig a piece of ribbon gauze is prepared, and, when the pressure is removed, the end of this is placed over the opening into the vessel by the help of a director. More gauze is then packed in, and the operation is proceeded with. It may be necessary to leave a special piece of gauze over the opening at the conclusion of the operation. The greatest care must be taken to avoid injury to the sinus, on account of the possibility of a resulting septic thrombosis of the vessel. Should the sinus be accidentally wounded every precaution must be taken to guard against infection. (2) Opening the middle or posterior fossa of the skull. Should this happen, without injury to the dura, serious consequences arc very iniprob- able. Should, however, the dura be injured, there is a possibility of Fig. 147. A preparation of tlie right temporal bone to show the l)one which must be removed in Stiicke's operation. A, The antrum. B, The aqucductu.s fallopii. C, The external auditory meatus. D, The remains of the posterior wall of the external auditory meatus. E. The external semicircular canal. septic infection extending to the brain or the meninges. Thus when the dura is known to be exposed the gouge and curette must be used in that region with great caution. (3) Injury to the facial nerve. This is very unlikely to occur in the opera- tion described above except in the case of children {see footnote, p. 339). It may, however, be damaged if, when curetting the antrum, the curette is introduced so as to press against the posterior part of the floor of the additus. When working in this situation the curette must be used with caution, and a watch kept for any twitching of the face. THE RADICAL MASTOID OPERATION It will now be necessary to consider the indications for the more complete, or radical, operation, founded on that originally described by Stacke. In this operation the mastoid cells and antrum are opened 344 OPERATIONS ON THE HEAD AND NECK up, the posterior wall of the meatus is removed, so that antrum, mastoid cells, attic, tympanic cavity, and external auditory meatus are thrown into one cavity. The aim of the surgeon is to remove all septic granulation tissue and all the diseased bone including the ossicles, and then to get the cavity completely covered by epithelium, thus leading to a cessation of the discharge. Generally speaking, the operation is called for in chronic suppuration in the middle ear and mastoid. The following are the chief indications for the operation in a patient suffering from chronic otitis media. (1) When acute mastoid disease becomes chronic, i.e. the wound behind the ear does not heal and discharge of pus from the ear persists. (2) Recurring attacks of swelling and pain over the mastoid process. (3) The spontaneous occurrence of facial paralysis. (4) Recurrent attacks of vertigo, either spontaneous or from syringing. This shows erosion of the bony wall of some part of the labyrinth. (5) When cholesteatomata are present in the attic and the mastoid. These masses of epithelium are usually regarded as derived from pro- liferation of the epithelium of the external auditory meatus through a perforation in the tympanic membrane. They may reach the size of a marble, are accompanied by a foul purulent discharge, cause absorption of the bone by pressure, and may penetrate the cranial wall opening up one of the fossae of the skull. (6) For tuberculous disease of the mastoid. (7) For necrosis of the temporal bone or for recurring masses of granulation springing from carious areas. (8) When occlusion of the meatus is associated with a chronic puaulent discharge. (9) When intracranial complications are present;. (10) In addition to these there are a number of cases in which a chronic otitis media persists, resisting all means of treatment. It is often very difficult to decide if operation is required in these cases. If the perfora- tion is in the postero-superior quadrant of the membrane and is marginal in position bone disease is likely to be present. In some of these cases removal of the ossicles or providing free drainage by removing the outer wall of the attic ^ may suffice. Should these operations fail the more complete operation is indicated. In chronic disease of the mastoid it is often surprising to find the extent to which the bone has been destroyed with very slight symptoms. It is quite possible to find the mastoid process a mere shell, containing pus and granulation tissue with possibly one of the fossae of the skull opened and the dura mater in contact with the septic cavity, and yet no symptoms beyond the discharge from the ear. In other cases one of the acute intracranial complications to be described below may suddenly develop without previous warning. The Operation. This may be considered in two stages, (1) the operation on the bone, (2) the plastic operation to provide the resulting bony cavity with an epithelial covering. The operation on the bone will, to a great extent, follow the lines of the operation described above for acute abscess. The preliminary prepara- tions, the incision, and the exposure of the field of operation are similar, but the cartilaginous meatus must be separated from the bony meatus, 1 For the indications for, and the mode of performing, these operations, the reader is r eferred to some standard work on diseases of the ear. MASTOID DISEASE AND OTITIS MEDIA 345 without tearing or injuring the former. In Stilcke's original opera- tion the antrum was exposed by chiselling away the postero-superior part of the meatal wall. It is, however, easier and more satisfactory to open the antrum in the manner described above by gouging the bone in the area bounded above by the posterior root of the zygoma, and in front by the wall of the meatus. The position of the lateral sinus must be remembered and the posterior limit of the field of operation should not extend farther back than half an inch behind the rim of the meatus. When the antrum has been exposed any diseased mastoid cells are to be thoroughly opened up in the way described above. A probe, or a Stiicke's gui(ki (Fig. 1 4(1), is now passed from the antrum into the tympanic cavity to exactly identify the position of the additus. The posterior wall of the external auditory meatus must now be gouged away, so as to expose the additus, or communication between the antrum and the tympanic attic. At first the bone may be freely removed, but as the bridge of bone between the two cavities is diminished in size the greatest caution must be exercised, for it is at this stage that the facial nerve and the horizontal semicircular canal are in considerable danger. The semi- circular canal is contained in a smooth white ridge of bone at the junction of the floor of the additus with its inner wall. The aqueductus Fallopii, which encloses the facial nerve, is situated immediately below and in front of this. Both these bony canals are extremely thin, and, should the gouge slip through the last portion of the bridge of bone between the antrum and the attic, and impinge against them, these structures are very liable to be injured. Injury to the facial nerve will result in complete paralysis of the muscles supplied by it ; while injury to the semicircular canal, besides causing serious vertigo, may be the starting-point of labyrinthine suppura- tion. The utmost caution must therefore be exercised in removing the last portion of the bridge of bone. After each chip of bone has been cut away the wound must be carefully dried by a pledget of sterilised gauze introduced into the depths of the wound. A Stacke's guide may be left in situ in the additus witli the view of protecting the nerve, or a piece of gauze may be packed into this cavity with the same object. When only a narrow bridge remains, this should be divided by the gouge cutting from above downwards just below the level of the tegmen tympani, i.e. as far from the nerve as possible. The removal of this piece of bone allows a probe to pass freely from the antrum into the attic and the tympanum. All overhanging edges, beneath which suppuration might possibly be kept up, must be carefully removed until the cavity has the appearance shown in Fig. 147. This refers especially to the outer wall of the attic, which is in part formed by a plate of bone projecting down from the tegmen tympani, and to the spur formed by the remains of the posterior wall of the meatus. The latter must be cautiously carried out, for the facial nerve is again in danger while the deeper part of this is being rounded off to secure a good view of the posterior part of the tympanic cavity. When these edges have been gouged away the whole cavity must be carefully curetted. All granulations must be removed and all carious patches in the bone thoroughly but gently scraped. A careful and systematic inspection of all parts of the cavity, including the tegmen tympani and tegmen antri, must be made with the help of a bright light. All discoloured or suspicious areas must be followed up with the curette, and, if necessary, he gouge. When the attic and the tympanum are curetted the incus and he malleus will very probably be found in a carious condition and more si \ 346 OPERATIONS ON THE HEAD AND NECK or less embedded in granulation tissue.^ They should be removed. The curette must always be used with care and gentleness : the wall of the cavity is in many places extremely thin and is in relation with very important structures. Thus in the floor of the tympanum a thin plate of bone alone separates it from the bulb of the jugular vein ; the front of the tympanum is in close relation with the internal carotid artery ; while the proximity of the lateral sinus to the posterior part of the cavity, the dura of the middle fossa to the tegmen tympani, and of the semicircular canal and the facial nerve to the additus, have already been insisted upon. It may here be pointed out that the facial nerve may be quite as readily damaged by the curette as by the gouge, for the bony aqueductus Fallopii is extremely thin and it is deficient in places or may be opened by caries of its walls. '^ While curetting in its neighbour- hood it is therefore wnse to keep a close watch for any twitching of the face. When the curetting has been satisfactorily carried out all edges and angles must be rounded off, and a search nnist be made for any loose chips of bone which are removed. The The vertical cut cavity is then washed out with hot lot. hydrogen peroxide (5 per cent.). The Plastic Operation. In all cases, except where there is some intra- cranial complication which requires drainage, the wound behind the ear should be closed and a flap be cut from the cutaneous lining of the meatus, to ensure drainage of the entire cavity and, at the same time, to provide a covering for part of it from which epithelium will eventually grow to cover the whole. There are a number of ways in which this can be accomplished. (1) Stackers metJiod. This is described in the following words by Heine.^ " After the tympanic cavity and the rest of the Avound have been temporarily packed with gauze, one hand (for the left ear the left hand, ^ The stapes should not be disturbed on account of the danger of opening the laby- rinth. •^ In such cases even gentle pres.sure by a piece of gauze for the jiurpose of drying the wound may cause twitching of the face. In the-^-e cases paralysis of the face coming on some hours after the operation is not uncommon and is probably due to inflammatory exudation pressing upon the nerve in its canal. 8uch paralysis will disappear, though sometimes tediously. This paralysis is especially likely to occur when there is any natural gap or iiathological erosion. Paralysis noticed immediately after the operation is probably due to injury, and is likely to be permanent. * Operations on the Ear, translated by W. L. Murphjr, 1908. Fig. 148. Stacko's plastic operation is shown with the edges gaping. The position of the horizontal cut is indicated by the dotted line. MASTOID DISEASE AND OTITIS MEDIA 347 ami vice versa) holds the auricl(> and turns it forwards, while with the otiier hand a narrow scalpel is pushed from behind through the soft parts at the level of the superior wall of the meatus, until the point appears in the entrance of the meatus at the j unction of the posterioi' and superior walls (Fig. I4S). The ]>oint at wliieh the knife is inserted lies close behind the anterior lip of the wound. The auricle must be turned a little back- wards while the blade is being pushed through from behind, in order that the surgeon may make sure that it emerges at the proper spot. Care must also be taken not to wound the anterior meatal wall. When the point is seen to appear at the spot indicated, the knifes is cai'ried vertically downwards ; that is, towards the apex of the mastoid, and in a direction perpendicular to the long axis of the auditory canal. In doing this the posterior part of the meatus itself and the soft parts behind it are cut A. B. ('. Fig. 149. A. Koiner's Rap. B. Pause's flap. C. Milligan's flap. through. The point of the knife must divide the skin of the meatus in the line where it passes on to the auricle. If the incision is lateral to this line, it will divide the cartilage of the ear ; if it is to the median side, the outer end of the meatus will remain attached to the auricle and the opening into the operation cavity will be too narrow. The second incision for the formation of the flap runs horizontally at the junction of the posterior and superior walls of the meatus, and splits the canal in its long axis. A small retractor is inserted into the slit in the posterior meatal wall and pulled forwards, in order to bring the lumen of the canal into view. The wall of the meatus is then grasped from behind with toothed forceps, and the soft parts are pulled backwards and outwards until the lumen gaps sufficiently. The gauze packing is now removed, and straight scissors are inserted through the vertical incision in such a manner that one blade lies in the meatus and the other outside. The scissors are brought as high as possible, and are pushed inwards until the point of the blade lying inside the canal comes into view deep in the wound. A single cut is then made with the scissors in the desired direction (Fig. 148) and the formation of the flap is complete." In order that the flap shall fall nicely into position it is necessary to snip away with a sharp knife some of the thick soft tissues at the outer end, taking care that the skin itself is uninjured. The flap is not kept in position by sutures, but is pressed against the lower and posterior part of the bony cavity by gauze packed through the external auditory meatus. The wound behind the ear is then completely closed by a few silkworm-gut sutures. Various modifications of the mode of cutting the flap have been 348 OPERATIONS ON THE HEAD AND NECK suggested. Korner (Fig. 149 A) cuts a rectangular flap by two incisions, one at the junction of the superior and the posterior walls and the other at the junction of the posterior and inferior walls of the meatus. These incisions are continued outwards for a short distance on to the concha. After the cartilage has been dissected away this tongue-shaped flap is turned backwards, and, after the post-aural wound has been closed, is kept in position by ribbon gauze packed into the cavity through the external auditory meatus. In Pause's method (Fig. 149 B) a single incision is made in the axis of the canal, along the middle of the posterior wall of the meatus. This extends to the concha : at its outer end two small cuts are made at right angles to the first, one in an upward direction and the other downwards. In this way two small flaps are formed, one of which is sutured to the upper and the other to the lower angle of the wound. Milligan's flap (Fig. 149 C) is thus described by its originator : ^ " A long and thin-bladed knife is inserted into the cartilaginous meatus at the junction of its upper and posterior walls and an incision made vertically outwards into the concha. With a sweeping motion an incision is made through the concha parallel to the curve of the antihelix down to the floor of the meatus (Fig. 149 C). The flap thus formed is turned downwards on to the floor of the bone wound and is kept in position by means of a couple of sutures passed through it and the adjacent skin and tied over a piece of rubber tubing." Mr. Ballance ^ recommends a different plan of after-treatment, which, when successful, saves much time, and avoids frequent dressings and pluggings — a point of great importance in hospital patients and in those who are timid. The first special point in Mr. Ballance's treatment concerns the cartilaginous canal. After the completion of the post-aural operation he introduces a long thin knife along the meatus and divides the inferior wall in a vertical direction : the incision is then continued in an upward and backward direction into the concha until it reaches the anterior commencement of the helix {see Figs. 150, 151). After the flap has been thinned by the removal of all redundant soft parts it is turned backwards and its raw surface is attached by a few salmon-gut sutures to the interior surfaceof the original mastoid flap (Figs. 152, 153). The post-aural wound is then closed .At the end of about ten or fourteen days an anaesthetic is given and the original wound is opened up and the pinna displaced forwards as at the first operation. The cavity in the bone, now covered by healthy granulations, is thus exposed. All oozing is now stopped by irrigating the wound with hot saline solution, or, if necessary, by the application of adrenalin (1 in 1000). A large thin skin graft is cut from a previously sterilised area of skin on the thigh. If possible this should be of such size as to cover the whole of the cavity. It should be transferred to the wound by a large microscopical section lifter, and is then, by careful manipulation, worked by needles so as to come evenly into contact with the whole raw area, care being taken that all air bubbles and blood have been removed. Should the first graft be of insufficient size, one or more further grafts must be cut until the whole surface is covered. As a protection for the grafts Mr. Ballance employs thin gold leaf, which, after being cut to the requisite size, is placed in exact position over the grafts. A strip of dry sterilised gauze is now evenly 1 Latham's System of Treatment, vol. iii, p. 925. ^ Med.-Chir. Trans., vol. Ixxxiii. MASTOID DISEASE AND OTITIS MEDIA 349 packed into the cavity and the retro-auricular wound again closed and the usual external dressings applied. At the end of four days the plug of gauze is removed from the external aiulitoiv meatus and the gold leaf then picked out with for- ceps or by gentle syring- ing. In a successful case rapid liealing results, but, to ensure success, it is es- sential that no infective material shall have been left behind and that the bony surface must have been thoroughly smoothed at the orginal operation. After-treatment. When skin-grafting is not em- ployed the outer dressings should be changed on alternate days, but it is advisable, to avoid dis- turbing the flap, not to remove the packing for five or six days, unless there is some special indication for so doing, such as pain, a rise of temperature, or ex- cessive or foul discharge. Fig. 151. The white line here shows the direction of .the in- cision in the concha. The knife is first carried through the concha backwards, and then backwards and upwards till the anterior extremity of the helix is reached. (Ballance.) Fig. 150. The posterior edge of the inner extremity of the cartilaginous meatus is shown dislocated outwards, and a long narrow knife has been passed along the length of the meatus through the conchal opening. The white space shown in this and in Figs. 152 and 153 represents the bony area which has been operated on. ( Ballance. ) The removal of the plug is facilitated by soak- ing it with hydrogen peroxide (3 per cent.). The packing should be renewed every second day and the cavity then be syringed with saline solution or some mild antiseptic. Later on the packing is omitted, and the granu- lating surface treated with drops of a solution of boracic acid in alcohol. Any excessive formation of granulations must be kept in check by the application of lactic acid (20 per cent.), or of trichloracetic acid, or by touching with a bead of chromic acid. The Treatment of the Intracranial Com- plications of Otitis Media. These are extra dural abscess, cerebral or cerebellar abscess, thrombosis of the lateral sinus and meningitis.^ In all except the last immediate operation is indicated, while in some cases of early men- ingitis operation oSers a possibihty of recovery 1 A more unusual condition than these is an intra- dural abscess (pachymeningitis Interna Circumscripta). " A circumscribed collection of pus internal to the dura mater, between it and the surface of the brain covered by the pia mater, occurs mostly when there is a fistulous perforation of the dura, provided an adhesion of the dura with the pia mater takes place in the neighbour- hood of the ulceration. Such a coUection of pus either leads to ulceration and softening of the cortex of the brain or to a brain abscess. (Politzer.) 350 OPERATIONS ON THE HEAD AND NECK When, however, pus is diffused over the whole hemisphere, surgical interference offers no prospect of success. In the great majority of Fig. 152. The concho-meatal flap is seen behind the mastoid flap. Supporting stitches (one, two, or three, as the case may be) are carried through the edge of the conchal cartilage. The two threads of each stitch are now threaded on one needle, so that they can be passed through the skin and other tissues of the mastoid flap without constricting them. Before the supporting stitches are passed the thick layer of tissue behind the posterior wall of the meatus is cut away so as to facilitate the application of the mcatal to the skin flap. ( Ballance. ) cases the septic process reaches the cranial cavity by direct extension from the tympanum or the an- trum by gradual destruction of their bony walls. Destruction of the thin tegmen tympani will open the middle fossa and will allow of the development of meningitis or of a cerebral abscess, while an extension backwards through the pos- terior wall of the antrum will admit of an extension of the septic process to the posterior fossa resulting in the formation of a cerebellar abscess, or of thrombosis of the lateral sinus. In unusual cases no such direct track may be seen. In such cases the intracranial infection may have been caused in one of the following ways : (1) By extension through the labyrinth (2) By extension through the Fig. 1.53. The supporting stitches are shown drawn tight, and supporting the raw surface of the concho-meatal flap against the raw surface of the mastoid flap. (BaUance.) and the internal auditory meatus. ABSCESS IN TIIK HKAIN ;551 floor of the tynipanuin to tlie hiilbot the jugular vein. (3) By exten- sion along some of the minute canals for emissary veins. (4) By extension through the anterior wall of the tympanum to the carotid canal and thence to the apex of the petrous. (5) An abscess may be pysemic, and situated at some distance from the affected ear, even in the opposite hemisphere. In typical cases, the diagnosis of an intracranial complication is easy, biit occasionally it is exceedingly diflicult. More than one of the above may co-exist, which increases the dithculty of an exact diagnosis. Occasionally a cerebral abscess may be present with few or no symptoms, while it is often only possible to suspect some intracranial trouble without Fig. 154. The .supporting stitches are shown passing through the angle of junction of the pinna and the mastoid flaj]. They were two in number in the case from which the drawing was made. They are tied over pieces of rubber tubing. This is shown too small, and the threads are tied too tightly. Ihe curved incision is entirely closed by gossamer silkworm-gut svitures. (Ballance. ) being able to locate it or to be certain of its nature. Needless to say the appearance of such symptoms as a rigor, severe pain, marked rise of temperature, convulsions, or drowsiness, will be an indication for an immediate exploratory operation. Extradural Abscess. The pus will be found between the bone and the dura mater. These abscesses occur more frequently in the posterior fossa, especially as a collection of pus and granulation tissue in the sigmoid groove — a peri-sinous abscess. The symptoms vary very much indeed. Not infrequently, in the case of a peri-sinous abscess, they may be com- pletely absent, the condition being found unexpected during a radical mastoid operation. In other cases there may be very severe pain, while in others this symptom varies from time to time owing to the pus being able to drain and the abscess occasionally to empty itself through the middle ear. Abscess in the Brain. When in the cerebrum the collection of pus is usually in the middle and back part of the temporo-sphenoidal 352 OPERATIONS OX THE HEAD AND NECK lobe ; when in the cerebellum, in the front and outer part of the lateral lobe. Symptoms. These may be divided into the following three groups : I. General. There may be pyrexia, which is, however, usually due to the otitis or to some other complication. A typical cerebral abscess will show a slightly subnormal temperature. A rigor may occur at the early stages but is rarely repeated. In an old-standing case there will be loss of flesh and constipation. II. General symptoms of cerebral disturbance. Headache is a very constant symptom, though the position of the headache is not, as a rule, any indication as to the situation of the abscess. Nausea and vomiting are common, the latter having no relation to the taking of food. Some mental disturbance is nearly always present. In the earlier stages there is mental dulness and apathy : later on there is stupor, or more or less complete coma. Optic neuritis may be present, but, on the other hand, is often absent. The pulse in a typical case is slow. III. Localising symptoms. These are usually but slightly marked and are often entirely absent. A temporo-sphenoidal abscess may, owing to pressure on the internal capsule, produce some paresis in the opposite arm and leg. Occasionally there will be some paralysis of the ocular muscles or alteration in the pupil. The symptoms vary a great deal and are often very indefinite. " Abscess in the brain may be latent,^ producing no symptoms directly referable to the brain, only general symptoms of ill-health, until excited to activity by a blow, or some minor operation, such as the removal of a polypus " (Ballance). Such latent abscesses possess a well-marked capsule. This is of twofold importance. It prevents the risk of rupture and, as will be seen later, it may baffle attempts to find the pus. On the other hand a rapidly enlarging abscess is very likely to rupture into the lateral ventricle, and the more acute the abscess the more will it be accompanied by an advancing affection of the surrounding brain. This condition, by causing such symptoms as a high temperature and dehrium, will be an additional cause of the masking of the typical symptoms of cerebral abscess. By leading to a diagnosis of meningitis, they may cause the abscess to be overlooked. Abscess in the Cerebellum. The above i;pmarks also apply to abscesses in the cerebellum. Abscesses in this situation may, however, present well-marked symptoms which aid in the locahsation of the trouble. Such are vertigo and ataxy, rigidity of the muscles of the neck, and in some cases well-marked optic neuritis. Dr. Acland and Mr. Ballance " have carefully gone into the question in an elaborate article. They throw some doubt upon the opinion usually held, that abscess in the temporo- sphenoidal lobe is more common than in the cerebellum. They quote statistics by Korner, shoA\"ing that in 100 cases of abscess in the brain, secondary to ear disease, 62 were in the cerebellum and 32 in the cerebrum, and in 6 in both cerebrum and cerebellum. Of 3.3 cases collected from St. Thomas's and the Great Ormond Street hospitals, 24 were cerebellar ^ With reference to the diagnosLs of latent cerebral abscess the reader is referred to a valuable paper read by Sir Victor Horsley before the Otological section of the Royal Society of Medicine (Proc. Roy. Soc. Med., February 1912, p. 45). In this paper Sir Victor Horsley discusses also the significance and importance of a number of symptoms such as optic neuritis, subnormal temperatures, and insists on the importance of a careful neurological examination. * St. Thomas's Hospital Be ports, vol. xxiii, p. 133. MENINGITIS 353 and 11 temporo-sphenoidal. In two cases an abscess was present in both the temporo-sphenoidal lobe and in the cerebolhim. Dr. Acland and Mr. Ballance drew attention to the fact that in their case certain symptoms were present which so closely resembled the effects produced by removal of one lateral lobe of the cerebellum, that they deserve to be fully con- sidered. These are : (i) Paralysis of the upper extremity on the same side as the lesion, (ii) Conjugate deviation of the eyes towards the opposite side, (iii) Lateral nystagmus, (iv) Exaggerated knee-jerk on the same side as the cerebellar lesion. (v) A tendency to face towards the side of the lesion in walking, (vi) Staggering gait, and a tendency to fall towards the side opposite to the lesion, (vii) Atti- tude in bed : the patient tends to lie on the side opposite to the lesion with the limbs flexed, and with the side of the face corresponding to the lesion uppermost. Thrombosis o£ the Lateral Sinus. This is a grave comphcation, from its tendency to cause general pyaemia and distant suppurations. The onset is usually sudden and is accompanied by a rigor, headache, and vomiting. Mr. Ballance ^ believes that the following group of symptoms, when present together, are pathognomonic of septic thrombosis : (i) A history of purulent discharge from the ear for a period of more than a year, (ii) The sudden onset of the illness, with headache, vomiting, rigor, and pain in the affected ear. (iii) An oscillating temperature, i.e. 104° in the evening and 98 in the morning, (iv) Vomiting repeated day by day. (v) Repeated rigors, (vi) Local oedema and tenderness over the mastoid, or in the course of the internal jugular vein.^ (vii) Tenderness on deep pressure at the posterior border of the mastoid and below the external occipital protuberance, (viii) Stiffness of the muscles of the back or side of the neck, (ix) Optic neuritis.^ In the great majority of cases metastatic abscesses are fomid in the lungs, though occasionally the toxaemia causes typhoid fever-like symp- toms. Meningitis. Several forms of this serious complication must be recognised, (a) Suppurative meningitis, in which pus is widely diffused over the hemisphere in the pia-arachnoid. In this condition the tempera- ture rises to 102 or 103° and there may be a rigor : there is intense head- ache with dehrium and more or less loss of consciousness. There is rigidity of the neck muscles and Kernig's sign will be present. Other symptoms are optic neuritis, vomiting, and there may be convulsions or paralysis of the opposite arm and leg. Later there will be coma, Cheyne Stokes breathing and a rapid irregular pulse. The prognosis in this diffuse form is absolutely unfavourable.'* (6) In rare cases, though the infection has penetrated the dura the suppuration remains localised forming a subdural abscess, i.e. an abscess between the dura and arachnoid, while the latter membrane and the pia mater escape infection. (c) In some cases there will be a serous meningitis in which there is an 1 Loc- supra cit- * (Edema or tenderness over the internal jugular may be due to extension of the clotting and phlebitis, or to enlargement of the deep lymphatic glands. Any examination of the internal jugular should be conducted with the utmost gentleness for fear of detaching thrombi. ^ The occurrence of optic neuritis is very variable. It may be present in any of the intracranial complications of otitis media, but on the other hand is often absent. * Lumbar puncture offers an excellent help to the diagnosis of the various forms of meningitis. SURGERY I 23 354 OPERATIONS ON THE HEAD AND NECK increased amount of clear fluid in the subarachnoid space. There may be symptoms suggesting suppurative meningitis, or the condition ma'y only be found and recognised during an operation. This form of menin- gitis can seldom or never be diagnosed with certainty. Though general suppurative meningitis will not be benefited by operation, the latter two forms of this disease are amenable to operative treatment. " If the clinical picture makes the diagnosis of suppurative meningitis probable, lumbar puncture should be carried out to remove any doubt that may remain. If the cerebro-spinal fluid is found to be purulent and to contain bacteria, further operative measures are useless. If the fluid is only turbid, even though bacteria are found, the cranium should be opened. If the fluid is purulent without micro- organisms or clear with micro-organisms, I now always operate. When a patient is so weak that any operation is dangerous, lumbar puncture should be done, so that the surgeon may learn whether there is anything to be hoped for from further interference or not." ^ For further information on this subject reference may be made to an interesting paper by Mr. F. G. Wrigleyon " The Cerebro-spinal Fluid as an Aid to Diagnosis in Suppurative Meningitis of Otitic Origin," with subsequent discussion.^ Mr. Wrigley says : " The diagnosis of suppiu'ative meningitis cannot be made with certainty (though it may exist) without the presence of bacteria in the cerebro-spinal fluid, and I consider that the following features are usually necessary before an absolute diagnosis can be made : The fluid is either turbid or deposits a coagulum quickly on standing. The albumen is increased 0- 1 Esbach or above. Microscopic ex- amination shows a polymorphonuclear leucocytosis, and bacteria are found either in Alms or cultures. If these features are present the diagnosis may be made with certainty." Operations for the treatment of intracranial complications of Otitis Media. In former days these were usually carried out by trephining in the region of the suspected disease. It is now, however, recognised that the intracranial complication should, as a rule, be exposed and treated via the mastoid process and the antrum or tympanum. The reasons for this are as follows : (1) Suppuration in the mastoid antrum and cells is the cause of the intracranial trouble. If the latter alone is treated the septic process continues in the bone and may extend, in other directions, to the cranial cavity. (2) Usually there will be a direct track through the bone from the antrum leading to the intracranial lesion. As will have been gathered from the remarks above the operation is often of an exploratory nature, and the information thus gathered is of the greatest service in discovering the nature and the situation of the lesion. (3) The pus will in this way be found where it is nearest the surface and will thus be drained with the minimum amount of damage to the normal brain tissue. (4) Occasionally pus will have made its way into both fossae. In this case there will be probably a direct track from the antrum through its roof and posterior wall. By trephining to expose one fossa, it is very likely that the suppuration in the other fossa might be overlooked. There may, however, be cases where it may be desirable to trephine directly over the situation of the pus. For example, there may be distinct localising signs of an abscess in the brain at some little distance from the situation of the antrum, or possibly the condition of the patient may be so grave that it may be felt advisable to drain the pus at once, leaving the treatment of the antrum and the mastoid cells until the condition of the patient has improved. ^ Heine, Operations on the Ear, p. 196. 2 Proc. Roy. Soc. Med. Otol. Sec, July 1912, p. 171. OPERATION FOR OTITIS MEDIA 355 The difToront sites for ap|)lyinp; the trephine are shown in Fig. 155 . Mr. BaMance advises tliat the point of the trepliine shouki he applied, f(jr (h-aining a cerebral abscess, ^ iiu-h above the siipratueatal spin(% tiu; obj(;(d being to ex])osc the lowest ])art of the middle fos.sa just above tiie tegnien antri and tegnien tyinjjani. Inimediateiy at)<)V(^ tiie tegniina are the tissues in wiiieh, as a rule, the infective process develops. Sir \V. Macewen gives the following rule for exploring a tenii)oro-s|)henoidal ab.scess : The centre-pin should be placed in a line with the posterior wall of the meatus, and three-(|uarters of an inch above the ])osterior root of the zygoma. IMr. Barker tliinks that nine-tenths of the abscesses in the brain Fig. 155. The figure shows the relations of the lateral sinus to the outer wall of the skull, and the position of the trephine-opening, a, for exploring it. Reid's base-line is shown passing through the middle of the external auditory meatus and touching the lower margin of the orbit, x x indicate the site of the tentorium as far as it is in relation to the outer wall of the skull. The anterior x shows the point where the tentorium leaves the skull and is attached to the upper border of the petrous bone, a, Trephine-opening to expose lateral sinus, its centre being 1 inch behind and j inch above the centre of the meatus. This opening can easily be enlarged upwards, backwards, downwards, and forwards (see the dotted lines), by suitable forceps. It is always well to extend it forwards so as to open up the mastoid antrum, c. b, Trephine-opening to explore the anterior surface of the petrous bone, the roof of the tympanum and the petro-sc^uamous fissure, its centre being situated a short inch above the centre of the meatus. At the lower margin of this treiihine-opening a probe can be insinuated between the dura and the bone, and made to search the whole of the anterior surface of the petrous, c, Trephine-opening for exposing antrum, J inch above and behind the centre of the meatus, d, Trephine-opening for temporo-sphenoidal abscess (Barker), 1;^ inch behind and above centre of meatus. The needle should be directed at first inwards, and a little downwards and forwards, e, Trephine-opening for cerebellar abscess, 1 ^ inch behind and 1 inch below the meatus. The anterior border of the trephine should be just under cover of the posterior border of the mastoid process. Such an opening is well removed from the lateral sinus, and a needle, if directed forwards, inwards. and upwards, would enter an abscess occuj^ying the anterior portion of the lateral lobe of the cerebellum, the usual site of an abscess in this part of the brain. (Barker.) are within a circle with a | inch radius, whose centre lies an inch and a quarter above and the same distance behind the centre of the bony meatus. For a cerebellar abscess Mr. Barker advises a point an inch and a half behind the centre of the meatus and an inch below Reid's base line (a line running from the lower border of the orbit backwards through the centre of the meatus). Mr. Ballance writes -A " A cerebellar abscess arising from ear disease is usually in the anterior part of the lateral lobe, close to the diseased bone (inner side of the mastoid or posterior surface of the petrous) which has caused the infection. Place the trephine so that its anterior border is just behind the posterior border of the mastoid process, and so that its upper border is below Reid's base line. ^ Loc. supra cit. 356 OPERATIONS ON THE HEAD AND NECK For exploring the lateral sinus Mr. Dean recommends that the pin of the trephine should be applied an inch and a quarter behind and a quarter of an inch above the centre of the external auditory meatus. Bone is then removed by bone forceps in an upward and downward direction so as to admit of exploration both of the temporo-sphenoidal lobe and of the cerebellum. Treatment oJ extra dural Abscess. The mastoid cells and the antrum having been opened in the way described above, and the tympanum ha\dng been exposed by removal of the posterior meatal wall as has been described in the account of the complete mastoid operation, a careful inspection is made of the tegmina and the posterior antral wall. This will probably show a carious patch through which a probe may be passed into the aft'ected fossa : pus in some quantity may be seen escaping through the opening. In the case of the middle fossa a few cuts with the gouge in an upward direction will suffice to expose more freely the abscess cavity. As soon as a sufficiently large opening has been made for their introduction a pair of gouge forceps may be employed to remove sufficient bone to secure free drainage. The dura should be exposed until its surface is devoid of granulations and is practically normal in appearance. Septic granulations and pus should be washed and sponged from the surface of the dura : the curette must not be applied to it for fear of injuring the mem- brane and thus opening up a fresh channel for the extension of infection. An extra dural abscess in the posterior fossa means that the infection has extended through the posterior wall of the antrum, and thus pus and granulation tissue are present in the sigmoid groove (perisinous abscess). This condition may be present with few or no symptoms and without thrombosis of the sinus. When the antrum is opened inspection and careful investigation with the probe will reveal a track leading directly backwards to the posterior fossa. This must be opened up by removing bone in a backward direction with gouge or cutting forceps. This must be carried out most carefully on account of the risk of injury to the sinus. Should it be accidentally opened it must be treated on the lines described at p. 342. Drainage must be secured and the diseased dura exposed and treated in the same way as for an abscess in the middle fossa. In all these cases the retro-auricular wound ought not to be completely closed even when the abscess is unexpectedly found in the course of a radical mastoid operation. Operation for Abscess in the Temporo-sphenoidal lobe. The antrum and the mastoid cells having been opened up as rapidly as possible the middle ear is exposed by removal of the posterior wall of the meatus and the external wall of the aditus. Examination of the tegmen will then probably show a carious area opening the middle fossa. Bone is next gouged away in an upward direction above the posterior root of the zygoma, and the whole of the diseased portion of the tegmen is also removed. With Hoffmann's forceps or gouge forceps the dura is now widely exposed for an inch and a half above the level of the meatus and is then carefully examined. If an abscess is present the membrane will be unduly tense and will bulge forward into the wound : its surface may be dull, hypersemic, or show an area covered by granulations, while in other cases it may appear to be normal. Typically the usual pulsation of the brain cannot be felt. A pulsation may, however, be present \yith. a small abscess with firm walls rather deeply placed, and hence, though pulsation of the brain is noticed, if the symptoms point to the presence of an abscess a search must be made for pus. OPERATION FOR ABSCESSES 357 The presouce of pus should be verified and its situation determined by means of an exploring syringe fitted with a large bore needle : this is a point of considerable importance, for a small needle may easily get blocked by brain substance. Other operators use a grooved director, an expand- ing trocar, or an ex])l()ratorv incision. The needle nuist not be pushed too deeply for fear of wounding and infecting the lateral ventricle, which is always in close proximity to the deep aspect of the abscess. As soon as the pus is found the abscess is opened by a thin-bladed knife introduced by the side of the needle which is then withdrawn. A free incision must be made, not a mere puncture, or the drainage will not be satisfactory. If the pus is found to one side of, or above the opening in the skull, more bone must be removed so as to allow of direct access to the abscess cavity. The pus is often remarkably offensive : the quantity may be only 3j or 3ij , but on the other hand there may be a large collection amounting to §j or §ij, or even more. The smaller abscesses will be the more difficult to find : the larger ones will be in dangerous proximity to the lateral ventricle. The question of drainage is a difficult one owing to the soft consistency of the brain substance and the likelihood of portions of the soft brain tissue blocking up the lumen of drainage tubes. When a tube is removed its satisfactory replacement, for the same reason, may be a difficult matter. The tube must be of sufficient length to enter the abscess cavity, but nmst not press against its inner wall on account of the danger of opening and infecting the lateral ventricle. A couple of windows may be cut close to its inner extremity and it should be securely fixed in position by a stitch passing through the margins of the skin incision, or to the dura mater. Mr. West, in the discussion before the Otological Society referred to above, says : " Where the abscess is well defined, I think it will be generally admitted that tubes form a satisfactory means of drainage. I use rubber tubes of good size, up to the thickness of the little finger, or a pair of tubes of smaller size stitched together with a silkworm-gut suture. If the tube is stitched to the edge of the dura mater, or to some other convenient point, and is of good size, it will not be pressed out by the brain. I have abandoned all lateral holes in tubes. They become blocked immediately, and large plugs of brain are torn away each time the tube is rotated or removed, exposing fresh surfaces to infection. The problem of drainage of areas of diffuse infection seems to me one of extreme difficulty. Tubes are ineffective and gauze, in my hands, has been very unsatisfactory. In bad cases I believe that the only method which offers any hope is the bold removal of a wide area of bone and dura mater, and then of the overlying cortex, so that a large amomit of the infected brain is exposed, and free to drain on the surface. In this way, free drainage is secured, and I can testify that the result may be little short of miracu- lous." Sir Victor Horsley recommends concentric tubes, so that, as far as possible, there is always a tube in the wound until final granulation occurs. In any case the tube should be left in position for six days before it is removed. The lower part of the wound is drained separately by a strip of ribbon gauze which is lightly packed into the antrum and the cavity in the mastoid. A similar strip is inserted into the meatus, and the size of the wound may then be diminished by a few sutures at its upper and lower extremities. The after-treatment of the abscess has been indicated above. The external dressing must at first be changed daily. The gauze plugs will 358 OPERATIONS ON THE HEAD AND NECK require changing daily or on alternate days according to the amount of suppuration, and the cavity in the bone must be kept clean by gentle syringing with some dilute antiseptic lotion. In a successful case the pressure symptoms, such as coma and paralysis, usually disappear at once, but death may occur some time after the operation. This may be due to infection of the lateral ventricle or to a diffuse infection of the brain, while in other cases no definite cause of death may be found at the post-mortem. An occasional complication is the appearance of a hernia cerebri. This may be cut away, or, as in the following case, be allowed to slough away. A. J., a boy ast. 10 years, was admitted to Guy's Hosjiital in March 1910 with the following history : For three weeks he had suffered from headache which was occasionally very severe. There had also been vomiting and troublesome constipa- tion. For a few days he had been very drowsy. There was a purulent discharge from the right ear, but the cause and the duration of this were not known. On admission the pulse rate was 52 and the temperature subnormal. The right pupil was dilated and fixed, there was ptosis of the right eyelid, some paresis of the left arm and leg, and double optic neuritis. There was no tenderness over the mastoid. A radical mastoid o^jcration was quckly performt'd, when pus and granulations were found in the antrum and the mastoid cells, while the tegmen was carious. On removing bone in an upward diiection tense, non-pulsating dura mater covered by granulations was found in the middle fossa. A large temporo- sphenoidal abscess was opened and drained. On the following day all pressme symptoms had completely disappeared. In the next few days a hernia cerebri the size of a golf ball appeared. The superficial part of this eventually sloughed away, when the rest of the hernia receded. The wound tlien healed, and he was discharged seven weeks after the operation. Fifteen months later he was re-admitted for a polypus in the right ear. This was removed and he made a complete recovery. Operation for an abscess in the cerebellum. The method of trephining for an abscess in this situation has been described above. When the abscess is found in this situation drainage is likely to be unsatisfactory, since the abscess is usually close to the posterior surface of the petrous and hence will only be reached after traversing a considerable distance through normal brain tissue. A cerebellar abscess may thus usually be found and drained in the front of the vertical portion of the lateral sinus in the small area bounded by the superior petrosal sinus, the vertical part of the lateral sinus and the posterior surface of the petrous. In the case of a large abscess a counter incision below the horizontal part of the lateral sinus may also be indicated. Exploration of the posterior fossa is indicated if the symptoms point to the presence of a cerebellar abscess, or if symptoms of an abscess in the brain are present and exploration of the temporo-sphenoidal lobe has been negative. The mastoid cells and antrum having been opened the posterior wall of the bony cavity is examined and in the majority of cases an opening into the posterior fossa will be found so that the dura mater is here exposed. Bone is then removed in a backward direction, at first with the gouge and then with the bone-cutting forceps, due care being taken to avoid injury to the lateral sinus, which must, however, be freely exposed. The dura in this situation is then inspected and pus is sought for by one of the methods described for abscess in the temporo- sphenoidal lobe. The opening of the abscess and the mode of securing drainage will be similar to that described above. Should a counter opening be considered desirable the lateral lobe of the cerebellum may be exposed bv removing bone in a backward and downward direction : should OPERATION FOR SEPTIC THROMBOSIS 359 pus not be I'ouiul in tlu> foinior situation a second exploration may be made here. The after-treatment will be similar to that described for a tem])on)-sp]ienoi(lal abscess. Operation for septic thrombosis of the Lateral Sinus. The great danger in these cases is tliat tlu^ thrombosis may ext<'nd in a downward direction to the jugular bulb and to the internal jugular vein, and also that portions of the septic clot may become detached, with the result that metastatic pyemic abscesses are formed in the lungs. Tiie treatment of these cases nmst thus, in the words of Mr. Ballance, " be twofold — viz. the free exposure and removal of the focus from which the pyajmic infection has occurred or is threatening ; and secondly, the establishment of a block in the highway along which the infecting agents are travelling from the local focus into the general circulation." The operation will thus be considered in two stages : (a) The treatment of the infected sinus ; (b) The treatment of the internal jugular vein along which the mfective process travels. When septic thrombosis can be diagnosed with certainty the latter may be carried out before the former. (a) The exposure and treatment of an injected sinus. After the antrum and mastoid cells have been opened, the posterior fossa is thoroughly exposed in the manner described for the opening of a cerebellar abscess. Sufficient bone must be removed to secure a good view of the sinus. If necessary, the sinus can be laid bare, with the help of gouge forceps from the torcula herophili to the jugular bulb, but this will not be necessary at this stage of the operation. The appearance of the sinus will vary : it may be hard and bulging, or its outer wall may be covered by granula- tions or may be gray or green in colour. Sometimes a perforation will be seen through which pus is oozing. In doubtful cases a sterilised needle may be inserted obliquely through the outer wall, or even an exploratory incision made into the interior of the sinus. It must, however be re- membered that such interference with a normal sinus may result in septic infection occurring, as the puncture is necessarily made through septic tissues. If possible the sinus should be exposed in a backward direction until it appears to be healthy. The sinus is then incised here and the bleeding arrested by packing sterilised ribbon gauze into the cavity. The whole of the exposed and thrombosed portion of the sinus is now slit open by a small thin-bladed knife and the septic clot removed by a small Volkman's spoon, which is also used to scrape the clot from the lower part of the sinus as near the jugular bulb as is possible. If bleeding then occurs from the lower end of the vessel, it also should be plugged with gauze. In some cases the sinus may be found to be thrombosed, but the clot is not infected. This condition may be found unexpectedly in the course of a radical mastoid operation when there is a perisinous abscess. Needless to say, in these cases, the lateral sinus should not be interfered with. The aseptic nature of the thrombus may be inferred from the absence or slightness of the symptoms. (6) Treatment oj the internal jugular vein. This is still, to a consider- able extent, under discussion. In those cases where the clot in the sinus is locahsed and where its lower extent is reached, ligature or other treat- ment of the internal jugular is not indicated. Too often, however, it is found that the thrombus extends downwards to the jugular bulb and vein. Hence the whole of the septic clot cannot be removed from above and some treatment of the internal jugular is then indicated. The vein 360 OPERATIONS ON THE HEAD AND NECK may be exposed low down in the neck and then be divided between two ligatures, or the vein may, after ligature, be freed up to the base of the skull and then excised. If the vein is merely ligatured a considerable amount of infected clot will be left, from which the septic process may easily extend along the tributaries of the internal jugular above the ligature, and so still lead to pyaemia or septicaemia. Removal of the infected portionof the vein, though a more severe operation, is the ideal procedure, for, since it has been shown that the lateral sinus can be opened up as far as the torcula herophili, it permits of removal or opening up of the whole infected venous trunk with the exception of the bulb which is in relation with such important structures that its exposure is practically impossible. It must be understood that in any case infection may spread via the petrosal sinuses or some emissary veins and so render pyaemia possible in spite of all treatment of the internal jugular vein.^ To expose the internal jugular vein an incision three inches in length is made along the anterior border of the sterno-mastoid which is made tense by turning the patient's head well over to the sound side : the centre of the incision is opposite the cricoid cartilage. The platysma and the deep fascia having been divided the sterno-mastoid is well retracted, thus bringing the carotid sheath into view. The position of the carotid artery may be recognised by feeling for its pulsation : the internal jugular vein is external to this and at rather a deeper level. It is exposed by incising the carotid sheath. The vessel may appear empty and collapsed and its wall thickened, or a definite thrombus may be felt. In the latter case it must be followed lower in the neck until the lower limit of the thrombus is reached. An aneurysm needle is then passed and the vessel is divided between two ligatures. It is next traced upwards until the common facial is reached, the latter vessel being also ligatured as far as possible from the jugular, which is again tied above the common facial and the portion between the upper and lower ligatures completely removed. If a more extensive removal is considered desirable and the condition of the patient permits, the vein may be dissected away as high up as possible and then ligatured just below the jugular foramen. Any tributaries that may be met with are, of course, ligatured and divided as far as possible from the jugular. It has been suggested that the septic clot in the bulb may be syringed away by means of a small syringe inserted into the upper end of the divided vein, the fluid escaping through the opened lateral sinus exposed in the retro-auricular wound. If the upper end of the vein is drawn forwards and fixed by a stitch in the upper end of the wound in the neck, this process may be repeated at the first few dressings. The wound in the lateral sinus is then packed with sterihsed ribbon gauze and a second strip of the same material loosely inserted into the bony cavity. If the skin wound is very extensive a few silkworm-gut sutures may be used to reduce its size, but free drainage is essential. The wound ^ Prof. Heine (loc. supra cit., p. 116), says : " Many writers under-estimate the im- portance of the collateral circulation and of the back-flow. Some even state that it is impossible for metastatic deposits to be carried in a direction opposite to the normal course of the blood-stream. It is well known that fever and rigors often persist after ligature of the jugular vein, but these are mostly put down to metastases which were formed before the operation. The autopsy, however, provides a different explanation in many cases. The direct path to the heart is found to be closed, but it is obvious that infective material has entered the circulation from the emissary veins, from the other sinuses, or even from the distal end of the decomposing thrombus, which has been found extending as far as the lateral sinus of the opposite side." OPERATION FOR SUrPURATIVE MENINGITIS ;361 ill the neck may be partly closed, but here also, as infection must neces- sarily have occurred, drainage is essential. Both wounds will require dressing with removal of the gauze plugs at the end of forty-eight hours, by which time there will probably be no further bleeding from the sinus. ^ After gentle syringing with saline solution, or with lot. hydrogen peroxide (3 per cent.), the drains must be replaced. The dressings will then require to be changed daily at first, and later, when the discharge has diminished, every second day. It must always be remembered that thrombosis of the lateral sinus may occur in addition to some other intracranial lesion, especially cere- bellar abscess, or even suppuration in the middle fossa. Any indications of these troubles should, theiefore, always be carefully looked for. Should such be present the thrombosis should be treated first and the abscess subsequently opened and drained with freshly sterilised instruments. Operation for Suppurative Meningitis. If diffuse suppurative meningitis can be diagnosed with certainty, operation will not be successful and hence is not indicated. This condition may, however, be closely simulated by other lesions, especially cerebellar abscess, serous meningitis, and localised suppurative meningitis (subdural abscess). In doubtful cases an ex- ploratory operation will be undertaken and hence suppurative meningitis may be unexpectedly met with. Prof. Heine ^ says : " The operation for suppurative meningitis consists in elimi- nating the focus of disease in the bone and exposing the dura as far as it is affected. If necessary, the membranes may be incised to allow of the escape of fluid, as is done in the serous forms of meningitis. Following Witzel's suggestion, Hinsberg recommends the insertion of large strips of absorbent gauze in the neighbourhood of the focus of suppuration in order to drain the subarachnoid space. As I have already stated, I doubt if effective drainage of this space is possible. Finally, lumbar puncture may be performed for the removal of some of the purulent cerebro-spinal fluid." For further information as to the diagnosis and treatment of these very grave and difficult cases reference may be made to a discussion on the " Treatment of Meningitis of Otitic Origin," opened by Dr. W. Milligan before the Otological Section of the Royal Society of Medicine.3 Dr. Milligan in his opening remarks said : " Some form of decompressive operation is called for, the essential feature of which is to provide by a sufficiently free removal of bone a window large enough to efficiently relieve existing pressure, and at the same time to provide a means of freely draining the infected meninges. . . . Some operators content themselves with the making of such a window and with the relief of pressure thus obtained. No doubt in certain cases of incipient meningitis this is sufficient, but in purulent meningitis it merely delays the fatal issue. To drain the pia-arachnoid cavity the dura may be dealt with in several ways: (1) By excising narrow strips in parallel rows ; (2) by raising as large a flap as the bone womid permits of, and (3) by removing entirely the dura corresponding to the bone womid. To Charles Ballance we owe the suggestion of attacking meningitis by the occipital route. In 1891 he performed the now classical operation of draining the posterior subaraclmoid space after trephining the occipital bone on both sides of the mid-line close to the foramen magnum. In 1893 Alfred Parkin proposed drainage of the cisterna magna, while in the same year Ord and Waterhouse drained the posterior fossa after removal of a portion of the occipital bone and incision of the miderlying membranes. Whether decompression be performed over the temporo-sphenoidal or cerebellar area, great difficulty is encomitered in dealing with the brain substance. The moment the dura has been incised the cortex is thrust into the wound and not only prevents the escape of infected cerebro-spinal fluid, but tends to lacerate its substance against the edges of the bone. To obviate this tendency, Haynes, of ^ Should bleeding occur it may readily be checked by packing a fresh strip of gauze into the opening of the sinus. ^ Loc. supra cit., p. 194. 3 Proc. Roy. Soc. Med., Oiol. Sec, February 1913, p. 41- 362 OPERATIONS ON THE HEAD AND NECK New York, has suggested drainage of the cisterna magna through the cerebello- medullary angk' as there is here no brain tissue in the immediate neighbourhood, and also because infected fluid is prone to collect here. An incision is made in the mid-line from the occiijital protruberance to the spine of the axis, the soft parts retracted, and a disc of bone removed by a trephine about one inch above the margin of the foramen magnum. The dura is then separated from the bone and two grooves made through the bone into the foramen magnum. When this triangular piece of bone has been removed, the dura presents mider pressure. A small incision is then made through the diira and the arachnoid with the im- mediate escape of cerebro-spinal fluid. The incision is enlarged and an inspection made of the posterior poles of the cerebellum, the notch between them and the posterior surface of the medulla. A drain is then inserted into the cisterna magna and suitable di-essings applied." This operation has been performed a number of times, but does not appear to have been attended with nmch success. Dr. Milligan and other speakers point out the necessity of early diagnosis if operation is to have any chance of success, and give many valuable hints with regard to this point. CHAPTER XVII OPERATIONS ON THE FACE. OPERATIONS ON THE FIFTH NERVE. OPERATIVE TREATMENT OF LUPUS, RODENT ULCER AND NiEVI. REMOVAL OF PAROTID GROV^^THS OPERATIONS ON THE FIFTH NERVE Preliminary remarks. As the surgeon will not be called in until all other treatment has failed, and as the patient will be desirous of relief as radical as may be, neurectomy alone will be described here. Opera- tions with this end fall into Peripheral and Central groups. Of the former or extracranial operations, some, the truly peripheral, are slight ; others performed near the base of the skull, are severe, not without risk, and leave considerable scars, which may greatly interfere with the use of the mandible. The central intracranial, or removal of the Gas- serian ganglion, is a severe and difficult operation, wdth many risks and a mortality that is not a small one, but it is the only one which can be relied upon to give, with very few exceptions, a complete cure. It is greatly to be desired that both the peripheral and central operations be performed at an earher date than has hitherto been done. In the case of the former the earlier the operation the greater the probabihty that the neuralgia is limited to one trunk, and the longer will be the interval of relief. In the case of the intracranial operations, the still high mortality is largely due to the depressed vitality of the patients from the long con- tinued inability to take food, the exhausting effects of the pain, the inability to sleep, and, perhaps, the morphia habit. We will suppose that all local causes connected with the teeth, nose, eye, ear, and cranial sinuses have been excluded, together with those such as growths or foreign bodies in the course of the nerves, and that medical treatment ^ has been fully tried where syphilis, alcohol, influenza, rheumatism, anaemia, &c., are possible causes.- The first question which will now arise is the value of peripheral operations, to what extent are they justifiable in severe trigeminal neuralgia ? To begin with, the answer must be that all mere neurotomies and nerve stretchings are absolutely futile. Radical lasting cures by peripheral neurectomies are practically unknown.^ All that can be promised is that, if performed with as thorough extraction as possible ^ Injection of alcohol, a most successful form of treatment, should also be tried. For information on this method of treatment see two papers by Dr. Wilfred Harris (Brit. Med. Journ.. 1910. vol. i, p. 1404 : and vol. ii, p. 1051). ' The pathology of tic douloureux is fully discussed by jMt. J. Hutchinson, jun. {The Surgical Treatment of Facial Neuralgia, p. 26), and Murphy and Neff (Journ. Amer. Med. Assoc, October 11 and 18, 1902;. ' Prof. Billroth, who had performed peripheral operations thirty times, stated that he never met with permanent cure. 363 364 OPERATIONS ON THE HEAD AND NECK of the peripheral branches^ they will give relief for varying periods. Hitherto the majority of authorities have held that peripheral opera- tions should be performed first, intracranial neurectomy being taken as the last step. Thus Prof. Keen considers that this is the right step to take, and on these grounds : (1) the balance of evidence points to the ganglion itself being the last of all to suffer, the disease being in many cases at least primarily peripheral, and the ganglion involved by extension upwards. This view of an ascending neuritis has the support of Sir V. Horsley, who holds that the inflammation often begins in the small dental nerves and spreads upwards to the ganglion. ^ (2) While the mortality of peri- pheral operations, which usually relieve for some time, is very slight, that following on operations on the ganglion is high (p. 379). Mr. J. Hutchinson, jun., whose successful experience enables him to speak as an authority, tabulates the following rules for the use of peri- pheral operations in epileptiform neuralgia. ^ With regard to the first division of the fifth, a case may now and then arise in which resection of the nerve is justified. " If the neuralgia be limited to the infra-orbital branches, resection of the nerve by following back the canal in the orbital floor may be tried. If the neuralgia concern also the palatine branches, intracranial resection of the superior maxillary trunk should be carried out. If the inferior dental nerve be alone affected, it should be resected through a trephine aperture in the outer table of the lower jaw. When the neuralgia concerns several branches of the inferior maxillary division (e.g. the inferior dental and the auriculo-temporal), intracranial resection of the trunk and adjacent part of the Gasserian ganglion is indicated. " For all other cases, those in which the neuralgia has already in- vaded two of the main divisions of the fifth nerve, the major operation on the ganglion should be carried out as affording the only hope of per- manent cure. " If these rules be followed the subject is rendered simple, a host of elaborate operations may be discarded, and the disappointing results which have followed them in the past may be avoided." Neurectomy of the First Division of the Fifth Nerve. The eyebrow having been shaved, and the parts sterilised, the incision should be horizontal and lie below the margin of the eyebrow, thus leaving little ^ Prof. Krause (Von Bergmann's " Syst. Prac. Surg.," Amcr. Trans., vol. i, p. 565) insists that in order to prevent regeneration of the excited nerve it should be extracted as extensively as possible, both centrally and peripherally, by Thiersch's method. This consists in dissecting the nerve freely from its surroundings, grasping it transversely in forceps which will not cut it through, then rotating these very slowly until the nerve trunk comes away. Where the nerve runs in soft parts or is not adherent in a bony canal a very long piece of the central portion can be removed. Occasionally paralysis, especially of the muscles of the upper lip and ala nasi, follow the operation owing to the endings of the anastomosing filaments of the facial nerve being also removed. These paralyses generally disappear in a short time. In all peripheral nerve operations the neuralgic pains do not always disappear immediately. They frequently come on as before during the first days after the operation, but they soon diminish and fuially disappear. The attention of the patient should be drawn to this fact before the operation. On the value of this step the experience of Mr. J. Hutchinson, jun., The Surgical Treatment of Trigeminal Neu- ralgia, p. 43, is contradictory. " Unfortunately the results obtained by avulsion with Thiersch's forceps are little if at all superior to a well-planned neurectomy." ^ Mr. J. Hutchinson, jun., from the negative results found in many cases of the excised Gasserian ganghon and peripheral nerves after removal dissents from this view. He considers that " the pathology of epileptiform neuralgia is still unknown." ' Loc supra cit., p. 74. OPERATIONS ON THE FIFTH NERVE 365 scar. The supra-orbital notch ^ being made out by firm pressure when the patient is under an anaesthetic, the eyebrow is drawn up and the eyelid down, and an incision an inch and a half long is made along the supra-orbital margin, with its centre opposite to the notch. The skin, occipito-frontalis, orbicularis, and palpebral ligament being divided, the cellular tissue is separated, the nerve found in the notch set free — if a complete foramen be present, part of the ring of bone must be removed with a small chisel — traced back as far as possible so as to include the supra-trochlear, if that be feasible, drawn up with a stra- bismus hook, and a full inch removed. Thiersch's method, if employed here, might involve some risk to the cornea. A small spatula will best depress the orbital fat. It is difficult to avoid injury to the closely contiguous supra-orbital vessels, which may cause a little trouble. As with the other branches of the fifth, the supra-orbital often appears smaller than it does in the dissecting room, and the arrangement of its branches is not constant. The wound should be closed by a few horsehair sutures. Supra-trochlear Nerve. In an inveterate case of neiu-algia of the first division of the fifth nerve, if the surgeon does not feel sure that he has in the preceding operation got behind the point of origin of the supra-trochlear. this nerve must be cut down upon. Sir W. MacCormac - gives the following advice : " The position of the supra-trochlear nerve is indicated by an imaginary line drawn from the outer angle of the mouth through the inner canthus of the eye to the orbital margin ; at this point the nerve will be found as a single branch, or as two or three slender filaments, escaping from the orbit above the pulley of the superior oblique. ... To reach the nerve, make a convex incision at the superior internal angle of the orbit, immediately below the eyebrow, and search for the pulley of the superior oblique, above which the nerve runs." Neurectomy of the Second Division of the Fifth Nerve. While this nerve, being most frequently the seat of neuralgia, has been most ofteii subjected to peripheral neurectomy, there is no agreement as to the best route. The following have been proposed. Each has its advocates, and each its disadvantages. A. Infra-orbital Route. An attempt is here made to follow the nerve along the infra-orbital groove as far back as the sphenomaxillary fossa. The disadvantages are great. The field of operation is very cramped, the oozing troublesome, and the operator is liable to divide the soft and comparatively slender nerve prematurely and to remove part only with the anterior dental branch, and haemorrhage into the orbit and exom- phalos have followed this operation. ^ The supra-orbital notch or foramen occupies about the junction of the inner with the middle third of the supra-orbital margin. From this point a perpendicular line, drawn with a slight inclination outwards, so as to cross the interval between the two bicuspid teeth in both jaws, passes over the infra-orbital and the mental foramina. The clirection of these two lower foramina look towards the angle of the nose. (Fig. 15 6-) ^ Operations, part 2, p. 467. Fig. 156. A, Position of the supra-orbital foramen. A line drawn downward from this, passing through the interval between the two bicuspid teeth, passes through B, the infra-orbital foramen, and C, the mental foramen. D, Incision for exposing the supra-orbital nerve. E, Incision for Carnochan's operation. 366 OPERATIONS ON THE HEAD AND NECK B. Antral Route. Either the modified Carnochan's operation or that which bears Prof. Kocher's name. The first is described below, and the second at p. 368. C. PterygomaxiUary Route. Krause's operation. The nerve is here reached in the sphenomaxillary fossa, not from the front, but at the side by turning down the zygoma and masseter. Prof. Krause, finding that the flap made by previous surgeons, Luke, Loosen, and Braun, injured the branches to the orbicularis and thus led to damage to the cornea, modified the operation so as to protect the branches of the facial running over the malar bone. The advantages of this route are that it enables the surgeon to get at the nerve before this has given off its posterior dental and palatine branches, and to resect the third di^asion as well, if this be affected. The disadvantages are that, even if the wound heals by primary union, the troubles of the patient and surgeon are not over ; they are best shown by Prof. Krause's own words : ^ " As soon as cicatricial contraction sets in, the mobility of the lower jaw is impeded in many cases. This may reach a very high degree, and will require careful treatment with Heister's mouth-gag." As the second di\'ision of the fifth nerve is often affected alone, and as it is to be hoped that in future patients will apply for surgical treatment earlier, before the palatine and posterior dental nerves are involved, two operations are described here, \az. the modified Carnochan's antral operation and that of Prof. Kocher. Where the patient comes late and the second division is involved far back, or where the third division is involved as well, the surgeon must decide between adopting the pterygomaxillary route, and resecting the two divisions by an intracranial operation, as strongly advised by Mr. J. Hutchinson, jun., on the grounds that this step is no more difficult, while it is certainly more radical. Blodified Carnochan's Operation. This has the advantage, if success- fully performed, of removing the whole of the second division of the fifth, together with the spheno-palatine ganglion as far back as the foramen rotmidum, the nerve forming the guide to the surgeon from the surface backwards. Carnochan 2 looked upon the removal of Meckel's ganglion as the key of the operation. Whilst his view was that this body could be likened to a galvanic battery, keeping up a continuous supply of " morbid nervous sensibility," there is no doubt that removal of the nerve beyond the ganghon is absolutely necessary, as by this step the spheno-palatine branches to the gums and the posterior dental branch are also removed. ^ Carnochan's antral operation is, for the reasons already given when the infra-orbital route was spoken of, an extremely difficult one. Owing to these difficulties it is very often rendered incomplete, and the neuralgia tends to return after an interval varying from a few months to a year or two. Mr. J. Hutchinson, jun., who speaks with authority, considers that this operation should be abandoned.^ He holds that if any extra- 1 Von Bergmann'.s " Syst. Pract. Surg.," Amer. Trans., vol. i, p. 583. 2 Amer. Journ. Med. Sci., 1858, p. 136. 3 Chavasse, Med.-Chir. Trans., vol. Ixvi. p. 151 ; and Clutton, St. Thomas's Hospital Reports, vol. xv, p. 213. In both of Mr Chavasse's cases the commencement of the pain was invariably re- ferred to the periphery of the posterior dental branches, and it appeared very doubtful if stretching would have any effect on slender branches at some distance from the extension point. Both of th?se cases remained practically well two years and a year and a half respectivel}' after the operation. Recurrence, " slight and relieved by quinint," ensued in both of Mr. Clu:ton's cases within the year. * Loc, supra cit., pp. 58 and 66. OPEHATIONS ON THE FIFTH NERVE tm cranial operation on the superior maxillary nerve be performed, the best one is that of Storrs, described by Dr. Cooke. ^ It is stated that Dr. Storrs operated on some ten or twelve patients, and that of these at least two remained free from neuralgia for over ten years, an unusually favour- able result for any form of peripheral operation. As the antrum will be opened, the mouth and accessory cavities must possess at least the normal germicidal power of health. The parts having been shaved and cleansed, and an anesthetic given, a horizontal incision is made reaching from canthus to canthus just below the orbit, and a vertical one nmning downwards added if needful (Fig. 156). The flaps thus marked out being reflected, and all haemorrhage stopped, the infra-orbital nerve is defined, its terminal branches dissected out as long as possible, and a piece of silk tied round it to make it serve as a guide. The periosteum is next incised horizontally down to the bone, and elevated with a blunt instrument from the floor of the orbit until the sphenomaxillary fissure is well exposed. The eyeball must be raised with a retractor under the periosteum. A bluish spot usually denotes the site of the nerve, thinly covered by bone, or the canal is found by a fuie probe passed in through the foramen. With a fine chisel the anterior wall of the antrum, including the foramen, is cut away for a space of half an inch square, and with the same instrument, aided by small and medium-sized bradawls, the roof of the antrum and its posterior wall — the latter for the same area as its anterior wall — are removed, so as to expose the sphenomaxillary fossa. Free and most troublesome haemorrhage must be expected, partly from the vascular bone,^ partly from the mucous membrane of the antrum and in the fossa itself, where the bleeding is always copious from the terminal branches of the internal maxillary. Pressm'e with small gauze pledgets, wrung out of very hot sterile saline or adrenalin solution in holders, must be relied upon. A good light is essential, and an electric lamp on the surgeon's forehead will be his best aid. The rest of the operation will be given from the article above quoted from the Annals of Surgery : " By making slight traction on the Hgature on the nerve, we can bring it into view, and by following it on can readily crush down the thin wall of the canal, removing the bone fragments with suitable forceps. When the nerve enters the sphenomaxillary fissure it passes out of the bony canal and is only surrounded by soft structures, which can easily be hooked or wiped away. Should the sphenomaxillary fissure be narrow and not readily admit the introduction of instruments, it can easily be widened by inserting a suitable blunt instrument, and by wedging or widening the walls. It is to be remembered that the upper wall of this fissure is the strong wing of the sphenoid, and that the lower angle is the thin wall of the antrum. If either bone should break, it would be the wall of the antrum, which would be crushed down and out of the way, and would cause no trouble. Having the nerve thus free to the foramen rotmidum, next slip the ends of the silk through a loop of wire held with a small nasal snare. The loop of wire is passed down the nerve to the foramen rotundum. It is then closed, and the nerve is cut and removed." To return now to the distal end of the nerve. 1 Ann. of Surg., 1903, p. 854. ^ The superficial haemorrhage will be all the freer iii proportion as the part has been recently submitted to blistering, liniments, &c. 368 OPERATIONS ON THE HEAD AND NECK The plexus of nerves going to the cheek, nose and Up is gathered up with a hook, and the distal end drawn out of the foramen. Storrs then put the nerve into the loop of a threaded needle and carried it down into the mouth, leaving the end which had been in the infra-orbital canal between the alveolus and upper lip ; this end he cut off, even with the mucous membrane. This was to prevent any restoration between the distal end of the nerve and the stump left at the formamen rotimdum. Arrest of bleeding, drainage, and, if needful, packing the wound and suturing, complete the operation. Prof. Kocher's Antral Operation. This surgeon, by dividing the malar bone in front and behind, and turning it upwards and outwards, gains much freer access to the foramen rotundum.^ The skin incision is Tjlanned so as to avoid division of the branches of the facial nerve. It begins just internal to the infra-orbital foramen and below the inner edge of the orbital margin, and is carried outwards and shghtly downwards over the lower part of the malar bone to the zygoma. The angular arterv is drawn aside or tied at the inner end of the incision ; Steno's duct lies below it. At its inner end the incision passes do'vsni to the bone between the lowest fibres of the orbicularis and above the origin of the levator labii. The former muscle, along with the periosteum, is dis- sected up as far as the orbit ; the latter is separated downwards sub-periosteally, so that the nerve may be exposed at the foramen and secured. The outer part of the incision passes above the origin of the zygo- matici, which are separated downwards, and the anterior fibres of the ma-^scter are detached from the lower and inner aspect of the malar bone. The outer and inner surfaces of the malar bone are next laid bare with a periosteal elevator, and the three sutures — malo-maxillary, fronto -malar, and zygomatico-malar — are exposed previous to their being chiselled through. The malar process of the upper jaw must be exposed on its anterior surface up to the infra-orbital foramen, and upon its upper surface as far back as the sphenomaxillary fissure. Anteriorly, the pro- cess is chiselled through from above the infra-orbital nerve downwards and outwards to just below the anterior fibres of the masseter, and superiorly along the orbital plate. In this way the outer part of the orbital plate and the superior external wall of the antrum, together with its posterior angle, remains in connection with the malar bone, and are levered out with it. Before this can be done the fronto-malar suture, exposed by upward retraction of the upper edge of the wound, is so chiselled through towards the back of the sphenomaxillary fissure, that its upper border, together with part of the zygomatic crest and of the orbital plate of the sphenoid, is removed along with it. The malar bone is dislocated upwards and outwards with a strong hook, and the orbital fat carefully raised vnth a blunt retractor. The nerve, which is kept drawn upon, can now be readily followed above the opened-up antral cavity as far as the foramen rotundum. A small hook is now passed behind the descending sphenopalatine nerves around the main trunk, which is either cut across, or, better, removed by Thiersch's method. The infra-orbital artery is avoided or tied. The operation is completed by replacing the malar bone (fixation sutures being unneces- sary) and closing the woimd with sutures. No bad results have followed the free opening of the antrum. The resulting scar is not disfiguring. 1 Kocher's Operative Surgery, translated by Stiles and Paul, p. 221. OPERATIONS ON THE FIFTH NERVE 369 Operations on the Third Division of the Fifth Nerve. Immediately below the foramen ovale this division of the iifth nerve consists of a large sensory portion and a smaller motor portion which supplies the muscles of mastication. These two parts are intimately bound together so that division of the trunk in this situation will be followed by paralysis of these nuiscles. Neurectomy of the individual branches is thus to be preferred to division of the main trunk. Neurectomy, first of the in- ferior dental, a nerve so commonly the seat of neuralgia, and then of the lingual gustatory, which is much less frequently afiected, will be described here. Inferior Dental : Neurectomy. This nerve may be attacked in three •places ; at the mental foramen, in the dental canal, and above the dental canal. Experience has shown that the relief after the first two methods is so transitory that the higher operation should always be resorted to. Neurectomy here usually gives relief for one, two, or more years. The face having been shaved and cleansed, the external auditory meatus cleansed and plugged with aseptic gauze, the patient is angesthetised. The surgeon then identifies the point of bone to be aimed at on the ascend- ing ramus by taking the point of meeting of the two following lines — one perpendicular to the lower border of the jaw passing upwards from its angle, and the other a continuation backwards of the alveolar margin (Hutchinson). This point on the cheek is well below the parotid duct and behind the facial vein. The skin incision here should be about an inch and a half long, mainly horizontal, to avoid the facial nerve, but curved slightly upwards. Kocher's incision is a curved one, with the angle of the jaw for its centre. The subjacent periosteum and masseter are separated from the bone, and the pin of a three-quarter inch trephine is then applied exactly over the spot above mentioned, and when the outer table has been cut through the crown is removed by an elevator.^ The inferior dental nerve and vessels will almost certainly be exposed in their groove. This is carefully enlarged by a small gouge or chisel, until the nerve, now freely exposed, can be raised on a blunt hook. It is then treated by Thiersch's method (neurexeresis), or as long a piece as possible resected. Care must be taken to avoid injury to the vessels which he just behind the nerve. Another method ^ is to expose the bone more freely by a larger flap, and to turn this upwards. The sigmoid notch and adjacent parts of the condyle and coronoid process are next laid bare. Care must be taken not to injure any of the branches of the facial nerve or lobules of the parotid gland during these steps. When the bone is reached, smart oozing must be expected from the mesenteric artery, and arrested by firmly apphed sponge pressure. The next step consists in enlarging the sigmoid notch as far as the upper orifice of the dental canal. This is done by applying a three-quarter inch trephine exactly on the spot mentioned above, the narrow bridge of bone between it and the sigmoid notch being subsequently clipped away wHth gouge forceps. Great care must be taken, owing to the varying thickness of the bone, in the use of the trephine ; otherwise the inferior dental artery will be wounded or the bone fractured. DeVilbiss's forceps are likely to be useful for this purpose. The bone having been removed ^ If preferred the bone may be removed by means of a gouge or chisel. 2 Sir V. Horsley, Brit. Med. Journ., 1891, vol. ii, p. 119; Sir W. Rose, ibid., 1892, vol. i, p. 160. SURGERY I 24 370 OPERATIONS ON THE HEAD AND NECK suflSciently, the inferior dental artery, and the internal maxillary, if this be in the way, should be secured between two ligatures. The inferior dental nerve is next identified and secured by a silk ligature. The external pterygoid having been levered upwards, or divided if needful, the nerve is traced close up to the foramen ovale, and divided as high up and as low down as possible, or dealt with by the method of Thiersch. If need- ful the lingual nerve, which lies somewhat anteriorly and on a deeper plane, is then treated in a similar way. Any venous bleeding which cannot be dealt ^\■ith by ligature should be controlled by firm pressure with small aseptic swabs. There is no need to replace any bone. The Avound, carefully kept aseptic throughout, is now thoroughly dried, a small drainage tube inserted if there be still much oozing, or if the parts have been much disturbed, and the incision accurately sutured. If primary union occurs there is no interference with the movements of the mandible. Lingual Nerve. Neurectomy within the mouth. In a few cases of epithelioma of the mouth, not admitting of removal, this operation may be performed in the hope of relieving the pain, and diminishing the rapidity of the growth, the profuseness of the dribbhng sahva, &c. In another small group of cases, neuralgia of the tongue, resisting other treatment, this operation may be resorted to with complete success. The best method is that of Roser, of Marburg, who introduced it in 1855. The mouth having been AAadely opened in a good light, and the tongue drawn over to the opposite side, an incision is made in the fold of mucous membrane between the side of the tongue and the gum, the centre of the incision being opposite to the last molar tooth. The over- lying mucous membrane is here so thin that the nerve can usually be seen below it. The nerve having been exposed where it lies, beneath mucous membrane only, just before it dips beneath the mylohyoid, is raised with an aneurysm needle, and a full inch removed. The only after-treatment is the frequent use of a mouth wash. Mr. Jacobson performed this operation on two occasions. In one the patient remained absolutely free from her neuralgia for twelve months, after which there was some recurrence owing to her entire neglect to avail herself of the fresh air and rest which were so necessary in the after-treatment. The second patient remained free from the neuralgia for the six months she was kept under observation. Neurectomy of the Second and Third Divisions of the Fifth Nerve in Front of the Ganglion inside the Skull. Peripheral operations on the second division of the fifth nerve in cases where the palatine and posterior dental branches are not yet involved, and one on the inferior dental and the lingual gustatory in cases where these branches are alone affected, and the mischief has not spread to other branches, e.g. the auriculo-temporal, have now been given. It remains to consider the operative treatment of cases in which the second or third division of the fifth is more deeply affected, cases in which peripheral operations have failed, and lastly those in which the neuralgia has already invaded two of the main di\"isions of the fifth nerve. Reference to p. 364 will show that Mr. J. Hutchinson, jun., is emphatic in his opinion that in these cases the operation should be intracranial, as this method alone gives radical relief. We have seen, however, that the extracranial routes which attack the nerves at their exit from the skull may be followed by serious fixity of the jaw (p. 366). The following is an instance in which Mr. Hutchinson put his opinion OPERATIONS OX THE (iASSERIAN GANGLION 371 to the test by resecting the second division of the fifth intracranially.' The case was one of typical epiIej)tifonn neural