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OPERATIVE SURGERY
B 1 N N 1 E

Regional Surgery

A Treatise on Modern Surgical Practice
Prepared by 41 Well Known Authori-
ties in Special Fields.

EDITED BY

JOHN FAIRBAIRN BINNIE, A.M., CM.

Illustrated by about 1100 Text Figures

and Colored Plates. 3 Volumes.

Cloth, $27.00.

Suffice it to say that the monographs are well
written, interesting and full of suggestions. As the
volumes stand they give to the reader the present
status of each subject satisfactorily.

The authors enter at once on the subject in hand,
without wasting time and space with the usual com-
monplace introductory remarks.

Dr. Binnie's thoroughness and mastery of detail
is evidenced in his own articles as well as in those
of the men selected to contribute their views.

MANUAL OF

OPERATIVE SURGERY

JOHN FAIRBAIRN BINNIE, A.M., CM. (Aberdeen): F.A.C.S.

SURGEON TO THE CHRISTIAN CHURCH, THE RESEARCH AND THE GENERAL HOSPITALS,

KANSAS CITY, MO.; FELLOW OF THE AMERICAN SLTIGICAL ASSOCIATION;

MEMBRE DE SOCIETE INTERNATIONALE DE CHIRURGIE, MEMBER

OF THE WrESTERN SURGICAL ASSOCIATION

EIGHTH EDITION, REVISED AND ENLARGED

WITH 1628 ILLUSTRATIONS
A NUMBER OF WHICH ARE PRINTED IN COLORS

PHILADELPHIA

P. BLAKISTON'S SON & CO.

TBE MAPX.K FKR8S VORK PA

o PREFACE TO EIGHTH EDITION

^ Since the previous edition of this work was published, death has claimed

^ Gwilym G. Davis and Walter S. Sutton who contributed valuable chapters on
^ "Congenital Luxation of the Hip" and on "War Surgery." Dr. Frank. D.
Dickson (lately Lt. Col. and consultant in Orthopedics to the 3d Army, A. E. F.)
has kindly revised the chapter of his teacher and friend, Davis. Dr. E. H.
Skinner (lately Lt. Col. and associate consultant in Roentgenology, A. E. F.)
has revised such portions of Sutton's article as had to do with the localization
of foreign bodies by roentgenological methods. Most of the article on War
Surgery has been omitted.

Probably the greatest changes in this new edition will be found in the
chapters on Thoracic, Abdominal and Plastic Surgery, which have been prac-
tically completely rewritten. The author regrets that Sir Robert Jones' great
book on "The Orthopaedic Surgery of Injuries" appeared so late that this mine
of rare worth could not be utilized.

Mr. Blakiston has economized space by some changes in the arrangement
of the chapters, otherwise the present volume would have contained more
pages than the previous edition, instead of fewer as is the case. The author
desires to express hearty thanks to his friends Doctors J. G. Hayden, F. R.
Teachenor and H. S. Valentine for aid ungrudgingly given in the tedious task
of proof reading. All these gentlemen as well as Dr. Skinner were associated
with the author in Base Hospital 28 and he owes much to them.

J. F. BiNNIE.
Kansas City, Mo.

PREFACE TO SEVENTH EDITION

In this as in all previous editions great care has been taken to avoid the
perspective of a text-book where emphasis must be placed on the common rather
than on the unusual operations of surgery. The constant endeavor has been
to give aid to the surgeon when he is in trouble, hence much greater space has
been devoted to some rather rare operations than to many of far greater every-
day importance but which ought to be familiar to every one. Thus a chapter
has been included on Cardiac Surgery even although, up to the present, such
work has been mostly confined to the physiological laboratory. Several chap-
ters have been rewritten, many obsolete illustrations discarded, new figures
inserted and a short chapter on Retroperitoneal Neoplasms added. In spite of
much new material careful pruning has prevented any great increase in the
size of the volume. At the present time of strife it has been thought wise to
append a short chapter on War Surgery. This has been made possible through
the kindness of Dr. Walter S. Sutton. It is hoped that the earnest effort to
keep the work up to date may have been successful.

Kansas City, Missouri.

Vll

PREFACE TO SIXTH EDITION

The original plan of this "Manual of Operative Surgery" was to devote
attention to the advanced operative surgery of the day and to avoid discus-
sion of those topics which were sufficiently described in the text-books on
"The Art of Surgery."

Various reasons have compelled the inclusion of subjects such as were
originally excluded, but great care has been taken to avoid using the perspec-
tive of a text-book where emphasis must be placed on the common rather
than on the unusual.

In this work, the constant endeavor is to give aid and guidance to the sur-
geon when he is in trouble, hence far more space is devoted to such rare and
difficult operations as hypophysectomy, than to many operations of much
greater every-day importance, but which ought to be familiar to every graduate.

In the present edition, the chapters devoted to operations on the stomach
have been largely rewritten, special attention being paid to the anatomy of
the gastro-intestinal lymphatics.

Many other chapters have been rewritten and a new chapter has been de-
voted to the treatment of tumors in general.

It is hoped that the earnest effort to bring the work up to date may have
been successful.

J. F. BiNNIE.

PREFACE TO FIFTH EDITION

K. M. Blakiston, Esq.,

Philadelphia,
Dear Sir:

You suggested to me that our Manual of Operative Surgery should be issued
in one volume instead of in two. I thoroughly agreed with you in your sugges-
tion and am glad to say that several friends, whose judgment I trust, concurred
in the wisdom of so doing. The original work was issued in one rather small
volume in which, for various reasons, no account was given of operations on the
bones and joints, etc. Later it was determined to include these subjects. It
would have been manifestly unfair to have compelled those who possessed the
original volume and who desired the complete work to repurchase what they
already possessed — hence, the new material was published in a separate volume.
This debt to the above class of purchasers having been fulfilled, I think we are
fully justified in returning to the original idea of one volume which is more
practical so long as the book is not too large and clumsy.

The present issue represents the fifth edition of Vol. I. and the second of
Vol. II. I have endeavored to bring the contents up to date and hope that the
book in its new dress man find favor with the medical public.

As on previous occasions I have to thank Dr. John G. Hayden and Mrs. C.
M. Bossier for most valuable assistance. Personally, I desire to thank you
for the great interest taken in the manual both by yourself and by your very
efficient stafi".

Yours sincerely,

J. F. BiNXIE.

DEDICATORY LETTER

Twelfth and Wyandotte Sts.,
Kansas City, Mo.
Dr. Robert F. Weir, New York:

Dear Dr. Weir: — Some considerable time ago you encouraged me in a
design to write a little book on operative surgery, in which there should be
omitted, as far as possible, all description of those procedures which are ordi-
narily thoroughly given in the usual text-books on general surgery. You were
good enough to look over and express approval of the scheme and of certain
sections of manuscript submitted to you. This volume is the outcome of your
encouragement, and it gives me intense pleasure to have your permission to
dedicate it to you.

Following out the ideas already expressed, I have omitted all reference to
such subjects as amputations and ligations. Such portions of genito-urinary
and of rectal surgery as are fully treated in the common text-books have been
passed over in silence. It was my intention to devote considerable space to the
operative surgery of the bones and joints, but having prepared several chapters
on these subjects, I found that any adequate treatment of them would require
a second volume. The exigencies of space forbidding a satisfactory review
of the operations on the bones and joints of the extremities, I prefer to omit such
entirely. My aim throughout has been to be practical: to describe operative
procedures as they are done on the living subject, instead of on the normal
cadaver.

For the bibliography of operative surgery, the reader is referred to the
Catalogue of the Surgeon General's Library in Washington.

In the preparation of this volume I have had the benefit of much advice and
criticism from our mutual friends, Drs. W. J. and C. H. Mayo of Rochester,
Minn. Drs. Block and Mark of this city have kindly revised the chapters on
genito-urinary surgery. Drs. E. F. Robinson and R. M. Schaufl9er gave me
much assistance in proof-reading, while my student assistant, Mr. Florian,
helped me in many ways. To all these gentlemen and to those who generously
placed plates and drawings at my disposal, I beg to return heartfelt thanks.

Hoping that this work of mine may never cause you to regret the encourage-
ment given by you,

I remain.

Your friend,

J. F. Binnie.

LIST OF CONTENTS

PART I

Head and Neck
Chapter Page

I. Scalp i

II. The Skull and the Brain 6

III. Frontal Sinus 57

IV. Tic Douloureux 59

V. Plastic Operations on the External Ear 76

VI. Empyema of the Antrum of Highmore 82

VII. Osteoplastic Exposure of the Orbit 84

VIII. Excision of Upper Jaw 85

IX. Lower Jaw, Resection 92

X. Odontomata loS

XI. Excision of the Cheek 109

XII. Lower Lip 115

Xin. Upper Lip 129

XIV. Hare-lip i34

XV. Cleft Palate 144

XVI. Tongue 158

XVII. Parotid Gland 173

XVIII. Oper.ations upon the Nose 181

XIX. Torticollis, Wry-neck, Caput Obstipum 204

XX. Excision of Cervical Ribs 208

XXI. Excision of Cervical Tumors 209

XXII. Excision of the Cervical Sympathetic 217

XXIII. Retropharyngeal Abscess and Tumors 222

XXIV. (Esophagus 224

XXV. Pharyngotomy, Laryngotomy, Partial Laryngectomy, and Laryn-
gectomy 230

XXVI. Tracheotomy 239

XXVII. Foreign Bodies IN Trachea OR Bronchus 243

XXVIII. Goitre; Bronchocele; Strxtma 247

XXIX. Thymus Gland 268

PART II

The Thorax

XXX. Operations on the Breast 271

XXXI. Operations on the Chest 286

PART III
The Abdomen

XXXII. Laparotomy; Celiotomy; Abdominal Section 343

XXXIII. The Stomach 355

XVI

CONTENTS

Chapter Page

XXXIV. Operations on the Intestines 409

XXX\'. The Vermiform Appendix and Peritoneum 464

XXXVI. The Rectum 482

XXXVII. Haemorrhoids and FisTULiC 519

XXXVIII. Ascites 528

XXXIX. Retro-peritoneal Neoplasms 534

XL. The Pancreas 536

XLI. The Spleen 547

XLII. The Suprarenal Bodies 552

XLIII. Operations upon the Liver SS3

XLIV. Operations on the Biliary Passages 562

XLV. Hernia 590

XL VI. Retro-peritoneal, Large and Diaphragmatic Hernia 622

PART IV

The Genito-Urinary System

XLVII. Oper.\tions upon the Kidney 629

XL VIII. Operations on the Ureter 661

XLIX. Operations on the Bladder 673

L. Perineal Section 704

LI. Urethral Stricture 715

LII. Epispadias 723

LIII. Hypospadias 727

LIV. Amputation of Penis 733

LV. Circumcision 737

LVI. Operations on the Testicles 739

LVII. Hydrocele 752

LVIII. Varicocele 753

PART V
The Spine

LIX. Operations on the Spine 755

PART VI

LX. Nerves 781

LXI. Arteriorrhaphy 812

LXII. Aneurysm 823

LXIII. Ligation of Arteries in CoNTiNmiY 834

LXIV. Operations on Veins 856

LXV. Operative Treatment of Simple Fractures, Exclusive of Those

Involving Articulations and of some Special Fractures .... 877

LXVI. Compound or Open Fractures 888

LXVII. Ununited Fractures; Pseudarthrosis 893

LXVIII. Fractures; Malunion 9iS

LXIX. Special Fractures 920

LXX. Osteomyelitis 94^

LXXI. Tumors of Bone 958

LXXII. Chondrectomy 962

LXXIII. Osteotomy 962

CONTENTS

xvn

Chapter Pace

LXXIV. Bow-leg; Genu Varum 972

LXXV. Operations on the Pelvic Bones 974

LXXVI. Sacro-iliac Disease 977

LXXVII. Hip 979

LXXVIII. Hip; Arthritis Deformans 989

LXXIX. Anchylosis Hip 990

LXXX Old Dislocations of the Hip 1005

LXXXI. Congenital Luxation of the Hip 1009

LXXXn. Knee-joint 1024

LXXXin. Patella; Tuberculosis 1046

LXXXIV. Osteotomy for Bony Anchylosis of the Knee 1049

LXXXV. Dislocation of the Patella 1057

LXXXVI. Ankle 1061

LXXXVII. Dislocation of the Astragalus 1067

LXXXVin. SUBASTRAGALOin DISLOCATION 1068

LXXXIX. Os Calcis 1069

XC. Bunion; Hammer Toe Metatarsalgia 1070

XCI. Operations on the Scaptjla and Cla\icle 1075

XCII. Shoulder 1084

XCni. Claviculo-humeral Nearthrosis 1104

XCIV. Operation for Subacromial Bursitis and for Rupture op the

SUPRA-SPINATUS TeNDON IIO6

XCV. Elbow 1108

XCVI. Old Dislocation of the Elbow 11 15

XCVII. Anchylosis Elbow 1117

XCVin. Wrist 1122

XCIX. Wrist Anchylosis 1125

C. Metacarpo-phalanxeal dislocations 1127

CI. Syndactylism; Webbed Fingers 1127

Cn. Operations on the Tendons of the Fingers 1128

CHI. Operations for lNF£CTr\-E Lesions of THE Hand 1132

CIV. Indications. Joints 114c

CV. Amputation or Disarticulation 1143

CVI. Flat-foot 1189

CVII. Tendon Sheaths and Tenorrhaphy 1192

CVIII. Tenotomy 1221

CIX. Contractures 1238

ex. Princlples of Plastic Surgery 1241

CXI. Methods of Drainage 1256

CXII. Acute Abscess 1259

CXIII. Operative Treatment of Neoplasms 1261

CXIV. Ligatures and Sutures 1263

CXV. Wounds 1268

CXVI. Localization of Foreign Bodies 1271

Index 1279

MANUAL OF OPERATIVE SURGERY

PART l.-HEAD AND NECK

CHAPTER I

SCALP

REMOVAL OF SEBACEOUS CYSTS (WENS)

Method A. — Make an incision through the skin into the cyst. The incision
must be nearly as long as the diameter of the tumor. Do not squeeze out the
contents of the cyst. Seize the divided cyst wall with a strong forceps (hemo-
stat). With a twisting motion it is easy to pull out the whole sac. Apply
pressure to the wound for a few seconds. Close the wound with one or more
sutures. Dress.

Method B. — Make a free incision through the skin (which is thin over the
tumor) down to, but not into the cyst. Dissect out the cyst unbroken. Close
the wound. Dress.

Method C. — If the cyst is infected and suppurating, treat it either as an
abscess or better excise it plus the infected portion of the skin.

In cases where the cyst is not adherent and not inflamed, method A is ex-
tremely easy and gives perfect results; opening the cyst permits removal through
a comparatively small cut, and the author has never seen harm result from
escape of cyst contents. Remember that sebaceous cysts occasionally become
malignant, hence look with suspicion on such as do not shell out readily.

ANGIOMA OF SCALP

When simple nevi of the scalp require removal by operation, the incision
must be made sufficiently far from the disease so that hemostasis may be easily
effected; the wound, if extensive, may tax the resources of plastic surgery.
Rapidly growing angiomata, those which penetrate the subcutaneous tissues or
are large and tumor-Hke and those which bleed or threaten severe hemorrhage,
all call for operation.

Angiomata over the fontanelles often communicate with the longitudinal
sinus, hence in these, radical operation should, if possible, give way to less
vigorous measures such as ignipuncture. The same is true in the case of cav-
ernous angiomata, which evidently penetrate the skull.

SCALP

(A) strangulation. — Pass a stout pin or needle under the middle of the
nevus from side to side. Pass a stout thread around the base of the nevus, under
the pin (which keeps the thread from slipping). Tie the thread very tightly.
Instead of one, two pins may be introduced at right angles to each other. In
time the strangulated tissues die, slough off and leave an ulcer. In the twentieth
century this treatment savors of barbarism.

(B) Subcutaneous Ligation.- — Many methods of subcutaneous ligation have
been used; most of them are exceedingly simple.

I. At the points A, B, C, D (Fig. i) puncture the
scalp with a knife. These points must be well away
from the disease. With a needle introduce a stout
chromicized catgut or a silk suture through A and bring
it out at B, reintroduce at B and bring out at C; in the
same manner carry the suture from C to D and from D
to A. Both ends of the suture now emerge at A. Tie
the suture tightly and let its knot retract under the
skin through the puncture at A. Apply dressings.

II. Krogius ("Centralblatt fur Chir.," Sept. 30, 1905)
found that compression and ligation even, of the afferent

vessels was inefficient in cases of large racemose (cirsoid) angiomata of the
scalp; that ignipuncture, injections and excision were dangerous. He therefore

B//

Fig. I. — Subcutaneous
ligation angioma.

i VWVA^fc^

Fig. 2. — Krogius' operation angioma.

devised the following method of subcutaneous ligation: Arm a full curved
needle with catgut. Pass the needle from .4 to B (Fig. 2), hugging the bone.

Fig. 3. — Krogius' operation angioma.

Remove the full curved and substitute a less curved needle. With this pass
the suture from B to A immediately under the skin (Fig 3). Both ends of the
suture now emerge at A. Tie the suture tightly.

ANGIOMA 3

Repeat the process all round ihe nevus unlil practically every vessel entering
or leaving the tumor is controlled. Each suture or ligature should to some
extent overlap into the territory controlled by the next one.

(C) Bryant's Operation. — Suitable in cases of cirsoid growth. Make an
incision outside and nearly round the growth, down to the periosteum. Leave
undisturbed that portion of growth containing the largest vessels. Raise the
flap and attend to hemostasis. Apply dressings under as well as over the flap.
When the wound is covered with granulations, replace and suture the flap.
If after elevation of the flap for a few days pulsations continue in the flap (the
tumor is in the flap), ligate at a distance the main vessel entering it. This
method has given J, D, Bryant much satisfaction.

In a case of angioma of the lower frontal region
the author operated as follows:

1. Shave the anterior portion of the scalp.
Make a tranverse incision over the head practically
from ear to ear but inside the line of the hair.

2. Reflect the skin flap thus formed downwards
and forwards until the angioma is almost reached
(Fig. 4). At this point, if necessary, cut through
the deeper structures until a layer of tissue is found
beneath the angioma and continue the reflection of
the flap downwards in this plane until the lower
limits of the angioma are passed. Working from Fig. 4,
the under side of the flap pass sutures or ligatures

around the main vessels entering the angioma from the base of the flap.

3. Treat the flap as in Bryant's operation and a few days later excise the
tumor. Replace the flap and close the wound with sutures. The object of this
method is of course to avoid making any visible scar.

Clairmont reports from v. Eiselsberg's clinic (" Archiv. ftir klin. chir.," Ixxxv,
549) an operation which combined the principles of Bryant's operation and
excision. Following Krause, the operation was completed in two sittings.
Figs. 5 and 6 show the extent of the disease. A skiagram showed that the
middle meningeal arteries were much enlarged. The occipital limits of the
tumor were clearly defined; elsewhere it was not well delimited. The use of
temporary hemostasis by an elastic band was impossible. Preliminary ligation
would have called for the tying of both occipital arteries, the frontal artery (the
size of the little finger), and both external carotids near their origin, which
might cause danger of embolism. Communicating vessels between the scalp
and the inside of the skull were so numerous as to make the gain from pre-
liminary ligations very doubtful. The operation performed may be taken as
a guide for the treatment of extremely extensive cirsoid aneurysm of the scalp.

Place the patient almost in a sitting posture. Anesthetize.

Step I. — Make an incision through the skin and epicranial aponeurosis
skirting the growth anteriorly and laterally. Make the cut inch by inch,
using compression on each side of the cut against the bone until the vessels are
secured by forceps and ligatures. Isolate and doubly ligate the main vessels

4 SCALP

before dividing them. This incision outlines a horseshoe-shaped flap having
its base at the occiput.

Step 2. — Reflect the flap from the cranium. This step requires the use of
many hemostats and ligatures because of the free anastomosis with the deep
vessels.

Step 3. — As in Bryant's operation, place gauze between the flap and the bone.
Replace the flap over the gauze. Apply dressings and bandage.

Step 4. — After three or four days remove the dressings and excise the tumor
from the under surface of the flap. Thrombosis of the vessels in the tumor,
and loosening of the surrounding connective tissue due to the edema, make the
excision of the growth easier than it would have been at the first sitting.

Step 5. — Replace the flap. Suture. Dress the wound.

ifpMH

p '

-'"'■'"^f^H

' i ^ii

Fig. 5. Fio. 0.

Figs. 5 and 6. — Cirsoid aneurysm. {Clalrmonl.)

(D) Excision.^ — It is very easy to excise small nevi and to close the wound
with sutures. When large nevi are being excised hemorrhage during the excision
may be avoided by tying an elastic constrictor tightly round the head as in
trephining or by having a rubber-covered ring (ring pessary) pressed firmly
against the scalp surrounding the nevus. The operation consists in excising the
disease by cutting through healthy tissue, in securing hemostasis and in closing
the wound either directly or by some plastic procedure.

The freezing treatment of nevi threatens to displace all other methods.

Liquid Air. — First get the liquid air. Make a very firm pad of cotton on the
end of a stick. Dip the pad in liquid air. Shake off any loose drop of the liquid.
Press the charged pad with moderate firmness on to the nevus for a few seconds.
Repeat the process on every part of the lesion. The treatment is usually pain-
less. Apply no dressings. If any raw surfaces are present on the lesion they
must be covered with thin gauze before being treated, otherwise the applicator
would freeze to them (Whitehouse) ; all scabs must be removed prior to
treatment.

MALIGNANT TUMORS OF SCALP 5

The applications may require to be repeated two to three times at intervals
of about one week.

Carbon-dioxide Snow. — Instead of liquid air, carbon-dioxide snow may be
used and is easily obtained in tanks such as are used in commerce. Permit a
spray of the gas to play into a bag of chamois leather. Snow is immediately
formed. Put the snow into a cylindrical mould of wood or metal and tamp it
down firmly with a stick or pestle. Remove the firm candle of snow from the
mould and trim it to the desired shape with a knife. Apply the point of the
snow-candle, with moderate firmness for a few seconds, to the part to be treated.

MALIGNANT TUMORS OF THE SCALP

The principles of operation are the same as obtain in other situations, viz.,
free excision and, especially in the case of epitheUoma, removal of the lymphatics
which drain the site of disease, when this is possible. The main features of the
anatomy of the lymphatics of the scalp are as follows:

(A) The lymphatics of the frontal, and the anterior part of the parieto-
occipital regions, drain into the parotid lymph glands. These glands for the
most part lie in the parotid, and their removal means removal of the parotid.
A cancer of the scalp, with secondary nodes in the parotid, is practically
inoperable.

(B) The lymphatics of the posterior part of the parieto-occipital region drain
into the mastoid group of glands lying on the mastoid portion of the sterno-
mastoid muscle. These are easily extirpated.

(C) The occipital region is^rained by two routes. From the outer part, the
lymphatics join to form a single trunk which runs downwards to a point under
the sterno-mastoid muscle, where it enters one of the external glands of the
sterno-mastoid group. From the inner part of the region, the lymphatics go to
the occipital glands.

From the foregoing it is clear that only in case of frontal and anterior tem-
poro-parietal cancer, are the lymphatic nodes "next in order" really inaccessi-
ble. When a cancer of the scalp is freely movable — excise it thoroughly but
leave the skull intact; the wound may be closed by sutures, by flaps of skin, or by
skin grafts. When the cancer is adherent to the bone, make an incision down to
the bone all round the disease, but in healthy tissue. With the chisel introduced
through the incision, cut away all the external table of the skull corresponding to
the diseased area. If for any reason it is thought that the disease has penetrated
the diploe it becomes necessary to remove the whole thickness of the skull.
The cranial defect should be closed at once by some plastic method, v.
Bergmann writes, "when the disease affects the frontal or occipital regions we do
not hesitate to penetrate the dura and remove portions of the cerebral cortex."

THK SKULL AND THE BRAIN

CHAPTER II
THE SKULL AND THE BRAIN

EXPOSURE OF THE SKULL

Many means of exposing the skull may be employed, all of which must be
preceded by the shaving of a large part, or, still better, of all the scalp. In cases
of open fracture, one may expose the bone sufficiently by enlarging the wound
already existing. When the operation is for the removal of a foreign body
lodged in the bone, a linear incision may be employed. The same incision may
suffice to lay bare enough bone for the application of Doyen's perforator or a
very small trephine. When a moderate sized trephine is to be used or one de-
sires to explore the surface of the skull, the best incision is one curved in the form
of a U or horseshoe. Unless specially contraindicated the open end of the U
should face downwards in the direction of the blood-supply of the scalp. The
knife penetrates to the bone at the first cut and the flap is rapidly and readily re-
flected downwards. Hemostasis must be attended to at once. Before incising

Fig. 7. — Alakkas' pin, and forceps for introducing it.

the scalp some surgeons tie an elastic constrictor round the head immediately
above the ears so that hemorrhage may be controlled. Lanphear attains the
same ends by surrounding the site of operation with a continuous chain suture,
each stitch of which includes the whole thickness of the scalp. Makkas sur-
rounds the area of operation with clamps, either straight or slightly curved,
which assure a bloodless field. Fig. 7. When operating in a region supplied
by the temporal artery, it is convenient to have an assistant exert pressure
thereon. The best methods of securing hemostasis are those described in
Cushing's decompression operation (p. 25) and in the osteoplastic opening of
the skull (p. 14).

METHODS OF OPENING THE SKULL

(A) The Trephine. — There are two species of trephine, but of these there are
many modifications:

I. The ordinary trephine is, in principle, merely a hollow steel cylinder

TREPHINING

Fig. 8. — Trephine and

"brace."
B. Trephine: i, Centre
pin; 2, movable guard; 3,
stem to fit into brace. C.
Extra stem by which burs
or drills may be attached
to brace. {Monod and
Vanverts.)

whose lower end is provided with a saw-edge. To keep the saw-edge in position
on the skull, a pin projects through the centre of the cylinder. The pin is with-
drawn as soon as the trephine has cut a groove in the
bone sufl&ciently deep to prevent it from slipping.
Power is applied to the instrument through a T-shaped
handle or a "brace" similar to those used by carpenters.
To prevent any sudden onward movement of the instru-
ment into the brain after the inner table of the skull is
penetrated, movable guards may be fixed to the outside
of the trephine. (See Fig. 8.)

2. The Gait Trephine. — The principle of this trephine
is identical with the preceding except that the cutting
part of the instrument is shaped like a truncated cone
(Fig. 9). The conical shape prevents any sudden onward
movement when the inner table of the skull is penetrated.
The Gait trephine is most commonly used in America.
The only disadvantage of this instrument is that on
account of its shape it necessarily makes the button of
bone removed much smaller than the hole left in the
skull, a matter of some importance if one intends reim-
planting the bone removed.

Trephining. — Place the patient with his head resting
on a sand-bag and held steady by the hands of an assistant (Fig. 10). Expose
the skull as already described. Make the centre pin of the trephine protrude
about one-sixteenth of an inch beyond the cutting-edge and bore it into the
skull at the selected site. By steady movements of the wrist, twist
the trephine from left to right and right to left until it has cut a
groove in the skull. Withdraw the centre pin and proceed with the
trephining. As soon as the outer table of the skull is penetrated
there will be less resistance to the operation and more escape of
blood. As soon as hard bone is again met, proceed with increased
caution. The inner table is often very thin. After every few move-
ments of the instrument probe the groove in the skull with the blunt
end of a straight needle. If probing shows greater penetration at
one part of the groove than another, lessen the pressure of the
trephine at that point. The inner table is usually found divided at
one place before another; when this is the case, by slightly tilting the
trephine the place where penetration has already taken place is
avoided while the rest of the skull is being divided. As soon as the
bone is divided the resulting button is easily removed and the dura
mater exposed. Along the edges of the osseous hole there will
always be found projecting spicules; these must be cut away with
rongeur forceps. If bleeding from the cut bone is severe, it may be
stopped by sponge pressure, or, if necessary, by slightly crushing the bone be-
tween the jaws of a rongeur forceps. In the author's practice this last procedure
has almost never failed to give satisfaction and to have no subsequent ill results.
Horsley's wax (beeswax 7, almond oil i, salicylic acid i) applied to the bleed-

tre-

FlG

Gait
phine.

(Tiemann.)

8 THE SKULL AND THE BRAIN

ing bone is an efficient hemostatic agent. Leonard Freeman finds sterilized
chewing gum most convenient for this purpose, but outside of the United States
this material will never be within reach. Should there be any intention to
reimplant the button of bone removed, it must, at once, be placed in sterile
water and kept at a temperature of about ioo° F.

Fig. io.

i-iG. II. — Use of Keen's forceps.
Appearance of trap-door opening in skull.

The most convenient size of trephine for ordinary purposes is one three-
fourths of an inch in diameter. Smaller instruments are often useful. Tre-
phines having a diameter much greater than one inch are useless owing to the
curvature of the cranial vault.

Should it be desired to enlarge the trephine opening, this is easily accom-
plished by biting away the surrounding bone with rongeur forceps. Keen's
forceps are excellent for this purpose (Figs, ii and 12).

OPENING OF THE SKULL 9

Occasionally the dura is accidentally injured by the trephine and bleeding
occurs. When this is the case, enlarge the hole in the skull so that free access is
obtained to the dural wound, surround any bleeding vessel by a fine suture,
and close the rent in the dura.

Keen's forceps.

Fig. 12.

(B) Chisel and Mallet. — Especially on the continent of Europe, the skull
is frequently opened by means of a chisel. In America and England the method
is not a general favorite. The writer has more than once observed severe
shock result from it. Either the ordinary chisel or a gouge with a V-shaped
cutting-edge may be employed. Support the patient's head on a sand-bag.
Expose the skull as already described. Apply the chisel nearly parallel to the
plane of the skull, and by careful use of the mallet make it cut a narrow groove
in the bone. The groove is gradually deepened until the inner table is divided.
Those skilled in the use of the chisel for this purpose can remove or reflect a large
piece of skull in a surprisingly short space of time. The chisel is very useful in
operating in cases of fracture, especially of fissured fractures, where it is desired
to shave away jagged and injured portions of bone. In the formation of trap-
door openings through the skull, the chisel was the original instrument employed.

(C) Gigli Wire Saw.— It is desired to remove a large area of skull in one
piece. Expose the skull by a U-shaped incision of appropriate size. At each of
the four corners of the area to be removed perforate the skull with a small trephine
or a Doyen's burr. Doyen's burr is a very efficient and safe instrument, most
conveniently operated by a brace or Stille's apparatus (Fig. 13). Before apply-
ing the perforator the outer table of the skull ought to be drilled so as to permit
the rounded perforator to bite. Hudson's drill is powerful and safe. With a

THE SKULL AND THE BRAIN

dural separator, separate the dura from the skull along a line stretching from
one trephine opening to another. Introduce an appropriately shaped grooved
du-ector to take the place of the dural separator. Pass a Gigli wire saw
along the grooved director and leave the director in place to protect the
dura. With the wire saw divide the skull from within outwards. Remove
the director. Repeat the procedure until the desired area of bone is entirely
detached. The Gigli wire saw is an excellent instrument for use in the forma-
tion of trap-door openings through the skull.

(D) Forceps.— After perforating the skull as described in the preceding
paragraph, one may divide the bone between the perforations with bone-cutting
forceps, e.g., Keen's or DeVilbiss' (Fig. 12), and attain the same result as when
the Gigli wire saw is employed.

Fig. 13. — Stille's drills and burrs.

(E) Electric Saws, Etc.- — Circular saws and drills driven by the surgical
engine are used by some busy hospital surgeons as a means of quickly opening
the cranium. They are rarely used in private practice, are useful but expensive
luxuries, and any full description of their application would be out of place in a
work such as this.

In all the methods of opening the cranial vault which have thus far been
described the bone is removed over a greater or less area. Is it necessary to
close this defect by anything more than replacement of the reflected scalp?
When the scalp is replaced, in time the bone defect becomes filled with exceed-
ingly hard and strong fibrous tissue sufficient to protect the cerebral contents
from injury by ordinary violence. To prevent the formation of adhesions be-
tween the scalp and the cerebral contents many surgeons are in the habit of
interposing between them divers smooth aseptic materials cut to such a shape
that they will fit into the cranial defect. Of these materials, mention may be

{'LOSIKE OF CRANIAL DEFECTS

made of gold-foil, celluloid, ihin rubber tissue, the membrane which lies be-
tween the shell and white of a hen's egg, etc. If the wound remains aseptic,
these foreign bodies will lie in place indefmitely. Their use is particularly in-
dicated after operations for epilepsy, but in the ordinary routine of cerebral
surgery the author has distinct doubts as to their value.

Carl Beck's method of using the temporal fascia may be employed (see
p. 50). As well as free transplants of fascia or of fat.

Macewen fills up the osseous defect with the fragments of bone removed.
These he arranges all over the exposed dura like a tesselated pavement. The
larger fragments or buttons of bone he breaks into small pieces before im-
planting them. Excellent results have
attended this procedure.

Instead of fragments of bone removed,
decalcified bone chips or particles of bone
obtained from other patients or animals
have been successfully implanted.

Osteoplastic measures have been devised
to close defects in the skull with bone.
Miiller, Konig and others have formed flaps
consisting of the scalp and the outer table of
the skull, and with these have covered the
defect.

MULLER-KONIG OPERATION

Step I. — Expose the cranial defect (O,
Fig. 14) by reflecting the skin-periosteal flap
ABC. Excise all scar tissue from the
cranial defect and freshen the edges of the
bone.

Step 2.- — Outline and reflect the flap
DFE. In forming this flap cut away with
the chisel a portion of the outer table of the
skull (G). The portion of bone G is an in-
tegral part of the flap DEF, and is of size
and shape suitable to be inserted into the
cranial defect (0).

Step 3. — ^Insert the graft G into the
defect O, and suture the edges of flap DEF to the bed from which flap ABC
was raised.

Step 4. — Implant flap ABC in the bed from which flap DFE was raised.

The operation may be modified by exposing the whole area ACDE by raising
a flap of scalp without periosteum and then filling the defect O by bone taken
from the area H attached to the periosteum and not to the scalp.

Criticism. — During the necessary manipulations, it is difl&cult to keep the
flap of bone from becoming detached from the pericranium. The pericra-
nium normally has little or nothing to do with the nutrition of the bone. The
scar in the Miiller-Konig operation is extremely uncouth. While the author

Miiller-Konig operation.

12 THE SKULL AND THE BRAIN

has successfully used the method, yet he considers free transplantation of bone
far easier, at least as successful and theoretically much preferable.

Ropke ("Zent. fur Chir.," No. 35, 1912) has used a part of the scapula in the
following manner:

1. After exposing the cranial defect by reflecting a flap of scalp, excise the
scar tissue over the brain and vivify the edges of the bone. Temporarily pack
the wound with gauze wrung out of hot water. Apply dressings.

2. Place the patient on his right side and pull the left arm forwards. Make
an incision about 3^ inch to the outer side of the vertebral border of the scapula,
exposing the fascia covering the infra-spinatus. Divide the fascia and infra-
spinatus just external to the vertebral border but do not divide the periosteum.
With a sharp knife dissect outwards, cutting the infra-spinatus from the body
of the scapula until an area of the bone is exposed fully as large or larger than
the cranial defect.

With surgical engine, sharp chisel or suitable forceps, e.g., DeVilbiss',
divide the bone all round the desired area, being careful to leave the vertebral
border of the bone intact.

Dissect the isolated plate of bone from the subscapular muscle. Place
the fragment of bone in warm salt solution.

3. Attend to hemostasis. Suture the divided infra-spinatus muscle and
fascia to the vertebral border of the scapula. Close the wound. Dress.

4. With scissors carefully remove all muscle attached to the bone implant,
and place the bone plate in the cranial defect. Replace the scalp. Close the
wound. Dress.

Macewen has long recognized the importance of closing cranial defects;
most other surgeons were later in doing so, and many to-day are skeptical
or disbelieve in its necessity. The later results in cases of skull fractures
treated in Korte's clinic support Macewen's ideas forcibly (p. 17). Stieda
("Archiv fur klin. Chir.," Ixxvii, 532) formulates the following rules:

1. If the wound can be rendered and kept aseptic, close the defect at once by
implantation of the fragments removed (Macewen's method).

2. If the wound is healed — do not wait for the appearance of epilepsy but
excise the scar tissue from the cranial defect and repair it by the Miiller-Konig
osteoplastic method.

Macewen's method is only applicable for closing the skull at the time the
skull is opened, i.e., when the bone removed is available for reimplanting.

In the Miiller-Konig operation the fragment of bone transplanted is supposed
to gain its nourishment from the pericranium. In the author's experience,
such great gentleness has to be exercised to prevent the fragment of bone from
actually falling off the pericranium that it is difficult to imagine any useful
amount of nutriment passing from the pericranium to the bone. If this is true,
then in view of the success of bone transplantation the complicated Miiller-
Konig operation should be discarded and the cranial defect closed by the free
(non-pedunculated) transplantation of bone.

This might be accomplished in several ways: v. Eiselsberg did it by using a
portion of the tibia covered with periosteum. Undoubtedly the same end could

TKAP-DOUK CRANIOTOMY

be attained by implanting fragments of the outer table of the skull obtained in
the neighborhood of the defect to be filled.

C. C. Coleman (Surg. Gyn. and Obst., July, 1920) has had large and favor-
able experience with this method, using a technique which he credits to C. H.
Frazier.

1. Excise the scar tissue of the scalp and cranial defect but do not injure the
dura. (If the scalp scar is so extensive that after its excision closure of the
resulting scalp wound is impossible without undue tension, cover the defect
with healthy skin and defer the cranioplasty until later).

2. Make an incision through the pericranium around the defect and about
yi inch from its margin. With an elevator separate the pericranium along with
any remnants of scar tissue from the edge of the defect and with it separate the
dura from the bone at the edge of the defect.

3. With a chisel pare the edge of the defect and bevel it. While doing this
protect the dura by a thin spatula. Cut a rubber dam pattern of the size and
shape of the defect. Pack the wound with gauze wrung out of hot water.

4. Over one parietal eminence make an incision down to but not through the
pericranium. Retract the scalp. Apply the rubber dam model to the skull.
With knife and chisel cut a graft of pericranium and a thin layer of the outer
table of the skull the size of the model.

5. Suture this graft (pericranium to pericranium) into the defect, the bony
surface being next to the dura.

6. Close the wounds. Dress. It is wise to keep the patient flat in bed for
two weeks as the intracranial pressure favored by the horizontal posture, gives
the thin transplant the proper curve in relation to the surrounding skull.

Primrose uses not only bone but cartilage for the closure of cranial defects.
Fascial grafts (fatty surface next the brain) are of much value to fill dural
defects.

Primrose (Annals Surg., July, 1919) in 34 cases of cranial defects from war wounds where
satisfactory closure was accomplished by a firm graft of bone or cartilage obtained the following
results.

Cases completely relieved of distressing symptoms 19

Cases rendered worse by the operation 2

Cases improved but not wholly relieved 8

Cases with no change in the svTnptoms 5

The relief of such symptoms as headache, dizziness, the fear of injury and the sense of
insecurity, occasionally the worry and mental depression dependent upon the possession of an
ugly deformity is as a rule immediate and complete. The value of the operation in cases of
epilepsy is less e\adent. In one of Primrose's cases the graft became a source of irritation and
had to be removed and a fascial graft substituted with relief from the convulsions.

Temporary Osteoplastic Opening of the Skull. Opening of the Skull by
Means of a "Trap-door." — This method is often of great value and the flap
reflected may be very large. The base of the flap should be in the direction
of the main blood supply, e.g., the temporal region where there is the added
advantage of having thin bone at the place where the bone pedicle must be
fractured.

14 THE SKULL AXD THE BRAIN

Step I. — By scratchinj? the skin, outline the desired flap. On each side of
the future pedicle penetrate to the bone. From one of these openings to the
other, pass a suitable elevator between the scalp and the bone. Pull a rubber
tube through the tunnel thus formed and put it on the stretch. Grasp the two
ends of the tube m the jaws of a long bladed clamp (Fig 15). A pad of
gauze placed between the clamp and skin protects the latter. Divide the

scalp along the line of scratches. The

. - - • ^ > tube and clamp prevents all bleeding

f ^ from the flap side of the incision. A

♦ Makkas' pin can be used instead of the

* tube and clamp.

^ Step 2. — At several points along the

line of proposed bone section perforate

the skull with a burr. Between these

openings separate the dura from the skull.

Divide the skull between these openings

" y J " V i by means of a Gigli saw. While sawing

(^;^/ -^ the bone, protect the dura by means of

Fig. 15. ^^ elevator or thin strip of metal. The

bone is thus cut from within outward.

It is well to cut so as to make a broad beveled edge. Much of the limbs of

the bone flap may be cut with the De Vilbiss forceps or their equivalent.

Many surgeons use a surgical engine.

Step 3. — Raise the flap with blunt instruments, fracture its base. At this
stage the middle meningeal artery may be injured and bleed, especially if it
tunnels the bone. A small pack of cotton pressed between the dura and the
bone will control this heeding.

Step 4. — Open the dura by a flap leaving enough margin for suturing.

CLOSURE OF THE SCALP WOUND

The scalp wound is closed by sutures. The author always prefers to intro-
duce as few sutures as possible, because there is little tendency to retraction,
and in this locality especially, any fluids which may be thrown out in the
wound are very much better soaked up in the dressings than retained beneath
the scalp. If few stitches are used, drainage is unnecessary even when thorough
cleansing of the wound has been impossible, except in the presence of pus, or
when a large cavity has been left after removal of tumor, etc. Drainage of the
wound by a strip or wick of iodoform gauze has proved e.xtremely unsatisfactory
to the author; the gauze has almost always acted as a plug instead of a drain.
Of course, where more extensive drainage or packing is indicated, gauze properly
introduced acts ideally. In suitable cases drainage-tubes of rubber, glass or
decalcified bone (chromicized )are to be employed.

After closing the wound apply the usual dressings. These are most con-
veniently held in place by a starch bandage.

CRANIAL TOPOGRAPHY.

HEMORRHAGE FROM THE MIDDLE MENINGE.AL VESSELS

The middle meningeal artery enters the cranium through the foramen spino-
sum, usually accompanied by two veins. It divides into an anterior and a
posterior branch, which ramify in all directions over the dura. Meningeal
hemorrhage is usually accompanied by fracture of the skull, but as it sometimes
is caused by violence which does not injure the bone, and even by contrecoup,
the operative treatment of the latter class of cases must be considered separately.

I. When focal symptoms permit the determination of the site of the bleed-
ing, the indications for treatment are exceedingly simple. Trephine the skull
at the site of the hemorrhage. A tough, dark-colored clot will be found. This
must be removed with forceps, probe, spoon, and stream of hot water. Prob-
ably the trephine opening will require enlargement; possibly, a second opening
may be required, as extradural clots are frequently very extensive. If active

Fig. 16. — Exposure of middle meningeal artery. {Esmarch and Kowalzig.)

bleeding continues, search for its source by enlarging the trephine opening with
forceps or making another opening as may be required. Ligate the vessel.
Examine the dura carefully for signs of injury. If that structure is torn, cleanse
the wound from blood-clots and close it with fine sutures. For suturing the
author prefers fine silk or celluloid hemp to catgut, merely because the former
are so thin that they can be readily threaded on very small needles. If the dura
be found distended and discolored, or pulsation is absent showing that subdural
hemorrhage is probably present, carefully incise that membrane, remove blood-
clot, stop bleeding, and close the dural wound. After the removal of extradural
clots the dura soon becomes pushed up against the skull in its normal position,
and the external wound may be closed without drainage.

II. In the absence of distinct focal symptoms the trephine must be applied
somewhere along the course of the artery so that further bleeding may be
stopped and, what is of greater importance, an opportunity may be obtained to
explore for and remove the blood-clot. Roswell Park writes: "Vogt and Beck
have suggested trephining at a point one and a half inches above the zygoma
and the same distance behind the angle of the orbit. An inch trephine at this
point is sure to expose the anterior branch of the middle meningeal artery.

THE SKILL AND THE BRAIN

Nevertheless, the removal of the clot which causes the compression is much
more important than merely finding the artery. Kronlein has made the sug-
gestion of trephining twice, if necessary, in those cases in which the chance of
finding the clot is good. He divides these hematomata generally into three
classes: (i) fronto-temporal; (2) temporo-parietal; (3) parieto-occipital. He
suggests trephining over the artery first, and then, if no hematoma be found
and the indications still point to meningeal hemorrhage, to trephine again just
below the parietal eminence, because an opening in this position would expose
either of the latter classes of blood tumors." (See Cushing's decompressive
operation.)

Figures 16 and 17 are self-explanatory.

Fig. 17. — Exposure of middle meningeal artery,
a, b. Base line from lower margin orbit through external auditory meatus, c, d. Parallel to a, b.
from upper margin orbit, backwards, e, f. Perpendicular to a,b, and about i l^i inches posterior to external
angular process, g, h. Perpendicular to a, b, and immediately posterior to mastoid. (Esmarch and
Kowalzig.)

Steiner has made a careful study of the surgical anatomy of the middle
meningeal artery, and as a result has worked out the following method of
reaching the vessel.

(A) (i) Draw a line from the middle of the root of the nose to the apex of
the mastoid process. (2) From the root of the nose draw a line backwards
parallel to a line drawn from the lower margin of the orbit through the middle
of the external auditory meatus. (3) Bisect the first line by one drawn at
right angles to it.

Where the third or vertical line crosses the second {i.e., that parallel to the
base line of the skull) is the point to trephine when searching for the anterior
branch of the artery.

(B) To reach the posterior branch of the middle meningeal artery, trephine
at the point where a line drawn directly backwards from the root of the nose is
crossed by a line drawn at right angles to it from the apex of the mastoid
process.

FRACTURES OF SKULL 1 7

OPERATION FOR FRACTURES OF THE CRANIAL VAIXT

In cases of compound or open fracture, the wound in the scalp may be en-
larged, so as to expose the skull, or, if more convenient, the scalp may be re-
flected by the usual U-shaped incision, as is done in simple fractures.

I. Depressed Fracture. — The principle to be followed is to elevate the
depressed bone, remove all dirt, remove all sharp spicules, stop bleeding, and
leave everything in the best possible condition for healing.

If beside the depression there is a sufficiently large hole in the skull, the de-
pressed bone, may be elevated or removed by means of periosteal elevators,
necrosis forceps, or rongeurs. It is imperative, especially in compound frac-
tures, to make an opening in the skull large enough to demonstrate the absence
of dirt and hemorrhage. Failure to attend to this may be disastrous; the extra
work involved in doing it does no harm. If no opening of sufficient size exists
in the skull beside the depression, it is necessary to make one. This is usually
done with the trephine. Apply the centre pin of the trephine to the solid
skull beside the depression. Part of the cutting-edge of the instrument overlaps
the fracture, but most of it lies on the unfractured bone. Remove a button of
bone. In operating do not exert any pressure on the fractured fragments of
bone lest injury to the cranial contents result. Remove or elevate the de-
pressed bone. Remove blood-clot and foreign material. Stop bleeding.
If desired, the fragments of bone may be cleansed and returned if conditions
are favorable.* If the dura mater is torn, it must be cleansed and sutured. In
severe injuries the brain itself is often much lacerated. The cerebral wound
must be cleaned by gentle irrigation with hot water and loose fragments of
brain removed. Bleeding must be stopped by ligature, application of hot
water, or packing with gauze. The divided dura must be sutured, leaving an
opening for drainage or for the gauze packing, and the external wound partially
closed. When the dura is destroyed to an extent that its closure becomes im-
possible, it is wise to cover it with some smooth aseptic material, such as gold-
foil, rubber tissue, or the like, unless drainage is necessary. Possibly the im-
plantation of a free mass of fat might be of value (see p. 52). Schulze-Berge
has covered the dural defect by splitting the neighboring dura into two layers
from the outer of which he formed a flap sufl&cient to fill the defect. When a
drain is required, the part of the brain bereft of dura must be left largely to it-
self. In one case of the writer's where there was much destruction of brain and
dura and the wound was infected the patient recovered perfectly in spite of the
appearance of a hernia cerebri. The patient was seen several years after the
accident and enjoyed perfect health. Twelve years later epilepsy developed.

When the fracture is situated over the longitudinal sinus the sinus is liable
to be wounded. Bleeding can commonly be controlled by means of packing.

* Brewitt ("Archiv fur klin. Chir.," Ixxix) studied the late results of Korte's cases of
complicated fracture of the skull. Of thirty-eight patients treated by reimplantation of the
bone twenty-four remained in good health, two had slight and two such severe disturbances
that they were unable to work. None were epileptic. Three out of four cases treated by a
secondary plastic operation were in good health, one had considerable trouble. Out of thirty
cases where the skull was left open only nine remained in good health; two had slight, one
severe disturbances; one had epilepsy; eight died from the injury; nine cases could not be
traced.

THE SKULL AND THE BRAIN

Wounds of the sinus have been sutured but its stiff hard walls do not lend
themselves easily to direct suture.

Revenstorf (" Centralblatt fiir Chir.," Sept. 21, 1907) recommends the in-
sertion of a suture such as is sufficiently shown in Fig. 18. The stitch seems as
if it would be inefficient but the blood pressure in the sinus is so low that the
pressure exerted by the suture suffices.

2. Fissured Fractures.^ — When the fracture consists of a fissure involving
both tables of the skull, the dangers to be combated are: (a) In compound frac-
tures, dirt, (b) Intracranial hemorrhage.
(c) Separation of spicules from the internal
table and injury to the brain from them.

These dangers are met as follows: In
compound fracture, that portion of the
fissure near the scalp wound must be
treated on the lines laid down for depressed
fracture, and the rest of the fissure treated
as if the fracture was of the simple variety.
In simple fracture the fissure should be
exposed, and with a small trephine,
rongeurs, or chisel the skull removed at
various points along the line of fissure
sufficiently to permit the surgeon to satisfy
himself as to the absence of hemorrhage or
of the penetration of the brain by spicules
of bone.
WTien the fissure does not involve the inner table of the skull, as demon-
strated by probing with the blunt end of the needle, it is to be left undisturbed,
unless in the neighborhood of a wound of the scalp. When exposed to dirt,
as is always the case in compound fractures, the fissure should be cleaned by
shaving its edges with a sharp chisel. Fissured fractures are usually met with
radiating from other fractures of the cranial vault.

All fractures of the cranial vault ought to be subjected to exploratory opera-
tion whether they are depressed or not. J. Abadie (La Pr. Med., Sept. 25, 1916)
gives the following advice.

1. Unless entirely and certainly superficial every wound of the scalp ought
to be explored by incision.

2. Every injury (even superficial) to the skull ought to be explored. In
cases where there is a mere shallow grooving like a scratch made by a nail it is
wise to cut into the bone with a saw to demonstrate the intactness of the diploe
and that the probe cannot depress the inner table.

3. In all other cases the skull should be opened, fragments removed and
edges smoothed.

4. The general condition of the patient can present no contraindication as,
in the apparently dying, coma may disappear after operation and operation
cannot increase the dangers inherent to the wound.

5. A saw or trephine is preferable to chisel and mallet in operating. The
rongeur is excellent but should cut and not crush the bone.

Fig. 18.

-Y, Longitudinal sinus with rent in it; 5, 5,
sutures; D, D, dura.

FRACTURES OF SKULL IQ

6. If the dura has l)een pciu-traU-d, hone ou<i;ht to he removed for at least
1-2 cm. heyond the dural wound toi)ermit certain removal of splinters of the
inner table. It is not necessary to remove the ui\injured outer table from over
the site of the removed sjilinters of inner table.

7. If the dura has not been opened by the injury ought it to be left intact?
Abadie finds incision of the dura does not increase the danger and has seen foci
of infection form under the unopened dura which might have been avoided by
timely opening. If there is blood under the dura or a focus of attrition (evi-
denced by depressability) open the dura and after evacuating, let the edges of
the wound fall together.

8. If the dura is torn, explore with the finger and remove any splinters.

9. Drain with a gauze wick kept wet with hypertonic salt solution.

10. Unless drainage is to be used, place gauze soaked in 4 per cent. Collargol
in contact with the dura (or brain) temporarily.

11. In non-infected cases without dural wound, close the wound completely.
Generally part of the wound should be left open for drainage.

12. Progressive headache, a rising temperature or marked slowing of the
pulse call for lumbar puncture.

13. Portions of projectiles not directly accessible at the primary operation
should be removed two or three days later under guidance of radioscopy.

14. The after history is either entirely good or entirely bad. If there is any
'upset' even on one day, the prognosis is bad. "This rule is not absolute, we
have personal experience to the contrary, but it is the general clinical impres-
sion."

Fractures of the base of the skull when they demand operation do so on
account of secondary complications such as hemorrhage and more especially
infection. The operation consists in exposure (and if necessary incision) of
the meninges low down. The middle fossa is the one most commonly affected
and may be reached by Cushing's decompression operation. In an exhaustive
paper ("Annals of Surg.," June, 19 10) Ransohoff comes to the following
conclusions:

"i. There will always be a large mortality connected with basal fractures —
death resulting from primary shock, brain laceration or hemorrhage. Thirty-
seven per cent, of the fatal cases die within six hours or less, and 56 per cent,
die within twelve hours. It is not probable that the mortality of this class of
cases can ever be reduced with or without operation. They are primarily fatal.

"2. Twenty-three per cent, of the fatal cases die during the second twelve
hours of the first day and 6 per cent, die during the second day. They are the
cases in which the coma is not profound, in which the pupils are not fixed,
in which the breathing is not stertorous, and in which there is not complete
muscular relaxation. With a slow full pulse and lumbar puncture indicating
hemorrhage and increase of intracranial pressure, a trephining operation is
indicated. In the doubtful cases, an operation is indicated.

"3. In this class of cases, where facilities for the major operation of tre-
phining are not at hand, repeated lumbar punctures should be essayed. This
procedure may be destined to take the place of decompressive operations.

"4. There is a large group of cases in which there is complete consciousness

20 THE SKULL AND THE BKAIN

or in which there is a somnolence or milder degree of coma, and in which the
concomitant symptoms do not indicate a grave intracranial trauma either to
the brain or its vessels. The pupils though uneven, react; involvement of one
or more cranial nerves may be evident. The symptoms singly or collectively
are not ominous at any time. Eighty per cent, of this class of cases have a
tendency to get well with or without operation. They should not be operated
on unless the symptoms indicate an increase of intracranial pressure from
hemorrhage or beginning cerebral edema, or distinct localizing (cortical)
symptoms.

"5. There is a distinct class of cases in which operation is indicated. They
are cases which seemingly not severe in the beginning grow progressively or
suddenly worse, showing signs of increased intracranial pressure. Decom-
pressive operation may save a considerable proportion of them.

"6. It has yet to be determined where the trephining should be done to
obtain the best results. Since most fractures involve the anterior or the middle
fossa, subtemporal trephining is doubtless the procedure oftenest indicated.
When, however, a hematoma in the mastoid or occipital region indicates an
involvement of the posterior fossa, the operation should be subtentorial. To
relieve the subtentorial tension by an opening made in the temporal region is
illogical and may be dangerous. I attempted it recently in a cerebellar tumor
the site of which could not be determined. The patient succumbed within
two weeks with symptoms of bulbar paralysis."

During 1920 the subject of trephining in basal fractures was discussed at
length in the Paris Surgical Society ("Bui. et Mem. de la Soc. de. Chir. de Paris,
1920). The general opinion was in favor of spinal puncture as opposed to
decompressive operation. De Martel however declared that when a patient
with cranial fracture was comatose, lumbar puncture should be done. "If
the puncture gave passage to a bloody liquid, flowed freely and was followed by
a slight amelioration, it was proper to make a series of such punctures. If the
puncture did not give the above results bilateral subtemporal trephining should
be practiced as by this means alone could rupture of the meningeal be recognized,
lumbar puncture facilitated and rendered inoffensive and effective decompres-
sion of the brain realized.''

REMOVAL OF TUMORS FROM THE BRAIN

Description of the methods of diagnosing and locating tumors of the brain
would be out of place in this work. The diagram (Fig. 19) here presented is
merely meant to act as a graphic reminder of the generally accepted position
of some of the chief centres. Sherrington and Griinbaum find that in monkeys
all the motor centres are anterior to the fissure of Rolando. F. Krause ("Die
deutsche Klinik," viii, 961) has substantiated these findings in man. Fig. 20
represents, on the left hemisphere, the results of Krause's investigations in
twelve operations. J. C. DaCosta and others agree with Sherrington's views.
It is necessary, however, to study the relations which the sulci and convolutions
of the brain bear to certain landmarks on the skull, so that it may be possible
to expose the brain at the desired spot.

CEREBRAL TOPOGRAPHY

Fig. 10-

£xlcn3ion and
Inward Rotation
Foot

Eltvation, Abduction
Arm

Extension )
flexion J

c.nAe4 \Flexion
Uil finders (Extenjion

, i Extension
•"•'"{Flexion

Extension little finfer

L'pperiLowr Eyelids
Anfle of Mouth

Zygomatic Muscles and
levator labii sup.

Masseter

Ulnar flexion \
-Volarflexion 1 1^„-.,
^ladiatflexionX'^"^
fforsaUlexion)
'.Strong tlexlon'\
Extensioit ( jf,umh
~ Opposition \
5pasm )

ExI. pterygoid

Fig. 21.— Bennefs method shown on the right; Thane's* on the left. {Esmarch and Kowalzig.)

* Thanes Method.— Dr^sv the line a-h (Fig. 21) from the root of the nose to the external
occipital protuberance. Take the point e, three-fourths of an inch posterior to the middle
point of a-h. A line drawn forwards and outwards from e, at an angle of 67 degrees to a-b,
corresponds to the fissure of Rolando.

THE SKULL AM) TIIK I5RAL\

The .simplcsl and most easily rcmcmhered means of finding the fissure of
Rolando is that devised by Bennet (Fig. 21). At right angles to the sagittal
suture draw two parallel lines, the anterior of which (c-d) runs along the anterior
margin of the external auditory meatus; the posterior (e-f) touches the posterior
margin of the mastoid process. These two lines will be about two inches apart.
On the anterior line take a point (g) two inches above the external auditory
meatus, and from it draw a line (g-e) upwards and backwards to the point where
the posterior line meets the sagittal suture. This oblique line is about three
and three-quarter inches in length and corresponds to the Rolandic fissure.

The simplest means to find the point of bifurcation of the Sylvian fissure is
the following (Esmarch): Draw a line one and one-half inches above and
parallel to the zygoma. Draw a vertical line three-quarters of an inch posterior
to the frontal process of the malar. These two lines cross at a point correspond-

FiG. 22.

ing to the bifurcation of the Sylvian fissure. Vogt's method of finding the same
spot is more easily remembered. The desired position is two finger-breadths
above the zygoma and one thumb's width behind the frontal process of the
malar (Fig. 16).

A more elaborate system for finding the cortical centres is that of Chiene
("Sajous' Annual," 1895) (Fig. 22): "Shave the head and find, in the median
line of the skull, between the glabella (G) and the external occipital protuber-
ance (0), the following points: The mid-point (M), the three-fourths point (T),
and the seven-eighths point (S). Find also the external angular process (E)
and the root of the zygoma (P) immediately above and in front of the external
auditory meatus. Having found these five points, join EP, PS, and ET.
Bisect EP and PS at N and R; also bisect AB at C and draw CD parallel to
AM. The pentagon (ACBRPN) corresponds to the temporo-sphenoidal lobe,
with the exception of its apex, which is a little in front of N. MDCA corre-
sponds to the Rolandic area containing the fissure of Rolando, the ascending
frontal and the ascending parietal convolutions. A is over the anterior branch of

CEREBRAL TOPOGRAPHY

■^0

the middle meningeal artery and the bifurcation of the Sylvian fissure; AC fol-
lows its horizontal limb. The lateral sinus at its highest point touches the line
PS at R. MA corresponds to the precentral sulcus, and, if it be trisected at
K and L, these points will correspond to the origins of the superior and inferior
frontal sulci. The supramarginal convolution lies in the triangle HBC. The
angular gyrus is at B."

n 1 Z 3 4 St

Fig. 23. — Osteoplastic exposure of cerebral tumor. {Krause, Die Deutsche Klinik.)

Having determined by measurement, etc., the point at which removal of
bone will expose the tumor, mark that point on the scalp with iodine, nitrate of
silver, the point of a cautery, or, what is far better, puncture the scalp with a
small drill which at the same time marks the outer table of the skull. If it
seems proper, any desired areas of the skull may be mapped out by a series of
drill marks.

Step I. — Reflect the scalp and open the skull as already described. Gener-
ally one of the osteoplastic or trap-door openings is best. If the patient is weak

24 THE SKULL AND THE HKAIN

or if there has been much loss of blood and shock sustained during this step
of the operation, attend to hemostasis, apply dressings, and defer further
proceedings for a few days. If the tumor cannot be removed, the mere opening
of the skull often relieves distressing symptoms, e.g., agonizing headache.

Step 2. — Examine the exposed cranial contents both by inspection and
palpation. In cases of tumor and blood-clot it is usual to notice an absence of
cerebral pulsation and the dura often bulges into the trephine opening. By
palpation tumors have been correctly located at a depth of one inch from the
surface. Fig. 23 shows the appearance of a subcortical gliosarcoma in the arm
centre, before and after incision of the meninges. Having recognized and de-
termined the superficial boundaries of the growth, reflect the dura mater as a
U-shaped flap. If the dura is involved in the growth, part of it must be sacri-
ficed. When encapsulated, the tumor itself is removed by careful dissection
with blunt instruments; a plain silver teaspoon is very useful for this purpose.
Infiltrating tumors are unsuited for operation. Hemorrhage is arrested by
gentle ligation of vessels when this is possible; by the application of gauze pads
wrung out of hot water and by packing with iodoform gauze. The cavity left
in the brain may require drainage by means of gauze, but the brain soon ex-
pands and fills up the space. After the active operation is completed, close the
wound in the dura and scalp, leaving of course, an opening for the emergence of
the gauze. If the skull has been opened by the trap-door method, enough bone
must be removed from the flap to permit of proper drainage. When a portion
of the dura mater has been excised, it is well to protect the brain by the applica-
tion of a layer of rubber tissue or celluloid. This measure is only feasible if
drainage is not required. If the tumor is cystic, drainage of the cyst is often
recommended as sufficient, but in the author's experience this has proved futile,
and he has been compelled to operate again and remove the cyst-walls.

Hemorrhage and shock are not the only dangers to be feared in cranial
operations. It is well known that when the ventricles have been opened a
dangerous condition of hyperpyrexia may develop. (Bergmann, de Verco,
Parry Davenport: quoted by A. Broca, "Precis de Chirurgie Cerebrale," p.
323.) Sir Victor Horsley is of the opinion that a thermo-taxic centre exists in
the cortex and that w^hen this centre is injured a condition of hyperpyrexia pre-
vails independently of any injury to the ventricles. One case seen by the author,
in which the skull was opened with chisel and mallet but the dura was undis-
turbed, died in a state of marked hyperpyrexia before sufficient time had elapsed
for septic changes to have developed. Another case reported to the author by
H. E. Pearse supports Horsley's contention. This case was one of depressed
fracture. At the operation a rubber drainage-tube was inserted. Immediately
the temperature rose to a high degree. The dressings were removed and the
drain was found to have slipped between the skull and brain. On removal
of the drain the temperature returned to normal and the patient made an
uninterrupted recovery.

DECOMPRESSIVE OPERATIONS ON CRANIUM

Macewen, Horsley and others have found much good follow exploratory
opening of the cranium in cases where tumor was present but could not be

DECOMPRESSION ^5

removed. The opening in the skull permits the tumor to grow without exercis-
ing so much pressure on the cranial contents. Under such circumstances the
non-elastic dura is capable of keeping up injurious pressure, hence when de-
compression is desired the dura should be incised or a portion of it be excised.

Operations of the class referred to are known as "decompressive operations."

Whenever feasible, tumors of the brain should be removed, but frequently
it is impossible to find the location of the tumor or to remove the tumor if its
precise situation is known. Under the above circumstances a decompressive
operation at the site of election is indicated not as treatment of the tumor but
as treatment of the distressing symptoms, vomiting, headache, choked disc, etc.

If the tumor is believed to be in the cerebrum, Harvey Gushing has shown
that it is advantageous to open the skull under the temporal muscle. In this
situation the bone is thin and non-vascular, while the temporal muscle and
fascia, if properly preserved, form an efficient covering for the brain and pre-
vent an undue hernial protrusion in case there is a great increase of intracranial
tension. If the tumor is below the tentorium cerebelli the skull may be opened
through the occipital bone.

Method A. — Cushing's Subtemporal Decompression Operation.

Step I. — From a point immediately in front of the attachment of the ear
make an incision upwards and slightly backwards for about three inches (Fig.
24). Do not employ a curvilinear incision in
the scalp. The cut penetrates the skin and
galea but not the temporal fascia. While making
the incision the surgeon controls bleeding from
one side of the wound by pressing the scalp
against the skull, the assistant exercising similar
pressure on the other side, and at the same
time controlling the temporal artery by pressure
with one finger.

Before releasing the finger pressure, clamp
the galea with hemostats about 3^^ inch apart. I

When these hemostats are laid flat on the scalp
the galea will cover the edge of the skin wound, and control bleeding (Fig. 25).

Step 2. — Cut through the temporal fascia and muscle to the bone. At the
upper end of the incision never separate the fascia from its bony attachments.
If there is bleeding from the lower end of the wound pack a strip of gauze
between the muscle and bone.

Step 3. — Free the muscle from the squamous portion of the temporal bone
over an area about 3 inches in diameter. To gain access to the denuded area
Gushing raises and retracts the soft parts by double angled retractors.

Step 4. — Penetrate the skull by means of a suitable burr. Separate the
dura from the bone. Do this with particular care, downwards and forwards
because of the middle meningeal vessels. If the operation is performed for
purposes of drainage as in fracture, a small opening suffices, if for decompression
as in cerebral tumor, the opening must be as large as the temporal muscle
permits.

Step 5. — The large cortical vessels are visible through the dura. Gut

THE SKULL AND THE BRAIN

through the dura at a spot free from these vessels but do not injure the pia-
arachpoid. Enlarge the opening by cutting on a grooved director. In case
of a fracture explore toward the base beneath the temporal lobe and remove
clots, etc. The object of the operation in tumor cases is to relieve tension and
preserve vision when the growth is unlocalizable or irremovable. If a tumor
is unexpectedly encountered, unless a cyst which may be emptied, it should be
left in situ until later when an osteoplastic procedure can be carried out to
expose it, temporar}- dependence being placed on the relief of tension to ameli-
orate symptoms.

iriG.

■{Cushing Manual .\curo. :>ur^. Med. Depart., U. i>. A.)

Step 6. — Close the temporal muscle with interrupted sutures of fine silk
(Gushing). In the same way close the temporal fascia. These two structures
will prevent undue cerebral herniation.

Step 7. — Suture the galea very carefully, the stitches being placed fairly
close together and cut close to the knot.

Step 8. — Introduce fine silk skin sutures on straight seamstress needles,
leaving the needles in situ until the last one is in place. This everts the skin
margin and brings a broad area of the cut surface into approximation. The
skin sutures may be removed in 48 hours.

William Sharpe (Am. Journ. Med. Sc, June, 1916) advised unilateral or
even bilateral subtemporal decompression in cases of 'Steeple Skull' (Thurm-
schadel) or oxycephaly ic which there is optic atrophy beginning from intra-
cranial pressure. The cranial deformity consists essentially of a ver\- high
forehead towering over the face, of poorly marked supracilian*" and temporal
ridges and in severe cases of a protrusion at the anterior fontanelle. There is

EXPOSURE OF CEREBELLUM

Fig. 26. — Showing outrigger for head and adjustable shoulder supports: before padding:
also hoop to support sheets. (Cushing, "Tumors of Nervus Acusticus.")

Fig. 2:

-Patient in position before anesthetization.
Acusticus.")

(Cushing, "Tumors of Nervus

28 THE SKULL AND THE URAIX

present exophthalmos, divergent (rarely convergent) strabismus and impair-
ment of vision. Without operation, once symptoms have arisen they tend to
progress and few, if any, of the patients reach maturity. The few cases reported
by Sharpe are encouraging.

Bilateral Exposure of the Cerebellum. (Gushing. Tumors of the Nervus
Acusticus, 1917.) — This operation may be used as a means of decompression
in cases of unlocalized subtentorial lesions or for the exposure and removal of
tumors of the cerebellum or of the acoustic nerve. In Cushing's hands the
operation, when it includes the removal of a tumor^ may be extremely long
(three hours or more) but reasonably safe, the operative mortality in the
acoustic cases having fallen to about 11 per cent., whereas it was formerly over
50 per cent.

Preparation oj Patient. — Omit breakfast. Give an enema if necessary.
Shave the back of the head (Fig. 27) on the mornmg of the operation.

The operating table is shown in (Figs, 26-27). The patient lies prone
on a thick mattress. The shoulders are supported on well-padded crutches,
the forehead is carried by a padded outrigger.

The anesthetic, ether, is administered by means of Connell's apparatus.

Preparation of the Field. — Wash with green soap on a gauze sponge. Wash
with alcohol and then with bichloride solution as the patient is getting well under
the anesthetic. Mark the proposed lines of incision by a knife scratch. The
transverse curvilinear incision runs from mastoid to mastoid arching about
4 cm. (13^^ inches) above the occipital protuberance. The vertical incision
runs downwards 9 or 10 cm. (33^^ inches) exactly in the middle line.

Cover the whole field with a large layer of bichloride gauze. Drape every-
thing, except the exact field of operation, with sheets which form a tent for
the anesthetist. Sheets should be pinned or clipped to the skin around the
field of operation. No towel should slip or be changed during the operation,
hence the importance of marking the proposed lines of incision prior to draping
and hiding anatomical landmarks.

Step I. — With finger pressure control hemorrhage while making the curvi-
linear incision which divides the scalp and galea (epicranial aponeurosis).
Before releasing the finger pressure, pick up the galea and the principal sub-
occipital vessels with hemostats. Lay the hemostats flat on the skin, thus
folding the galea over the edge of the scalp wound (Fig. 28) and so preventing
subsequent bleeding. Reflect the curved flap downwards to slightly below
the occipital protuberance and the muscular attachment of the superior curved
line. Make the vertical incision (Fig. 29) exactly in the midline through the
intermuscular spaces to the skull and the spines of the upper vertebrae. Apply
clamps symmetrically on the two sides as guides for future closure. The ver-
tical incision shows the exact level at which the transverse cut should be made
along the line of muscular attachment. Apply a distinctive forceps on each
side to the two upper edges of the vertical incision in the fascia (Fig. 29).
Divide the fascia along the superior curved line and reflect it downwards.
Treat the muscle similarly. Leave enough of the fascia and muscle attached
to the bone to serve for subsequent suture. With an elevator separate the
muscle from the bone on each side far enough to expose the margin of the fora-

EXPOSURE OF CEREBELLUM

men magnum, the edge of each mastoid and well down under the occipital
bone on either side. Bleeding from emissary vessels may be controlled by
plugging with Horsley's wax or a fragment of muscle. With a burr open the
skull. Enlarge the openings with rongeurs (Fig. 30) to the full extent of the
denuded area. The lower margin of each lateral sinus is usually exposed.

3B«pa»Wfcf)W^«i» II I 111 ■■

Fig. 28. — Showing control of incision for completion of incision. (Gushing, "Tumors of

Nervus Acusticus.")

Bone wax may occasionally be required to stop bleeding. Often it must be
applied after each bite of the forceps during the removal of the thicker bone
in the mid-line.

Opening of the Dura. — Should an opening be made over one of the hemi-
spheres the cortex would protrude and be damaged because of increased intra-

THE SKULL AND TilK BRAIN

dural Icnsion. To avoid this make a niiiuilc opening through the dura near
the foramen magnum so as to withdraw iluid from the posterior cistern. If
this fails to lessen tension do not enlarge the opening but at once tap the lateral
ventricle. To do this retract the scalp in the subaponeurotic layer and burr a
hole through the skull about 3-4 cm. {iji inches) above the superior curved

Fig. 29. — Mid-cervical incision carried to spine. Placement of identifying clamps on corners
before lateral incisions are made through. {Gushing, "Tumors of Nervus Acusticus.")

line and 2 cm. {% inch) from the midline. Through this hole pass a blunt
cerebral aspirating needle slightly upward and outward to a depth of 4-5 cm.
(i%-2 inches). Usually the first tap succeeds. Leave the needle in place
during the rest of the exploration.

It is now safe to open the dura. "Care must be taken in crossing the
median line, for the sagittal cerebellar sinus may be of considerable size and

EXPOSURE OF CEREBELLUM

the cerebellar falx may penetrale in some cases for a considerable distance. As
the midline is crossed the cerebellum should be held away with a spoon spatula,
and the sinus may be caught, before division, with silver clips. Stellate inci-
sions of the membrane to the margin of the bone defect are then made and the
hemispheres fully exposed."

{' 4

Fig. 30. — Showing denudation of suboccipital region: exposure of foraminal field by reflection
of flaps: primary bone openings. {Cushing, "Tumors of Nervus Acusticus.")

When decompression is alone the object sought, the wound may now be
closed. If there is any doubt of the diagnosis, compare the two hemispheres
for dijBferences of tension, of form, or of vascularity. "An intracerebellar cyst
can usually be detected by palpation; an involvement of one hemisphere rather
than the other by displacement of midline structures." If it is believed that a
cerebello-pontile angle lesion is present, slight pressure with a spoon spatula

THE SKULL AND THE BRAIN

on the cerebellar hemisphere (Fig. 31) gives access to the region, provided
that the margin of the mastoid has been included in the cranial defect.

The sigmoid sinus is first brought into view and at a varying distance
beyond it, the arachnoid attachment or an encysted collection of fluid within
the arachnoid, is ecountered. On opening the cyst the surface of the tumor

IlG. 31. — Showing exposure of encysted fluid within the arachnoid overl\-ing a tumor, from a
sketch during operation. {Gushing, "Tumors of Nervus Acusticus.")

will usually be seen. The best line of approach is toward the jugular foramen
rather than directly toward the porus. With wet cotton pledgets wipe the
arachnoid and the margin of the cerebellum from the tumor. The cerebellum
must be protected continuously by a covering of wet cotton. Do not endeavor
to extirpate the tumor, incise it bluntly and enucleate as much els possible intra-
capsularly with a spoon like a gall-stone scoop. If there is much bleeding

CALLOSAL PUNCTURE ^^

insert pledgets of cotton wet with Zenker's solution. When the deep cavity
is absolutely dry, allow the dislocated cerebellar lobe to settle back, in place.

Closure of the Wound. — Close the vertical wound accurately with many
interrupted sutures of fine silk. The four guiding clamps apj)lied early in the
operation aid much in assuring accuracy. This closure is made in several
layers. Close the transverse wound by suturing the muscle, the fascia, the
galea and the skin each separately. Apply temporary dressings and leave the
patient on the table until conscious. Then put on voluminous dressings held
in place by a starch bandage (wet crinoline bandage). Leave the dressing in
place about lo days.

Anton suggested that in cases of inoperable or unlocalized brain lesions
(tumors, internal hydrocephalus, etc.) intracranial pressure might be lowered
by perforating the corpus callosum, whereby a free communication would be
established between the ventricles and the subdural space. If the intra-
ventricular pressure is above normal the fluid must flow out into the subdural
space and in doing so keep the perforation patent. Experiments made by
Rehn show that such a flow does take place. The anterior and middle thirds
of the corpus callosum form the best site for puncture as it is thinnest here
and one or other of the lateral ventricles is sure to be penetrated. A careful
study of callosal puncture has been made by v. Bramann ("Archiv fur klin.
Chir.," xc, 68g), who operates in the following manner:

1. Choose a spot about one finger-breadth behind the bregma (i to i}^ cm,
behind the coronary suture) and expose the skull here by any suitable incision.

2. With a bur make an opening i cm. by i}'2 to 2 cm. through the skull
at right angles to the sagittal suture.

3. Note the longitudinal sinus and at its margin make a small opening
through the dura mater.

4. Pass a sinus forceps (v. Bramann uses a special pliable silver cannula with
a mandrin) alongside the sinus into the longitudinal fissure where it meets the
falx. Guided by the falx, pass the instrument vertically downwards until it
penetrates the corpus callosum.

5. Open the blades of the forceps (or remove the mandrin from the cannula)
and permit the ventricular fluid to escape. Enlarge the callosal opening by
moving the instrument gently backwards and forwards (not laterally).

6. Remove the instrument and close the wound in the scalp.

V. Bramann has performed callosal puncture in twenty-two patients without
a death attributed to the operation (cerebral tumors thirteen; hydrocephalus
eight; epilepsy one).

Anton and v. Bramann believe callosal puncture indicated: i. In all cases of
hydrocephalus where internal treatment has failed.

2. In all cases of tumors and pseudo tumors of the brain accompanied by
internal hydrocephalus and choked disc which threatens blindness.

3. When intracranial pressure is so great as to interfere with palpation
of the brain or with the removal of tumors, preliminary callosal puncture may
aid.

34 THE SKULL AND THE BRAIN

OPERATIONS FOR INFECTIVE DISEASE OF THE MIDDLE EAR
AND CRANIAL CONTENTS

Cerebral abscess is almost always the result of chronic otitis media. Proper
treatment of the cerebral abscess requires removal of the original focus of dis-
ease. In the following pages the author makes free use of Macewen's classical
work on the "Pyogenic Infective Diseases of the Brain and Spinal Cord." The
reader is advised to carefully study the above book before attempting any
operation for cerebral abscess. The present chapter is only written in the hope
of aiding some parctitioner who is forced to operate without the advantage of
such study.

Suppurative disease of the middle ear unrelieved by treatment administered
through the external meatus is always complicated by disease of the mastoid.
The chief indications demanding operation on the mastoid cells are:

1. Repeated inflammations of the mastoid antrum and cells with swelling
over or fistulae leading into the bone.

2. Acute inflammation with retention of pus in the antrum or cells.

3. The occurrence of initial symptoms of intracranial involvement asso-
ciated with chronic purulent otorrhoea.

4. Persistent chronic otorrhoea, not principally due to the condition of the
tympanum or Eustachian tube, and which is considered by the aurist otherwise
incurable, even although there are no clear indications of mastoid involvement.

5. If the discharge contain virulent organisms, if it be highly offensive, mixed
with osseous debris or cholesteatomatous masses, operation is indicated, as
most serious intracranial mischief is often present without marked mastoid
swelling.

The Operation. — I. Cleanse the external and middle ear as thoroughly as
possible. Shave the scalp above and behind the mastoid. Cleanse the skin.

Step I. — Place the patient on his side with the affected mastoid uppermost.
Have the parts well lighted. Pull forward the external ear. Palpate the mas-
toid and the posterior root of the zygoma. Make a perpendicular cut about
one-quarter inch behind the posterior border of the external bony meatus from
the posterior root of the zygoma to a point about one-third of an inch from the
tip of the mastoid. The knife penetrates to the bone. With the elevator
separate the periosteum and soft structures from the bone in front of the cut
and thus fully expose the posterior aspect of the external audority meatus.
Attend to hemostasis. Hold the reflected tissues and auricle forward with a
sharp retractor.

Step 2. — Observe the limits of the suprameatal triangle, viz., the posterior
root of the zygoma above, the upper and posterior segment of the bony external
meatus below, and an imaginary vertical line (EF, Fig. 32), extending from the
most posterior portion of the external osseous meatus to the zygomatic root,
behind. This vertical imaginary line is the base of the triangle. Observe
the degree of obliquity of the posterior wall of the external auditory meatus as it
leads inwards and forwards to the middle ear. By the aid of a probe observe
the depth of the inner wall of the tympanic cavity from the level of the skull.

The best instrument for use in penetrating the bone is a bur rapidly rotated

EXPOSURE OF MASTOID ANTRUM

by a surgical engine. One may conveniently use a bur operated by the " brace"
shown in Fig. 13. Apply the bur to the bone at a point inside and beside the
base of the suprameatal triangle. Penetrate the outer shell of hard bone. In
some cases the whole mastoid is thickened and sclerosed by disease. With the
bur, slowly and cautiously advance through the bone in a direction inwards and
a little forwards, parallel to the posterior wall of the external auditory meatus.
Do not use the bur as if it were a drill, making a uniform cylindrical perforation
the same size as the instrument; this would be dangerous and nearly useless.
Use it to make a hole in the mastoid very much larger than the instrument —
large enough to permit of the continuance of the work under the guidance of the
eye as well as of touch. The external opening may safely be made the whole
size of the suprameatal triangle. Whenever a dark spot is seen on the cut

Fig. 32. — C, F, E (X^ Suprameatal or Alacewen s triangle.

A. B. Upper two-thirds of this line overlies the sigmoid sinus. C, D. Overlies sigmoid sinus
from knee to commencement.

surface of bone, examine it at once with a fine probe or searcher (a dental probe
is good). The dark spot is probably an opening into one of the mastoid cells
or even the antrum; if the latter, the probe will find a large cavity communicat-
ing with the middle ear. The depth of the antrum from the surface varies from
/'i to ^ inch. A small opening having been made in the antrum and its
cavity explored with a probe, bur away all its external wall, remove all pus,
granulation tissue, or other disease products.

II. Observe the position of the opening between the antrum and the middle
ear, the position of the facial nerve traversing the inner half of the floor of the
antral passage obliquely from without inwards, as it passes into the inner wall
and roof of the tympanum above the foramen ovale. The nerve route is often
indicated by a cylindrical ridge of bone smoother and denser than that in the
neighborhood. If the position of the nerve is not positively made out, have
an assistant observe the patient's face for the occurrence of twitchings if the
nerve is endangered in the subsequent proceedings. In observing the condition
of the tissues deep down in the wound light should be thrown in, either by means

36 THE SKULL AND THE BRAIN

of a head mirror or of an electric lamp (with reflector) held by an aid. Ex-
amine the roof of the antrum for evidences of bone disease. If buds of granu-
lation tissue sprout from the roof, examine them; they may come from inside
the skull and show the presence and location of intracranial involvement.

Step 3. — Examine the mastoid cells opened during exposure of the antrum;
if they are diseased, as evidenced by the presence of granulation tissue, pus. etc.,
destroy their walls wuth the bur, so that instead of numerous, irregular, small
cells, one large cavity with smooth walls is formed. Remember the location of
the sigmoid groove and sinus (Figs. 32 and 34). Because of the sinus it is wise
to open the mastoid cells by working from the antrum downwards and back-
wards. Never attack an exposed cell before thoroughly exploring it with a
probe. Remember that granulation tissue and other disease products may be
continuous from the middle ear through the antrum, mastoid cells, sigmoid
groove, and sinus to the cerebellum. If granulations are found sprouting out
from the sigmoid groove or other evidences show disease in that locality, do not
yet attack it. Complete the thorough cleansing of the antrum and mastoid,
bur away all partitions, and leave them as one cavity with smooth walls.

Step 4. — The middle ear is diseased and requires to be opened. Apply a
small bur at the junction of its roof with the outer wall of the antral passage.
Do 7iot touch the floor or inner wall of the passage for fear of injury to the facial
nerve or semicircular canal. Freely expose the tympanic attic and examine its
roof in the same way as the roof of the antrum was examined. Examine the
malleus and incus ; if diseased, remove them. It is important to leave the stapes,
if possible; but if diseased, it also must be removed. If the mastoid antrum,
and middle ear are the only seats of disease, the active operation is ended; the
cavity is packed with iodoform and boracic acid (1:4) and with iodoform gauze.
Closure of the wound is facilitated by removal of a portion of the posterior
bony wall of the external auditory meatus. Dressings are applied.

Step 5. — If on examination of the roof of the antrum or tympanic cavity
erosions of the bone exist and granulations sprout out from the cranial cavity,
or if there are symptoms of intracranial involvement, active operation is con-
tinued. With the bur remove the eroded bone of the antral or tympanic roof in
a direction outwards from the perforation. If pus and granulation tissue pre-
sent, there is an extradural focus which must be carefully cleansed. Do not
inject any fluids until the whole space between the dura and bone has been
explored and the presence or absence of openings through the dura made certain.
If there is no dural opening, gentle washing is safe, and the extradural space
may be dressed with iodoform and boracic acid and iodoform gauze. If there
is evidence of disease under the dura, clean the extradural space and freely
open the dura.

Step 6. — Pus in the arachnoid or pia or on the surface of the brain must be
gently washed away, and iodoform and boracic acid powder must be applied.
If an abscess exists in the temporo-sphenoidal lobe, enlarge the opening through
the roof of the antrum and tympanic cavity, apply iodoform and boracic acid
to the wound, and proceed to Step 7.

Step 7. — Extend the cut through the soft parts upwards and expose the
skull above the ear. Open the skull with a small trephine whose centre pin is

INFECTIONS OF MASTOID 37

applied at a point three-fourths of an inch above the posterior root of the zygoma
and in line with the posterior osseous wall of the external auditory meatus.
Rub iodoform into the cut surface of the bone. Incise the dura. If necessary,
make a crucial incision. Stop bleeding. If the abscess is large, the brain will
probably bulge and fail to pulsate; if smaller, neither of these signs may be
present. To explore for pus use a trocar and cannula or a sinus forceps. A
hollow needle is liable to become plugged. Introduce the instruments inwards,
downwards, and slightly forwards, so as to impinge, if pushed far enough, against
the cranial aspect of the roof of the tympanum. If a trocar and cannula are
used, the trocar should be removed at every quarter inch of progress to see if pus
escapes; if a sinus forceps, the blades should be slightly opened for the same
purpose. After pus is found, remember that the abscess probably contains
sloughs and shreds of tissue too large to escape through the cannula and which
must be removed. Alongside the cannula introduce closed, narrow-bladed
hemostatic or sinus forceps; open the blades gently and permit the sloughs to
flow out between the blades. If the sloughs cannot escape by themselves, they
may be assisted out by forceps or spoon; their removal is of prime importance.
After removal of the sloughs replace the hemostatic forceps by a small cannula.
Through the mastoid wound and the opening through the antral roof introduce
into the abscess cavity a cannula at least one-half as large again as that already
in situ. Be sure that the end of this tube is in the cavity. It is wise to let the
two cannulas come in contact. Gently introduce a stream of hot water or mild
antiseptic solution through the smaller tube and see that it all escapes through
the larger. Lest fluid should enter the Eustachian tube, fill the middle ear with
the iodoform and boracic powder. In an acute abscess which has been
thoroughly cleansed of infective matter, a drainage-tube is of little value and
may do harm. If there is doubt as to the thoroughness of the evacuation, intro-
duce a decalcified bone drain so that its opening is just within the abscess.
Stitch the drain to the skin. If the abscess cannot be properly drained, in the
above manner, use a rubber or glass tube for from twenty-four to forty-eight
hours. Treat the mastoid opening as already described. Close the temporal
opening with or without drainage on ordinary surgical principles.

[If abscess of the temporo-sphenoidal lobe exists, without indication of dis-
ease requiring the mastoid to be opened, the operation is carried out practically
as described in Step 7; but in washing out the abscess an escape for the fluid
must be provided by means of a cannula, at least half as large again as that
through which it enters. The two cannulae lie side by side.]

Step 8. — It has already (Step 3) been shown that disease of the sigmoid
groove may be discovered while the mastoid cells are being obliterated.
Examination with the fine probe or searcher shows that buds of granulation
tissue coming through osseous openings are continuous with the same tissue in
the sigmoid groove. Apply the bur to the posterior wall of the antrum and
with it remove the bone horizontally backwards for half an inch. In a majority
of cases this will open the greater part of the diameter of the sigmoid groove
after which it may be opened above and below that point as may be indi-
cated. The anterior knee of the sinus is situated from one-eighth to a quarter of
an inch behind the base line of the suprameatal triangle (Fig. 7,2). If it seems

38 THE SKULL AND THE BRAIN

necessary to open the sigmoid sinus to remove septic blood-clot, fully one inch of
the sinus ought to be exposed, vertically, by removal of bone. Remove any
diseased tissue lying between the groove and the sinus. If, on examination by
the eye and the probe, the disease is found to extend through the bone into the
cerebellum, this disease route must be followed and cleansed and any cerebellar
abscess attended to in the manner to be described. If there is septic sinus
thrombosis, open the sinus and remove the filth within it. After cleansing the
sinus, introduce into it a quantity of iodoform and boracic acid powder, make
the walls of the sinus collapse, gently pack the sigmoid groove with the same
powder, and loosely pack the whole cavity with iodoform gauze. If during the
operation hemorrhage take place from a non-thrombosed sinus, it may be
stopped, if slight, by temporary pressure; if more severe, by separating the wall
of the sinus from the bone and pushing the loosened wall inwards by means of
iodoform gauze packing. In certain cases Horsley has found it valuable to
doubly ligate and divide the internal jugular vein. This is intended to prevent
dissemination of the infective material throughout the body.

Step 9. — In the preceding step it has been shown how extension of disease
through the sigmoid sinus to the cerebellum may be discovered. If this is
the case, the disease is followed and the bone between the sigmoid groove (outer
aspect of the groove) and the cerebellum is removed by the bur. The mem-
branes covering the cerebellum are treated in the same manner as were those
covering the temporo-sphenoidal lobe. If a cerebellar abscess exist, enlarge-
ment of the osseous opening already made permits of its evacuation and treat-
ment on the principles already described.

After-treatment. — If there is no evidence of petrous or internal ear disease,
the wounds must be packed with iodoform gauze to compel healing to take place
from the bottom. The whole cavity ultimately becomes a solid mass of scar
tissue. In the presence of petrous or internal ear disease a seton of iodoform
gauze must be passed from the middle ear, through the antrum out by the mas-
toid opening. This gauze seton is frequently renewed and its route kept clean,
until epithelium from the mucous membrane and the skin has so covered the
track that a permanent fistula is assured through which any discharge from the
internal ear or petrous bone may escape. The formation of the permanent
sinus may be hastened by lining it with skin grafts.

After the dressings are applied put the patient to bed, and keep him there
until the wounds are completely healed. A low liquid diet is recommended for
a fortnight after cerebral abscesses have been evacuated. The only peculiarity
of the after-treatment is the necessity of a little extra insistence on quiet, and on
the observance of the usual rules adopted after major surgical operations. It
is well to have the room darkened.

Abscesses in other localities of the brain, after being diagnosed and located,
are operated upon on the same principles as have been described in the pre-
ceding pages.

OPENING THE MASTOID WITH THE CHISEL AND RONGEURS

Undoubtedly the bur operated by a surgical engine is the most elegant instru-
ment with which to open the mastoid antrum, and it possesses many advan-

OPENING THE MASTOID 39

tages over the chisel; but comparatively few surgeons possess the necessary
instruments nor are they convenient to carry to a patient's home when the
patient cannot or will not enter a hospital. Most surgeons possess some dex-
terity in the use of the chisel but are not educated to the bur, hence the
chisel and its relative, the rongeur forceps, are the instruments commonly used
in the mastoid operation.

The operation often ends immediately after the mastoid antrum is opened.
This is improper, as the antrum is only one of many mastoid spaces, any or all
of which may be diseased.

Whiting ("The Modern Mastoid Operation"), in his superbly illustrated
book, shows how the "air-cells" may extend above and over the bony meatus,
and unless these are obliterated, the suppurative process is sure to continue.
The principle of the complete operation on the mastoid is the obliteration of all
the mastoid cells and the removal of all disease wherever situated, as described
in the preceding pages. The method of operating usually adopted by the
author is much as follows:

Clean the ear as well as possible. Shave and clean the skin over and around
the mastoid.

Step I. — ^Make an incision parallel to the insertion of the auricle and about
34 inch posterior to the external auditory meatus. The incision stretches from
just above the root of the zygoma to a little below the tip of the mastoid. Ex-
pose the whole surface of the mastoid by reflecting the soft parts along with
the periosteum. A second incision at right angles to the first may be necessary
to insure exposure. Examine the bone for points of necrosis or for the escape
of pus at the vascular orifices.

It is especially important to examine the mastoid vein at its outlet, which is
usually near the posterior margin of the bone. The vein varies in size and may
divide into several branches as it passes through the skull. As the vein com-
municates directly with the sigmoid sinus, when the latter is thrombosed the
former is likely to be in the same state. Thrombosis of the mastoid vein is
positive evidence of sinus thrombosis; apparent patency of the vein is of no sig-
nificance. Pus oozing from the mastoid foramen signifies pus situated outside
the dura in the cerebellar fossa, about the sigmoid groove.

Step 2. — Pull the external ear well forwards with a retractor. Observe the
depth and direction of the external auditory canal. Beginning at the upper part
of the suprameatal triangle, shave off thin slices of bone downwards and forwards
towards the tip of the mastoid, always hugging the posterior margin of the bony
meatus. This shaving is to be done with a chisel or gouge about 34 inch in
width, propelled by a mallet. The chisel must be held almost parallel to the
surface of the bone, and must always be directed downwards and forwards.

The usual chisels and gouges supplied for mastoid work are short and have thin shanks
and handles. Such may be safe and convenient in the hands of aurists, but to the general
surgeon a chisel with a handle like a Macewen osteotome, or even a carpenter's tool, is much
safer and more practical. It is well to have a number of chisels or gouges of different sizes.

After several exceedingly thin slices of bone have been removed, the diploe
will be reached, unless there is much sclerosis.

40 THE SKULL AND THE BRAIN

With a narrow curette scrape away the superficial portion of the diploe. If
pus or fluid appears, note its quantity, as this gives some index to the size of the
cavity from which it comes; note also if the pus is thrown out in jets or pulsating
fashion, because such pulsation is communicated from the brain and is almost
absolute proof that the disease has penetrated at least to the meninges. With a
probe gently explore the pus-cavity and enlarge the opening with curette, gouge,
or rongeur, as may be convenient. Never endeavor to clean out a pus-cavity
in the mastoid with the curette through a narrow external opening — it is too
dangerous. If no pus or fluid appears, deepen the groove already cut in the
bone to the extent of 3-3 inch. If the sigmoid sinus is abnormally far forwards,
it ought now to be visible as "a soft, bluish-looking structure, very fluctuant to
palpation and perhaps pulsating demonstrably, which
upon gentle pressure of a probe yields readily but does
not bleed" (Whiting). When the sinus is found in this
abnormal position, the rest of the operation consists in
exposing all the diseased cavities and evacuating all
infective material, without injuring the sinus, unless
that structure is involved in the process. When the
sinus is not abnormally placed, proceed with the re-
moval of all the outer wall of the mastoid process.

Step 3. — With the chisel repeat the manoeuvres by
which the mastoid was originally opened, and so widen
the existing opening that the blade of a rongeur (Fig. t,;^)
can easily enter it and pass under the bone. With a
rongeur carefully bite away the whole bony outer wall of
the mastoid process. Never attack any part of the bone
before making sure that the sigmoid sinus will not be
injured.

Instead of widening the original opening in the bone
with the chisel, the author usually inserts into it, par-
FiG. Z2>. — Narrow-bladed tially, one blade of a heavy rongeur, the other blade of
rongeur forceps. ^^,j^.^j^ ^^^^^ against the mastoid farther back. By ex-
erting a twisting force it is easy to use the posterior blade of the forceps as a
fulcrum, and with the anterior blade (the blade engaged in the bony opening)
to scrape off a thin layer of the cortical bone. This method of using the ron-
geur is difi&cult to describe, easy and safe to practice, and aids materially in
the operation. When the mastoid has once been opened to such an extent
that the ronguer can be used efficiently, either as a biting or as a scraping in-
strument, put the chisel and mallet aside as of no further use. If much
sclerosis is present, this rule does not apply.

Step 4. — No attempt has been made, as yet, to find the antrum or systemat-
ically to obliterate the mastoid cells; the cortical bone has been removed, at least
to a large extent; the diploe has been but little disturbed. Remember that the
antrum in 99 per cent, of cases (Macewen) lies in whole or in part within the
suprameatal triangle; that in the adult its depth beneath the cortical bone varies
from one-eighth to three-fourths of an inch.

With a probe, once more observe the direction and depth of the bony meatus.

INFECTIONS OF MASTOID

With the curette, cautiously remove the cancellous bone from the suprameatal
triangle in a direction parallel to the posterior wall of the bony meatus. This
will almost inevitably open the antrum. If the bone is much sclerosed, a small
gouge must be used instead of the curette. Having opened the antrum, explore
it thoroughly with a probe. With the curette, aided, if necessary, by rongeur
forceps, remove all the external wall of the antrum. In the same manner
remove all the mastoid air-spaces. Every step in the removal of bone must be
preceded by careful examination of the tissues to be removed; remember par-
ticularly the normal site of the facial nerve (Fig. 34) and the normal, and
particularly the abnormal, course of the sigmoid sinus.

Fig. 34. — ^Left temporal bone.

Antrum and most of the mastoid cells obliterated. I. Semicircular canals. 2. Location of facial nerve
in aqueduct of Fallopius, which has been opened. 3. Location of sigmoid sinus.

The mastoid has now been converted into a comparatively shallow pit.
Examine the walls of the pit carefully to see whether the disease process does or
does not penetrate the cranial cavity. If the disease involves the sigmoid sinus
or the meninges elsewhere, it must be attacked according to the principles
already enunciated.

In acute mastoiditis, after the antrum, etc., have been cleaned out, the in-
flammation of the tympanum will promptly recede; hence it is unnecessary to use
the curette in the tympanic cavity (Whiting). This is fortunate, as otherwise
much damage to hearing might easily be inflicted. In cases of chronic mastoid-
itis and otitis the tympanum must be thoroughly opened and appropriately
treated along the lines laid down on page 36 et seq.

Step 5. — With rongeur forceps and curette make smooth the floor and sides
of the bony defect Partially close the wound in the soft parts with sutures.
Pack the remainder of the wound with iodoform gauze. It is comforting to the
patient to have the gauze separated from the wound by a layer of perforated

42 THE SKULL AND THE BRAIN

oiled silk or rubber tissue. After granulations have formed along the course of
the pack they may be covered by Thiersch's skin-grafts. This is usually two
or three weeks after the operation.

It must be remembered that in children under three years of age the mastoid
process is either absent or its presence is merely indicated, while the antrum is to
be sought rather higher than in the adult. In these young children the bone is
so soft that the antrum may be opened with a curette.

In cases of acute (not chronic) mastoiditis Stenger makes a short incision
over the mastoid, reflects the periosteum and, if no fistula is present, chisels or
bores a narrow passage towards the antrum. He curettes this passage (which
need not penetrate the antrum) or the fistula, if such is present, and loosely packs
with gauze, dries the surrounding skin and applies a cupping glass provided
with some form of pump for suction. A sterile ointment spread on the skin
makes the cupping glass act better. The suction is kept up not longer than three
hours at a time. The suction causes pain while it acts, but the relief is great
during the intervals. Stenger and Hasslauer report excellent results and a
shortening of convalescence. ("Muenchner med. Wochensch.," Aug. 21, 1906.)

The use of suction by means of the cup undoubtedly may help drainage, but
its main object is to obtain hyperemia and the whole procedure is based on the
ideas of Bier.

OPERATIVE TREATMENT OF MENINGOCELE AND
ENCEPHALOCELE

Operation should not be undertaken in cases of the above tumors when there
are serious concomitant malformations or when it is believed that portions of
brain, necessary to life, are present in the growth. Horsley has suggested the
application of the induced current to the tumor in order to diagnose if impor-
tant cerebral tissue is involved. Some surgeons — e.g., Berger — believe, and act
on the belief, that any cerebral material present in a meningocele is neoplastic
in nature and possesses no physiological function and may safely be disregarded.
With the exceptions mentioned above, Chipault considers all cases of menin-
gocele suitable for operation. [Meningoceles of the cranial vault are alone
referred to at present.]

The Operation. — Trace out two flaps of skin alone, over the tumor. The
base of each flap corresponds to the pedicle of the tumor. Reflect the flaps.
Expose the pedicle of the tumor at its exit from the skull. Transfix the pedicle,
with a blunt needle, close to the skull, in one or more places, and apply two or
more interlocked catgut ligatures. Tie the ligatures. Cut away the tumor
distal to the ligatures. Replace the skin-flaps. Suture. Dress. Instead of
ligating the pedicle as above described, it is better to open and explore the sac.
If brain tissue is present, looks normal in character, and is reducible without
giving rise to symptoms of compression, reduce such brain tissue, excise the
rest of the tumor, and close the opening in the cerebral membranes with suture.
If no brain tissue is present, excise the sac. If brain tissue is present but is
either abnormal in appearance or irreducible, it must be excised. From the

HYDROCEPHALUS 43

literature of nine years Chipault collected fifty cases of meningocele subjected
to operation with only nine deaths.

Meningoceles protruding through the base of the skull are rarely in situa-
tions accessible to the surgeon. In one case Fenger gained access to the tumor
by temporarily resecting the superior maxilla, and saved his patient. When it
is possible to expose a basal meningocele the principles of operation are the same
as those already described.

MICROCEPHALUS. IDIOCY

Lane, Fuller, and Lannelongue advised removal of portions of the skull in
cases of microcephalus, on the supposition that the early closure of the skull and
consequent defective bone cavity, impeded cerebral development. Variously
shaped portions or strips of skull have been removed by many surgeons and the
primary results seemed promising. The author in several cases was astounded
to find, even on the day following operation, marked improvement in the con-
dition of such patients. The improvements in speech and mentality were truly
incredible, but in not one of the cases observed by him were these improvements
retained, and he is forced to conclude that such operations are worthless. They
will not be described here.

HYDROCEPHALUS

The earliest attempts to treat hydrocephalus by surgical means consisted
in the application of strapping to the head in the endeavor to prevent its in-
crease in size or to diminish its size. Such means were doomed to failure.
Later, paracentesis was resorted to, and cerebrospinal fluid was removed in
greater or less quantity, but though repeated paracentesis occasionally gave
relief yet sooner or later meningitis generally developed and death ensued.

Mikulicz suggested draining the cerebrospinal fluid into the tissues under the
scalp and this procedure was carried out in several different ways. Metal tubes
were inserted so as to conduct fluids from the ventricles to the subcutaneous
tissues. Silk threads, formalinized arteries or veins were used for the same
purpose but, as is noted elsewhere, while temporary success was not infrequent,
the subcutaneous tissues refused to continue acting as absorbents and per-
manent good results were notable because of their absence.

Leonard Hill (quoted by Cheyne and Burghard) has shown that the amount
of cerebrospinal fluid is regulated by absorption and exudation from the veins or
lymphatics of the brain, more especially towards the base; ahd if any cause
interferes with the normal regulation of this cerebrospinal fluid the result on
the brain will be very serious. Meningitis interferes with this regulation, so that
the fluid collects in the ventricles and causes hydrocephalus. See also W. E.
Dandy, Diagn. & Treatment Hydrocephaly resulting from Stricture of Aque-
duct of Sylvius, Surg. Gyn. and Obst., Oct. 1920.) The meningitis at fault is
specially present at the base of the brain near the fourth ventricle, obstructing
the exit of fluid from the ventricles, and hence its proper absorption. Based

THE SKULL AXD THE BRAIN

on the above, G. A. Sutherland and one of the authors referred to, attempted
to establish the natural absorption by the following operation:

Reflect a flap of scalp and open the skull near and posterior to the anterior
fontanelle (occasionally the lower angle of the fontanelle itself has been opened).
Incise the dura. Take about twelve strands of thin catgut 2 to 3 inches in
length and tie the ends together. Pass one end of this bunch of catgut down-
wards and backwards between the brain and the dura until about ^-^ inch is left
projecting from the opening in the dura. Seize the free end of this projecting
portion in a forceps and push it through the brain into the lateral ventricle.
Thus a catgut drain is made to stretch from the ventricle into the subdural space.
Close the wound in the dura and the scalp. As a rule, the temperature runs up
to 104° or io5°F., but falls again in the course of a week or ten days. The skull
soon diminishes in size to a very marked degree.

Fig. 35. — Ballance's method of ventricular drainage.

The results have been better in congenital than in acquired hydrocephalus;
in the latter it has been extremely difficult to keep up a channel of communi-
cation between the ventricles and the subdural space, and it has been sug-
gested to use a more resistant form of drain. In spite of the success at-
tained, the patients have generally succumbed, after a few months, to pro-
gressive meningitis.

Ballance ("Am. Surg. Assoc," 1906) finds the thread drainage insufl&cient,
therefore he uses a fine F-shaped tube of pure platinum or of gold and iridium
(pure gold is too soft). One limb of the tube is provided with a small ring or
loop near the angle. One leg of the tube is made to penetrate the ventricle,
the other leg lies between the brain and the dura, being fi.xed to the latter by
sutures (Fig. 35).

Ballance has had a number of complete recoveries from hydrocephalus
following ligation of both common carotid arteries at an interval of about ten
days. In these cases there is no special danger from shutting off both common
carotids.

V, Bramann endeavors to attain the same end by means of puncture of
the corpus callosum (see p. t^;^.

The blood pressure in the cerebral tissues being very low Payr conceived
the idea that it would be possible to drain cerebrospinal fluid directly into the
longitudinal sinus. As an aqueduct from the lateral ventricle to the sinus a
tube lined with endotheUum and provided with valves to prevent reflux of blood

PAYR S OPERATION 45

is desirable. Such a vein as the great saphenous, if transplanted, is calculated
to fulfill the requirements.

Payr's Operation ("Archiv fiir klin. Chir.," Ixxxvii, Hft. 4).

1. Make a transverse U-shaped flap consisting of skin periosteum and bone
as shown in Fig. 36. The convexity of the flap is on the side to be drained
and its pedicle, 2 to 3 cm. wide, is at least one finger's breadth to the opposite
side of the mid-line. Reflect the flap.

2. On each side of the longitudinal sinus elevate a U-shaped flap of dura
having its base towards the sinus.

3. With an exploring needle of small size and having a scale marked in
3'^ cms. on it, puncture the lateral ventricle at a spot not far from the longi-
tudinal fissure and drain off slowly a small quan-
tity of fluid and at the same time note the depth
of the ventricle from the surface. Remove the ex-
ploring needle — it has served its purpose of reliev-
ing tension and showing the distance of the ven-
tricle from the surface.

4. Have an assistant make an incision over
the long saphenous vein and by sharp dissection
remove a segment of it. There must be no bruis-
ing of the vein. The length of the vein requisite
must be from 50 per cent, to 60 per cent, longer
than the distance from the longitudinal sinus to

the ventricle as the excised vein shrinks very pj^ ^5 Payr's operation.

markedly. When excised place the vein on gauze {Payr.)

soaked in warm salt solution and keep it warm.

Note and remember which is the proximal end of the vein as that is the end
which must be sutured to the sinus in order to take advantage of the valves
in the vein.

5. Penetrate the ventricle with an aluminum trocar (2 to 3 to 4 mm. in
diameter) which has a 3=-^ cm. scale marked on it. Permit the fluid to escape
very slowly; a plug of cotton in the trocar permits the fluid to escape in drops.

6. At least 2 to 3 cm. of the longitudinal sinus is exposed. Lift up the two
dural flaps made in Step 2. This permits one to see the falx under the sinus.
With semiblunt needles threaded with thin elastic or with a thin rubber tube
perforate the falx anteriorly and posteriorly to the exposed segment of sinus..
In this manner an elastic band goes from side to side under the sinus — one in
front and one behind the site of proposed anastomosis — and when fixed by a
stitch to the scalp on each side of the sinus these exercise pressure on the sinus
and so stop the circulation temporarily.

7. To the right and to the left of the site chosen for anastomosis intro-
duce and tie a suture of fine silk which penetrates only the external tunics of the
sinus. Leave the ends of these sutures long. If bleeding takes place when
the sinus is incised it can be promptly stopped by crossing the sutures.

8. Incise the sinus and introduce into it obliquely and backwards the
proximal end of the excised long saphenous vein. It is wise to have the end of
the vein folded back like a cuff so that any part of it which may protrude into-

46 THE SKULL AND THE BRAIN

the sinus is covered with endothelium. With fine silk sutures fix the vein to
the opening in the sinus and, as supporting sutures, tie together gently the two
threads introduced in Step 7.

9. Remove the aluminum trocar from the ventricle and push the free end of
the segment of vein along its course into the ventricle. This may be done with
a stilet of stiff silver wire. It is well to have the end of the vein turned
back on itself in cufiF fashion.

10. Remove the elastic constrictors from the sinus. Close the dural wound.
Close the cranial-scalp wound.

Several observers have noted that when drainage has been established
between the ventricles or the meninges and the cellular tissues, absorption of
the fluid was at first satisfactory but that later the cellular tissues refused to con-
tinue absorbing the fluid and encysted it instead. A. H. Ferguson drilled a
hole through the body of the fifth lumbar vertebra and passed a silver wire
through it from the spinal to the peritoneal cavity. Nicoll proposed the
following steps: laminectomy; resection of a transverse process; insertion
of a tube (decalcified bone, glass) from the spinal meninges to the perito-
neum; instead of inserting a tube Nicoll has sutured a tag of omentum to the
meninges.

Heile has sutured the meninges to the peritoneum of the large intestine.
Harvey Cushing has endeavored to establish drainage between the meninges
and the neighborhood of the peritoneum. The following is quoted from
Cushing's article in Keen's Surgery: "It is essential in the first place to deter-
mine if possible where the obstruction lies, for if it is evident that the foramina of
Magendie and Luschka are occluded, some method of direct ventricular drainage
must be resorted to. As the first step a lumbar puncture is performed, the
tension of the fluid is registered, and if an amount sufficient to demonstrate that
it must come from the ventricle can be withdrawn, the needle is removed and
the fluid analyzed.

"The second step, carried out some days later, is to determine whether the
child will withstand the withdrawal of a large amount of fluid, for though I have
never seen convulsions, collapse, etc., from this source, such accidents have been
recorded by Keen and others. To do this, a combined puncture of the lumbar
region and ventricle is performed. A long glass tube of small calibre connects,
by a short rubber tube, with each needle, and the fluid, when lumbar or ven-
tricular space has been entered, spurts up into the tube to its tension level, about
which it fluctuates with the cardiac and respiratory rhythm. If the foramen of
Magendie is open the fluid seeks the same level in both tubes, and when either
of them is dropped and the fluid allowed to escape the level in the other falls.
Thus, the ventricle may be emptied by either tube — rapidly by the ventricular,
slowly by the lumbar — and I have withdrawn in this way from the lumbar
subarachnoid space alone as much as a litre of fluid. The tubes are then with-
drawn, the small scalp wound closed, dressed, and the fluid allowed to reaccu-
mulate. A comparative chemical analysis of the fluid taken from the two
sources should show them to be the same. When thus demonstrated that the
ventricular fluid already communicates by natural channels with the subarach-
noid space, it becomes evident that an additional operative communication

HYDROCEPHALUS

between ventricle and the subarachnoid spaces over the hemisphere is super-
fluous and unavaiHng. The indication is clear that one must find some other
means of escape for the fluid, and I have attempted to drain into the retro-
peritoneal space as follows:

''Third Step. — It having become established (i) that the ventricle can be
emptied by the lumbar route and (2) that the withdrawal of fluid is not pre-
judicial to the child's well-being, the following procedure, after an interval of
some days, is carried out. A laparotomy is performed; the posterior layer of
peritoneum to the left of the rectum is split; the body of the fifth lumbar vertebra
just under the bifurcation of the vessels is exposed; the bone is trephined by a
specially constructed small-calibre trephine, and one-half (the female portion)
of a silver cannula, exactly the size of the trephine, is inserted and held in posi-
tion. The child is then turned on its face and a laminectomy is performed;
the subarachnoid space is opened, the strands of the cauda separated, and the

Fig. 37. — Puncture of the lateral ventricle by the lateral route at A. {Keen,
Am. Text-Book of Surg.)

posterior half (male portion) of the cannula is invaginated, so that it locks into
the portion inserted anteriorly. Both wounds are then closed. The fluid
for a time finds its way into the peritoneal cavity, but ultimately only into the
retroperitoneal space, whence it is taken up by the receptaculum chyli, as
experimental observations have shown. It can be seen that this combined
lumbar method is especially desirable in cases of hydrocephalus complicated
by spina bifida, a radical cure of which may be made in association with the
posterior part of the operation. I have carried out this procedure, which is
briefly recorded here for the first time, in twelve cases, with a considerable
measure of success."

ACUTE HYDROCEPHALUS, DRAINAGE OF LATERAL VENTRICLE

Keen's Method. — (A) Choose a point i^ inches above the upper margin

of the external auditory meatus and the same distance behind the meatus.

48 THE SKULL AND THE BRAIN

Open the skull at this point with a 3-^ inch trephine. On the opposite side of
the head choose the point H (Fig. 37) 2}^^ to 3 inches above the meatus audi-
torius. Through the trephine opening pass a grooved director or fine cannula
towards the point H. The cannula should reach the ventricle at a depth of 2 to
2^^ inches. If drainage is required introduce some threads of horse-hair or a
fine tube of rubber.

OPERATIONS IN CASE OF EPILEPSY

I. Idiopathic Epilepsy. — (A) Prophylactic Treatment. — The report of results
obtained in Korte's clinic (see p. 17) in cases of complicated fractures of the
skull very strongly indicates the propriety of restoring the integrity of the
skull after operations or fractures. The methods of doing this are discussed
elsewhere (see p. 11).

Prophylactic treatment resolves itself essentially into the avoidance of local
irritation and obtaining the most complete repair feasible.

(B) Operative Treatment. — The name idiopathic epilepsy is used as a cloak
for ignorance and to denominate the non-focal forms of the disease. Many
operations have been performed for the cure of the disease; the results have
been good, bad and nil; negative results being the rule. The fact that many
operations on regions apparently unconnected directly with the head have been
followed by symptomatic cure of the disease led J. W. White to speak of "opera-
tions per se" being occasionally curative. Undoubtedly it is good practice to
correct possible sources of irritation in epileptics, such as eye-strain, tight fore-
skin, decayed teeth, etc.

After shaving the head, scars will commonly be found on the scalp, even
when no history of trauma has been elicited. Many of these scars are
undoubtedly the result of accidents directly due to the epilepsy, but as
undoubtedly, in occasional cases, one of the scars is the visible evidence of a
trauma which occasioned the epilepsy. All such scars should be carefully ex-
amined as regards (o) tenderness to touch or to percussion, {b) mobility or
adhesion, (c) condition of periosteum or bone, {d) the production of vasomotor
or psychic symptoms on manipulation.

Keen is so strongly convinced that a scar of the scalp may be the cause of
epilepsy that after having excised the scar and having found the bone without
evidence of injury, he closes the wound and waits; if excising the scar fails to
cure, he then — and not until then — considers the advisability of performing
some other operation.

Friedrich, in traumatic epilepsy, chooses the site of trauma as the site for
operation even when the "aura" would indicate some other location as the
starting-point of the epileptic explosion.

Kocher, believing increased intracranial pressure to be the important
etiologic factor in idiopathic epilepsy, trephines and excises the dura over the
right fronto-parietal region, as a rule; to this he sometimes adds drainage of the
lateral ventricle.

Friedrich's results ("Archiv fiir klin. Chir.," Ixxvii, Hft. 3) in eight cases
kept under observation for years after operation show one case cured of epi-

EPILEPSY

lepsy and coincident mental disturbances; two cases of very great improvement;
one of improvement; one of temporary improvement; three unimproved.

If not guided by the evidences of old trauma Friedrich follows Kocher and
operates over the posterior portion of the frontal lobes (right).

The operation is as follows:

Step I. — Reflect a large flap of scalp, having its pedicle below. Open the
skull and excise with forceps or other instruments a segment of bone. The size
of the segment of bone removed varies from 20 to 48 sq. cm. (8 to 19 sq. in.).

Step 2. — Very carefully remove an area of dura varying in size from 9 to 33
sq. cm. (3^-^ to 13 sq. in.). Do not injure the subjacent pia. Avoid as far
as possible all hemorrhage.

Step 3 — Replace the flap of scalp and suture. Apply dressings.

C. H. Mayo has had some success after operating as follows: Reflect a large
osteoplastic flap; cut the fractured edges of the bone smooth. Reflect a flap of
dura corresponding to the osseous defect. Push the dural flap into a pocket

Fig. 38. — C. H. Mayo's dural drainage.

between the scalp and the bone (Fig. 38). Replace the osteoplastic flap, the
bone of which lies next to the pia arachnoid. The dural flap acts as a drain
between the meninges and subcutaneous lymphatics. Gushing' s decompressive
operation may be employed.

Although all such operations are perfectly justifiable under proper condi-
tions, yet the surgeon must not be too sanguine as to results. Almost any
operation is frequently followed by a temporary cessation of epileptic seizures,
but recurrence is the almost invariable rule. Jonnesco's method of sympa-
thectomy cannot be considered of proved value.

n. Focal or Jacksonian Epilepsy. — In focal epilepsy the irritation seems
to originate in some particular point on the surface of the brain and to radiate
to other parts. The parts affected are those which have been mapped out in
the study of cerebral localization. The causes of this condition are numerous.
Depressed fracture, osteophytic growths, neoplasms, localized meningitis caus-
ing adhesions, hemorrhage, abscess, etc., are all efl&cient causes and ought to be
removed or corrected. If no macroscopic lesion can be found when the skull is
opened and the brain exposed, the precise area from which the attacks radiate

THE SKULL AND THE BRAIN

may be defined by means of stimulation by weak electrical currents. The gray
matter of this area, plus the pia mater covering it, may be excised. Of course,
excision of an area of cortex means paralysis of the regions controlled by this
area, but the paralysis seldom remains permanent. Immediately after the
operation there is often a very temporary paralysis of parts supplied by neigh-
boring centres. A few good results have followed cortical excision, but the rule
is that epilepsy recurs when healing takes place. If a scar is removed from the
brain, another scar is necessarily formed in the process of repair. There is a
great difference, however, between the scar resulting from a clean incision or
excision and one resulting from a coarse trauma or from inflammation. Cover-
ing a cerebral wound with celluloid, goldfoil, or rubber tissue prevents adhesion
between the brain, meninges, and scalp or skull, and is a useful precaution. An
implant of fat may also be of service.

Carl Beck's Operation. — In some cases of epilepsy ("Annals of Surg.,"
Aug., 1906) due to adhesions at the site of a hiatus in the skull, the result of
fracture or operation, Beck has obtained some good results^by plugging the skull
defect with temporal muscle and fascia, the fascia being placed next the brain
or dura.

Fig. 38A. — Beck's operation for traumatic epilepsy.

The Operation: Step i.— Make the fl incision ABC (Fig. 38 A) and reflect the
flap or scalp thus formed. This exposes the defect in skull. Carefully remove
all scar tissue and exostoses from the defect and its surroundings. This means
usually removal of dura. With chisel or rongeur remove enough bone from
around the defect so that an edge of intact healthy dura is exposed. Attend to
hemostasis.

Step 2. — Continue the incision BA to D and BC to E, and reflect the flap
DFE. This flap must consist of scalp alone; the temporal fascia must be left
intact.

Step 3. — Form the flap HKI consisting of temporal fascia, temporal muscle
and pericranium, and having its pedicle towards the skull defect. This flap
must be large enough to completely fill the defect. Turn the flap HKI upwards

EPILEPSY

and place it in the skull defect, the temporal fascia lying on the brain. Suture
the temporal fascia to the dura.

Step 4. — Attend to hemostasis. Replace the flap DEF and fix it with
sutures, providing for drainage, if necessary. Apply dressings.

In cases similar to those for which Beck devised his operation other surgeons
reflect the scalp, remove scar tissue, etc., at the same time excising scars in the
dura and freshening the edges of the bony hiatus. The usual methods of
endeavoring to prevent fresh dural adhesions have been described elsewhere.
Finsterer replaced destroyed dura with a portion of a hernial sac placed with its
serous surface towards the brain. The sac, obtained during an operation for
hernia, had been preserved in a 2 per cent, formol solution but was thoroughly
washed in normal salt solution before use ("Beitrage z. klin Chir.," Ixvii,
193). In experiments made on dogs Finsterer found that such peritoneal
grafts preserved their vitality (?) and did not contract adhesion to the
subjacent brain.

Perthes (German Surg. Congress, 191 2) has used fresh hernial sac after
Finsterer's method in seven cases, with success in six, and death in one due
to infection secondary to a meningeal fistula.

Hanel ("Archiv fiir klin. Chir.," xc, 823), stimulated by Morris' recommen-
dation of Cargile's membrane, prepared material from the intestines of sheep as
follows: Bend a glass rod so as to make a four-sided frame; split open and
stretch on the frame a segment of sheep's intestine. Soak in a 4 per cent, solu-
tion of formalin for twelve hours; wash in running water twelve hours; boil in
water for ten minutes; preserve in the following solution: sublimate 0.8,
glycerine 40.0, alcohol 800.0. Hanel used this material in the same manner
as Finsterer uses hernial sac and Morris uses Cargile membrane. Hand's
membrane is absorbed after the lapse of about two or three weeks.

Kirschner ('"Archiv fiir klin. Chir.," xcii, 894) recommends the use of
fascia in covering dur^l defects. He obtains the material by excising a suffi-
ciency of the fascia lata from the patient himself and after cutting away all
fat from it places it over the dural defect and pushes its edges under the skull
between the dura and the bone. At the German Surg. Congress, 191 2, he
reported seventeen cases from Korte's clinic. He writes: "(i) In all the cases
the transplanted fascia healed without reaction.

" (2) In the cases where the implantation was made to replace dura patho-
logically affected in cortical epilepsy, there were no more convulsions." (Too
short a time has elapsed to permit of final conclusions.)

" (3) When diseased dura was widely excised, water-tight closure of the sub-
dural space was at once obtained by implantation of fascia. No meningeal
fistulas developed.

" (4) When operation is imperative in circumstances where the external
wound cannot, with certainty, be rendered clean, the implantation of fascia
hinders infection of the cerebrospinal fluid." (To the author this appears
very dubious in view of the necessity of absolute asepsis when implanting any
foreign material, even autoplastic.)

" (5) When much dura and bone are both removed the implanted dura
prevents cerebral prolapse."

52 THE SKULL AND THE BRAIN

Lexer in a case of traumatic epilepsy, after excising an old scar uniting the
meninges to the soft parts, implanted a free (non-pedunculated) flap of fat
between the brain and the scalp. The result was very happy. In a case in
which pain and giddiness resulted from adhesions between the meninges and
scalp, the author followed Lexer's method and implanted a free flap of fat
obtained from the patient's abdominal wall. The result was very satisfactory.

HEMORRHAGIC PACHYMENINGITIS

BuUard and John C. ^Munro have made strong pleas for the consideration
of hemorrhagic pachymeningitis as a surgical condition demanding operation.
The disease, when not found in infants or the insane, is one belonging to the
later years of life. Alcoholism, syphilis, acute and wasting diseases, as well as
trauma, seem to have some causal relation to the disease. The symptoms are
those of diffuse subdural hemorrhage, coming on slowly, producing mental
irritation, spasm, paralysis, the sequences being more or less irregular. The
cranial nerves are not liable to be affected. Without relief by operation the
prognosis is practically hopeless; with operation, it is still very poor but better
than without. One of JVIunro's cases recovered; it was that of an alcoholic
sixty-two years of age, picked up on the streets unconscious. On admission to
hospital he could not be roused. There was no bleeding from the mouth, nose,
or ears. Temperature was normal, pulse 80; right knee-jerk absent; no rigidity;
hematoma in right parietal region. Trephined on right side; no pulsation of
dura, which was bulging and dark blue. Subdural clot covering the whole
hemisphere removed. Trephined on left side; a diffuse, thin clot was found
and removed. Towards the close of the operation consciousness returned.
The result was complete recovery. In another case failure to trephine on both
sides led to death, though immediate improvement followed the operation.

HYPOPHYSECTOMY

Attempts have been made to cure or relieve patients suffering from hyper-
pituitarism (acromegaly) and hypopituitarism by excising the hypophysis
(pituitary body) either completely or incompletely. The pituitary body lying
as it does in the sella turcica may be approached from above and the side through
the cranial cavity or from in front and below.

A. Operation from Above. —

Bogojawlensky's Operation. — ("Zent. fiir Chir.," No. 7, 191 2).

Stage I. — From a point 23^^ cm. (i in.) external to the middle line of the
forehead and the same distance above the upper margin of the orbit make a
cut upwards for about 9 cm. (3^-^ in.), then continue the cut backwards for
9 cm. and downwards for the same distance. Along the line of the scalp inci-
sion divide the bone with forceps, saw or surgical engine. A large osteo-
plastic flap with pedicle below is thus outlined. Attend to hemostasis and
apply dressings.

Stage 2. — After several days or weeks elevate and reflect downwards the
outlined flap of bone and scalp. Raise the head end of the table to 30°. Let
the patient's head hang backwards over the end of the table. The raising of

llVPOl'UVSECTOMY 53

the head end of the table prevents loss of cerebrospinal fluid. Make an H-
shaped incision through the dura and reflect the dural flaps thus formed. With
finger and brain spatula slowly and carefully lift the frontal lobe from the roof
of the orbit. The dependent position of the head permits the weight of the brain
to aid in this maneuvre so that it is not necessary to apply retractors to the brain.
The optic commissure and any tumor of the hypophysis become visible and
accessible.

McArthur's Method (Trans. Surg. Section A. M. A., 191 2).

1. Place the patient in Bogojawlensky's position. Make the incision
ABCD, Fig. 39, penetrating to the bone. The incision AB is 3 to 4 cm. (i^^
to i}<2 in.) long. Reflect the flap (including the periosteum) upwards.
With the elevator introduced through the wound CD
separate the periosteum from the orbital roof and
displace the orbital contents downwards using a tea-
spoon as a depressor. The periosteum being kept intact
the orbital contents are not seen.

2. With a yi inch trephine penetrate the frontal
prominence 4 cm. (i)^ in.) above the middle of the Fig. 39. — McArthur's
supra-orbital arch. Preserve the button of bone in ^ectomy. ^°' ^>'P°P^>-
warm salt solution. Beginning at the trephine opening,

with DeVilbiss forceps make a curviHnear cut through the bone, concavity down-
wards, the inner end terminating at the frontal sinus, the outer at the outer aspect
■of the external angular process, thus invading somewhat the temporal fossa. With
■an osteotome divide the outer wall of the frontal sinus. Divide the external
angular process. Elevate and remove the loosened frontal fragment; preserve it
in warm salt solution. With rongeurs cut away the orbital roof back close to
the optic foramen, being careful not to injure the dura.

"With this completed one can slowly and carefully detach from the bone
the dura covering the inferior surface of the frontal lobe, at the same time having
the latter raised by a long thin angular retractor in the hand of a skilled assistant,
in whose other hand a spoon retractor displaces the orbital contents downwards.
When one has reached the anterior clinoid process and the free edge of the wing
of the sphenoid, which can be recognized with probe, blunt hook or finger,
orientation becomes easy."

3. Note the dura between the chnoid processes and make a 2 to 3 cm.
04: to i}i in.) transverse incision through it with a fine hook-shaped knife
about 0.5 cm. 04 in.) above the level of the floor of the anterior fossa, thus
avoiding '' the small, transverse venous sinus that occupies the groove between
the optic foramina (this groove it was long taught, harbored the optic chiasm)."
Through the dural opening the optic nerve, chiasm and the pituitary tumor
come into view.

4. Treat the disease by evacuating fluid or removing tumor tissue with a
fine curette.

5. Permit the frontal lobe to fall back into place. Replace the bone re-
moved. Replace the flap of soft parts, suturing the periosteum separately.
Close the skin wound. Introduce a rubber tissue drain to the dura.

McArthur has found that but little scar or deformity results. His method

THE SKULL AND THE BRAIN

is perhaps the safest and easiest means of performing an extremely difficult
operation.

Frazier's method ("Annals Surg.," Feb., 1913) is almost the same as
McArthur's. Reflect an osteoplastic flap from the right frontal region, the
pedicle being lateral; remove the supra-orbital ridge en bloc with a portion of the
orbital roof; remove with rongeurs the remainder of the roof of the orbit down
to the optic foramen; elevate the frontal lobe; depress the orbital contents;
incise the dura sufficiently to lay bare the cavity of the sella turcica (Fig. 40).

Fig. 40. — Hypophysectomy. {Frazier, Annals of Surgery.)

B. Operation from in Front and Below. —

Kanavel (" Journ. A. M. A.," November 20, 1909) devised an intranasal
route by which to expose the hypophysis and yet avoid all disfiguring scars.
This operation he worked out on the cadaver, but it was first used on the living
by A. E. Halstead ("Surg., Gyn., Obstetrics," May, 1910) who associated
Kanavel with himself in the operation. Montgomery West ("Journ. A. M. A.,"
April 2, 1910) has devised a method similar to Kanavel's but does the work
entirely through the nostril without dislocating the nose. Both Kanavel and
West suggest that it may be well to operate in two stages; in the first stage clear-
ing the way to the sella turcica (this may be done under local anesthesia), in the
second stage removing the tumor.

HYPOPHYSECTOMY

The following description is made up from the writings of Kanavel, Halstead
and West and refers to operation completed in one stage.

Anesthesia. — After anesthesia is induced in the usual manner Kanavel con-
tinues the administration of ether by the rectal method, while Halstead per-
formiS tracheotomy and gives chloroform through a Trendelenburg cannula.
To the author it seems that laryngotomy and the use of chloroform through
Butlin's cannula is simpler and safer than tracheotomy. The advantage of
anesthetizing through a tracheotomy or laryngotomy cannula over the rectal
method consists in the ability to plug the pharynx thoroughly and the avoid-
ance of all respiratory troubles. Before giving the anesthetic, plug the nasal
passages carefully from the anterior nares to the sphenoidal cells with strips of
gauze soaked in adrenalin solution.

The Operation. Step i. — Tampon the pharynx. Remove the adrenalin
pack. Raise the upper lip. Make a horizontal incision through the mucosa of
the lip about % inch from the muco-cutaneous junction and parallel to the
alveolus. Through this wound dissect upwards freeing the nose from its lateral
attachments.

Fig. 41. — Hypophysectomy. {Kanavel, Jour. A. M. A.)

Step 2. — With strong scissors or bone forceps divide the septum along its
inferior attachments (line b, Fig. 41). Divide the attachment of the septum to
the vertical plate of the ethmoid (line a, Fig. 41). Turn the nose and with it
the separated part of the septum upwards on to the forehead.

Step 3. — Remove the lower and middle turbinates, the vomer and the per-
pendicular plate of the ethmoid. The anterior wall of the sphenoidal sinus is
now exposed.

Step 4. — Penetrate the anterior wall of the sphenoidal sinus. Sometimes
the tumor will now appear having eroded the sella turcica. If this has not
occurred, open the sella turcica by means of a long narrow chisel. While
opening the sella turcica it is of prime importance to adhere strictly to the
middle line for fear of damaging the carotid arteries and the optic nerves.

Step 5. — Treat the disease by evacuating any cyst which may be present or
gently curetting away tumor tissues.

THE SKULL AND THE BRAIN

Step 6. — Pack, the cavity with iodoform gauze. Replace the nose. Suture
the septum. Suture the wound in the mouth.

Results. — The results of Kanavel's operations have been most excellent as
regards absence of deformity. There has been no recognizable deformity in
any of the patients submitted to operation.

The following surgeons have operated by the Kanavel method or some
modification of it:

Halstead, A. E. ("Surg., Gyn., Obst.," May lo), two, one death. Kanavel,
two, one death. Mixter, S. J., one, no death.

In Mixter's case and in Halstead's successful case the results were most
gratifying. Kanavel (personal communication) writes: "My first case lived
about five weeks and then died from a recurrence. After the operation he

Fig. 42. — {Cushing, Jour. A.M. A.)

had been up and left the hospital. My second case was one of the adipose
genital type, and has remained perfectly well ever since the operation, which
relieved him of all the symptoms of which he complained, and with the use of
the anterior lobe of the pituitary gland he is now beginning to grow."

Fig. 42 (Journ. A. M. A., Oct. 31, 1914) gives some idea of how Cushing
attacks the pituitary body. That surgeon in 1914 had performed 16 trans-
phenoidal decompressions with 3 deaths and 58 transphenoidal extirpations
(on 52 patients) with 4 deaths. He writes:

"The results of the transphenoidal operation, which, as has been made
clear, is carried out chiefly for the relief of chiasmal involvement, have been
most gratifying in the 61 survivors in the 68 cases. Progressively failing vision

EMPYEMA OF FRONTAL SINUS 57

has become stationary or has been slightly regained over periods varying from
a few months to several years in 22 cases. There has been a prompt widening
of the field with marked improvement of vision, often with return to the normal,
in another 22 cases. In two patients vision was temporarily made worse as a
result of the operation, but there was subsequent great improvement. Though
vision had been completely lost in 5 cases before the operation, in 2 of the
cases it was partially regained. In 8 cases it was unaffected before the opera-
tion, and still remains so. In only 3 cases was there a progressive failure of
vision despite a successful operation and in all of them the tissues removed
showed a malignant transformation of the lesion to which the patients have
since succumbed."

CHAPTER III
FRONTAL SmUS

Operation on the frontal sinus is indicated in empyema of that cavity.
Frontal empyema is usually a concomitant of some form of chronic rhinitis.
Either as a preliminary or complementary step in the operation it is wise to
remove the anterior portion of the middle turbinated bone in order to simplify
drainage.

The Operation. — Shave the eyebrow. Clean the field of operation. Pro-
tect the eyes with aseptic pads.

Step I. — From the root of the nose make a curved incision outwards, parallel
to and 3'^ inch above the upper margin of the orbit. The incision extends to a
point just external to the supraorbital notch and penetrates to the bone. With
the periosteal elevator separate the soft parts from the bone until the outer
wall of the sinus is exposed

Step 2. — With a bur, small trephine, or gouge carefully remove the exposed
wall of the sinus, immediately to the outer side of the middle line, above the
root of the nose. Only a very small area of bone should be removed at this
time, and care is necessary lest such an instrument as the chisel should suddenly
penetrate the thin bone and injure the posterior or inferior walls of the cavity.
As soon as the bone is penetrated, the mucosa lining the sinus pouts into the
wound. Incise the mucosa. Gently explore the cavity with a probe and with
gouge or forceps (guided by the probe) remove the anterior wall of the sinus.
Some surgeons are careful not to remove any of the orbital margin lest an ugly
deformity result; others carefully remove every particle of bone which might
interfere with the soft parts being brought in absolute contact with the deep
wall of the sinus, the aim being to obliterate the cavity. Obliteration of the
cavity is often necessary, but as it causes marked deformity one is wise to try
less mutilating procedures first.

Step 3. — With a sharp spoon remove all granulation tissue from the sinus
and from its opening into the nose. With a small sharp spoon cleanse every
nook and cranny. Be careful not to injure the orbital plate. Pass the sharp
spoon from the postero-internal angle of the sinus downwards into the nose.

58 FRONTAL SINUS

The instrument goes through some of the ethmoidal cells and creates a good
passage for drainage.

Step 4. — Pass a rubber tube from the sinus into the nose. Some surgeons
do not permit the upper end of the tube to emerge through the skin, but close the
cutaneous wound entirely, trusting to nasal drainage alone, as in Earth's opera-
tion; most operators place the tube so that it emerges both through the skin and
the nose. Through-and-through drainage is probably best to begin with.
During the after-treatment, if it becomes necessary to withdraw the tube tern
porarily, it is well to fasten a thread to the tube, so that as the tube is withdrawn
the thread may take its place and serve as a guide for the introduction of a clean
drain. Close all excess of wound with sutures. Dress.

After-treatment. — Warn the patient not to blow his nose violently, other-
wise emphysema will result. When nasal drainage alone is provided, leave the
tube in situ as long as possible, because once removed it is very difficult to
replace. When through-and-through drainage is provided, withdraw the drain
gradually, through the nose, as suppuration lessens. When drainage fails to
cure the disease, the sinus must be obhterated by the method indicated in Step 2.
Killian^s operation is very radical and successful. (Freudenthal, "Jour.
Am. Med. Assoc," Feb. 11, 1905.)

Step I. — Make an incision down to the bone the whole length of the eyebrow,
just above the orbital margin. Continue the in-
cision at its inner end down the middle of the
nasal process of the superior maxilla.

Step. 2. — Open and explore the sinus either
above or below the orbital margin.

Step 3. — With chisel and mallet make a fur-
row through the bone immediately above and
parallel to the margin of the orbit. Remove with
forceps the whole anterior wall of the frontal sinus
above the furrow.

Step 4. — Clean out the sinus and remove its
Fig. 43.— Earth's operation, mucous membrane.

Step 5. — Remove with forceps the whole (or-
bital) floor of the sinus, leaving the orbital margin intact for cosmetic reasons.
Step 6. — Resect the frontal process of the superior maxilla and the rest of
the floor of the sinus.

Step 7. — Resect the anterior and middle ethmoidal cells and the respective
parts of the middle turbinal. These structures are always affected.

Step 8. — Close the wound after providing for drainage by a rubber tube.
The extensive removal of the floor of the sinus and consequent opening of the
orbit cannot be without danger. The inevitable entrance of pyogenic organisms
into the non-resistant fatty tissues must often give rise to orbital abscess.

Earth's Operation. — A little to the side of the middle at the root of the
nose make a longitudinal incision i inch in length, down to the bone. With
a chisel carry the above incision through the nasal process of the frontal bone
and the nasal bone. At the upper and lower angles of the wound, by means of a
narrow chisel, make horizontal cuts outwards through the bone. The flap of

INJECTIONS IN TIC 59

bone thus formed is pried outwards (Fig. 43) like a trap-door with hinge placed
externally. The upper part of the opening is filled with the mucous membrane
of the frontal sinus. Cut through this bulging mucous membrane. Through
the above opening diseased tissue may be inspected and removed, free drainage
through the nose may be provided, and if necessary the opposite sinus may be
opened and treated. When the operation is completed, the bone flap is restored
to place and the vertical skin-incision is sutured.

CHAPTER IV
TIC DOULOUREUX

In severe cases of trigeminal neuralgia, after treatment by medicine and
by removal of sources of peripheral irritation and particularly of infection
has failed, operation offers the only hope of amelioration or cure. Very many
operations have been devised, but not all of them are useful. The earliest
operations consisted in the subcutaneous or open division of the nerve
trunks as they left or entered their bony canals. The supraorbital nerve
was divided as it emerged from the notch of the same name, the infraorbital
at the infraorbital foramen, and the inferior maxillary as it entered the pos-
terior dental canal. In certain cases such operations gave marked and occa-
sionally permanent relief, but after simple division of a sensory nerve repair
can take place with great rapidity, so that the neuralgia usually recurs at an
early date.

Thiersch, after exposing the nerves at their exit from their bony canals,
seized them in strong forceps and by slow twisting and pulling, forcibly extracted
a varying amount of them from their canal. Recurrence after this procedure
was neither so prompt nor so constant as after simple division. Undoubtedly
the best method of operating upon the nerve-trunks is by the removal of as much
of them as is possible, or by injecting into them materials which will either de-
stroy or diminish their power of conduction.

INJECTIONS INTO THE NERVES

Schlosser was the first to make injections into the trunks of the nerves at the
base of the skull in treating trifacial neuralgia. Ostwalt followed him and
injected the three branches of the nerve through the mouth. Levy and Bau-
douin devised and systematized a simple and safe method for making the injec-
tions without incurring the dangers incident to invading the mouth. Patrick
has followed their method with much success. The author has followed Mur-
phy's modification of the Levy-Baudouin procedure and finds it easy and
fairly satisfactory.

Ostwalt's Injections ("La Presse Med.," Dec. i6, 1905). — Ostwalt in-
jects I to 1 3'^ c.c. of 80 per cent, alcohol (to which is added .01 cocaine or
stovaine) into the trunk of each of the branches involved where it emerges
from the skull. "As usually several branches (most commonly the second and
third) are affected at the same time, I make an injection in two or three stages;

TIC DOULOUREUX

first at the foramen ovale then at the foramen rotundum and last, if necessary,
in the sphenoidal fissure. To reach the foramen ovale, I introduce my bayon-
ette-shaped needle (Fig. 44), mounted on the syringe, behind the wisdom tooth
and make it penetrate the mucosa, submucosa and external pterygoid muscle,
then I pass up into the pterygoid fossa along the external wing of the pterygoid
process until it strikes the great wing of the sphenoid. I then direct the point of
the needle backwards into the angle formed by the pterygoid process and the
great wing of the sphenoid until bony resistance disappears, and the foramen
ovale is reached. As soon as the fluid is injected here I conduct the needle,
always in the above-mentioned angle of the pterygoid fossa, forwards until once
more the sense of bony resistance is lost. The needle is now at the border of the
sphenomaxillary fossa. Keeping the needle continuously on the anterior surface
of the pterygoid fossa I push the needle upwards 6 to 9 mm., reaching the fora-
men rotundum, and can feel the upper border of the foramen formed by the

Fig. 44. — (Ostwall.)

little osseous bridge with separates it from the sphenoidal fissure. In the rare
cases where the first branch is involved along with the second or with the second
and third branches, it is only necessary (once the injection of the superior
maxillary is completed) to pass the needle about 2 mm. higher, passing above
the little osseous bridge already mentioned, where it encounters the ophthalmic
branch in its passing through the sphenoidal fissure." Ostwalt has made 250
deep injections in tic without any ill effect. In at least one-third of the cases
there was recurrence at the end of four or five months, but these recurrences
were less serious than the original tic and were relieved by one or two more
injections. Although as a rule one injection gives improvement in tic, yet two,
three or four seances are generally required.

Levy and Baudouin write ("La Presse Med.," Feb. 17, 1906): "We have
used, experimentally and clinically, alcohol and chloroform in which we have
dissolved sublimate or carbolic in the proportion of i per cent." [One per
cent, of sublimate is evidently a mistake — Author.] "We do not employ os-
mic acid for fear of necrosis. The following is our practice. We inject i or 2
c.c. of alcohol (with or without cocaine) of increasing strength — 70, 80, 90
per cent.; then we repeat the injections of these strengths of alcohol after
adding 4 drops of chloroform to each c.c. of alcohol. Experiments on animals
show that these substances in the doses employed by us are harmless even
when injected intravenously. The puncture itself is but slightly painful.
Generally when the nerve trunk is reached the patient complains of a pain

INJECTIONS IN TIC 6 1

through the corresponding territory. . . . The injection should be made
very slowly and the needle ought not to be withdrawn for fifteen or twenty
seconds. . . . After from two to five minutes the patient complains of a
feeling of stiffness, of swelling, then of numbness in the territory of the in-
jected nerve. Sometimes one can demonstrate a complete anesthesia which
may persist for a long time. Usually the injection is followed by an exacerba-
tion of the pain for some hours and the patient ought to be warned of this. In
the region of the injection there is a slight temporary edema and after injection
of the inferior maxillary nerve there is a certain difficulty in opening the mouth.
As a rule six or eight injections are required at intervals of three or four days.
The tolerance of the patient must regulate the time and strength of the injection.
Experience has taught us that it is necessary to inject at least two of the branches
of the trifacial nerve. In case of neuralgia of the inferior maxillary or of the
ophthalmic nerves, the superior maxillary ought also to be injected. In case of
neuralgia of the superior maxillary we inject the inferior maxillary also." J.
B. Murphy uses from seven to fifteen minims of a 2 per cent, solution of osmic
acid as an injection material. The author has had the pleasure of seeing some
of the excellent results secured by Murphy.

The Operation. — The only special instrument required is the Levy-Baudouin
cannula. The cannula is of steel 10 cm. long, i}'^ mm. in diameter (Fig. 45),
and. is graduated in centimeters. The mandrin with which the cannula is

Fig. 45. — -Levy-Baudouin cannula.

3<^3— ef

provided, when pushed home protects the short point of the cannula so that
no injury can be inflicted on such structures as arteries.
A. Injection of the Inferior Maxillary Nerve.

1. Levy-Baudouin Method. — Note the bony prominence at the junction
of the zygoma with the anterior bony wall of the external auditory meatus.
Choose a point on the lower edge of the zygoma 2.5 cm. anterior to the above
bony prominence. At this point introduce the cannula directly inwards and
immediately under (in contact with) the zygoma for a depth of 4 cm. when its
point must be at the foramen ovale. To avoid injuring the middle meningeal
artery, push the mandrin home in the cannula (thus rendering the instrument
blunt) as soon as a depth of 1.5 cm. is reached, retire the mandrin when the
depth of 4 cm. is attained, and inject the chosen solution.

2. Murphy's Method. — Choose a point at the middle of the upper edge
(Figs. 46 and 47) of the zygoma and here introduce the needle passing it directly
inwards until it strikes either the squamous portion of the temporal bone or
the great wing of the sphenoid and guided by these passes inevitably over the
foramen ovale at a depth of i3^ inches (4 cm.) from the outer surface of the
zygoma.

3. Gascard's Method. — (La Pr. Med., August 25, 1919.) Palpate the angle
formed by the zygoma and the ascending portion of the malar bone. Introduce

TIC DOULOURETJX

the needle vertically in this angle immediately above the zygoma. At a depth
of about 23'-^ cm. the needle will hit the vertical portion of the great wing of
the sphenoid. Lower the point of the needle a few millimeters to pass round

Fig. 46. — Injections for tic.

the angle formed by the vertical and horizontal parts of the great wing of the
sphenoid and push the needle onwards with its point scraping against the infe-
rior surface of the bone until it reaches the foramen ovale exactly 5 cm. from

Fig. 47. — Injections for tic.

the superior zygomato-malar angle. The needle cannot penetrate to the depth
of 5 cm. unless it is in the right direction.

B. Injection of the Superior Maxillary Nerve.

I. Levy-Baudouin Method. — Prolong the line of the posterior border of the
ascending (orbital) process of the malar bone to the lower edge of the zygoma
and insert the needle 3^ cm. posterior to this point. Direct the needle inwards

INJECTIONS IN TIC 63

and slightly upwards in a direction which would attain at the depth of the fora-
men rotundum (5 cm.), the level of the inferior extremity of the nasal bone.
When the needle has penetrated 5 cm. its point has reached the nerve where
it emerges from the foramen rotundum into the pterygo-maxillary fossa.

2. Murphy's Method. — Draw an imaginary line vertically downwards from
the external angular process of the frontal bone; where this line crosses the
inferior margin of the zygoma introduce the needle directly under the zygoma.
Pass the needle inwards and a trifle upwards until it impinges against the back
of the superior maxilla. Guided by the maxillary bone push the needle on
until its point has penetrated i^ inches (43^ cm.) or slightly more from the
surface of the malar and has reached the foramen rotundum.

C. Injection of the Ophthalmic Nerve.

Levy-Baudouin Method. — These authors write: "The first branch of the
fifth pair dividing inside the cranium one cannot attack its trunk. Of the three
branches the nasal is hardly accessible in the midst of the important motor
nerves which surround it. To reach the frontal and lachrymal nerves the orbital
route is indicated. As a path to the nerve we have chosen the external wall of
the orbit at the level of the inferior extremity of the external angular process of
the frontal bone. Inserted here the needle passes below the lachrymal gland
and follows the periosteum without injury to the eye or to any important
organ. At a depth of 35 or 40 mm. one makes the injection after withdrawing
the mandrin. The patient ought to have his eyes closed. The needle has
some difficulty in penetrating the outer portion of Tenon's capsule which is
very thick,''

Hugh Patrick has had much experience in the use of deep injections of
alcohol for the relief of tic and makes some characteristically cautious and
sensible remarks thereon ("Journ. A. M. A.," Sept. 19, 1907), a synopsis of
which is given here:

The number of injections necessary for relief depends on the accuracy with
which the alcohol is placed. A single injection within the nerve sheath will
stop the pain at once. A number of trials may be necessary before this can be
accomplished. An injection near though not in the nerve is not without value
because the alcohol "undoubtedly diffuses sufficiently to reach it. In such
cases the relief comes after some minutes or hours and does not last long.
Consequently I believe it is wise to continue the injections even though the
patient is having no pain, until the characteristic sensory phenoma" (pain and
feeling of swelling and stiffness in the area supplied by the nerve; analgesia in
area) "announce marked action on the nerve." If pain returns there seems to
be no objection to secondary injections. In conversation with the author
Patrick gave the impression, no doubt correct, that a permanent cure could
hardly be expected from injections; but the operation is trivial, usually gives at
least temporary relief and may be apparently repeated indefinitely.

Fischer ("Miinchener med. Woch.," 1907, No. 32) reporting the result of
injections of alcohol in Erb's clinic for various neuralgias warns against their
use in mixed or in motor nerves as dangerous consequences have arisen; yet
Patrick and others have injected alcohol into the facial nerve with good results
in facial spasm (not tic) without causing troublesome facial paralysis.

64 TIC DOULOUREUX

D. Injections into the Gasserian ganglion itself have been made not only^
to relieve the pain of tic but to produce anesthesia under which extensive
operations have been performed.

Harris' Method. — Step i. — Draw an imaginary line from the "incisura notch"
(the deep notch in the external ear above the lobule and between the tragus and
antitragus) to the lower border of the ala nasi. This line in the average skull
corresponds to the lower border of the sigmoid notch. Mark out the lower
border of the zygoma, especially the tubercle in front of the glenoid fossa;
the anterior margin of this tubercle is precisely i inch in front of the external
auditory meatus. Draw a vertical line through the anterior margin of the tuber-
cle. This line meets the incisura-ala nasi line practically at right angles.
"A plane through this vertical perpendicular to the zygoma and side of the
cheek passes through the foramen ovale."

Step 2. — Choose a point on the incisura-ala nasi line /^ to 3^ inch in front
of the crossing-point of the two lines and there introduce the needle upwards,
backwards and inwards. Harris writes: "My needle must be directed very
slightly backwards in order to hit the plane through the tubercle line at the
depth of the foramen ovale, which I have found to vary from 42 to 54 mm.,
according to the thinness or fatness of the cheek, and according to the narrow-
ness or great width of the head of the individual. The angle of backward direc-
tion varies from 15° in thin-faced narrow-headed subjects to even vertically
inwards in stout wide-headed people. Similarly the angle of upward direction
varies rarely as much as 15° and it may be almost horizontal."

When the inferior maxillary nerve is reached the patient may complain of
pain in the lower teeth and lip. Attach a syringe to the needle and inject about
i)-^ c.c. of I per cent, eucaine solution. If the nerve itself has been injected
there will be immediate anesthesia of the lower lip and chin and the rest of the
operation will be practically painless.

Step 3. — Keeping the needle in the original direction, feel with its point for
the foramen ovale. When the foramen is found push the needle onwards into
the substance of the ganglion for about }/i inch. Attach a syringe to the
needle and slowly inject a drop or two of alcohol. If the needle is in the gang-
lion considerable resistance to the push of the piston will be noticed, when
another i to 1^2 c-C- may be injected a few drops at a time. During the in-
jection test sensation on the forehead by pricking with a blunt pin; when a
pin prick or pin pressure is no longer noticeable, stop the injection and slowly
withdraw the needle. If when the injection is begun no resistance is felt to the
push of the piston and if the patient instantly complains of severe pain at the
base of the skull and back of the head, the needle is not in the nerve but in
Meckel's cave and cerebrospinal fluid may escape through the needle. Under
these circumstances withdraw the needle slightly and reintroduce it through the
posterior portion of the foramen so as to keep its point within the substance of
the ganglion. If the patient complains of sudden pain in the cheek and nose
after the needle enters the foramen, it means that it has passed in front of the
ganglion and has struck the root of the superior maxillary nerve before the nerve
has reached the foramen rotundum. Harris uses nickelled-steel needles 3
inches and 3^^ inches in length and 1.25 mm. and 1.4 mm. diameter, provided

NEURECTOMY 65

with a stylet, and with a short sharp point bevelled at an angle of 20 per cent.
The Levy-Baudouin cannula — 10 cm. long, i^^ mm. diameter, graduated in
centimeters and provided with a mandrin — ought to do well.

HdrteVs Method. ("Zent. fur Chir.," May 25, 191 2.) — A stylet passed from
the "impressio trigemini" through the foramen ovale will reach the masseteric
region midway between the anterior margin of the ascending ramus of the lower
jaw and the posterior margin of the maxillary tubercle; in 90 per cent, of skulls
the stylet hits the upper alveolus in the molar region. The distance from the
foramen ovale (extra-cranial) to the cheek is 5 to 6 cm.; from the outer surface
of the skull at the foramen ovale to the impressio trigemini it is not less than
1.5 cm., averaging 1.9 cm. A needle passed up this line is so limited in its
lateral movements that it cannot injure the cavernous sinus internally, the brain
above or the carotid below the Gasserian ganglion.

Technic. — Use a very fine graduated canula 9 cm. long. Choose a point
on the cheek 2 to 3 cm. behind the angle of the mouth. Anesthetize the skin
here and introduce the needle upwards to pass between the ascending ramus and
the maxillary tubercle until the infratemporal plane is reached. When the
needle hits the hard, smooth temporal bone, feel or explore backward with the
point of the needle for the foramen ovale. Hartel uses the following important
landmarks to direct the needle: Viewed directly from in front aim the needle
at the pupil of the eye on the same side; viewed from the side aim it at the
articular tubercle of the zygoma.

As soon as the third branch of the nerve is touched there is paresthesia or
shooting pains in the lower teeth and the needle may be slowly pushed through
the foramen ovale until the pain in the upper jaw is evident. Now inject as
slowly as possible 3^ to i)^ c.c. of 2 per cent, novocain-adrenalin solution.
Anesthesia is immediate and lasts i to 2 hours.

NEURECTOMY OF THE FIRST DIVISION OF THE
FIFTH NERVE

The first or ophthalmic division of the fifth nerve enters the orbit through
the sphenoidal fissure and divides into three branches — the frontal, lachrymal,
and nasal. The frontal nerve, the only branch of surgical importance, divides
into the supraorbital and supratrochlear. The supraorbital leaves the orbit
through a notch or foramen situated at the junction of the inner and middle
thirds of the supraorbital margin. With it run the supraorbital artery and
vein.

NEURECTOMY OF THE SUPRAORBITAL NERVE

Locate the supraorbital notch or foramen. Make a horizontal incision
through the skin, parallel to and a little below the eyebrow. Separate the
fibres of the orbicularis muscle. Expose the nerve as it passes through the supra-
orbital notch. Divide the orbitotarsal ligament. With a flat retractor depress
the orbital fat. Follow the nerve backwards from the supraorbital notch,
separate it from its surroundings, divide it as far back as possible, and remove
all of it in front of the point of section. Close the wound with sutures. Dress,

66 TIC DOULOUREUX

A good modification of the operation is the following: Expose the nerve
at its exit; isolate it for a short distance; seize its undivided trunk with a narrow-
bladed hemostat; rotate the hemostat so that the nerve becomes wound around
the jaws of the forceps; reverse the direction of rotation. By repeating the
manoeuvres of rotation and working slowly and patiently almost the whole
peripheral portion of the nerve and much of its central trunk can be extracted.
(Thiersch.)

NEURECTOMY OF THE SUPRATROCHLEAR

The supratrochlear nerve is generally divided in the preceding operation,
but occasionally it is missed and demands special attention. Draw an imagi-
nary line from the angle of the mouth through the inner canthus of the eye.
At a point a little below where a continuation of the above line crosses the
eyebrow make an incision through the skin parallel to the fibres of the orbicularis
muscle. Find the trochlea, which acts as a pulley for the superior oblique
muscle. Locate the posterior portion of the superior oblique muscle. The
supratrochlear nerve and its branch, the infratrochlear, lie upon the superior
oblique muscle and may be separated from it by a strabimus hook and excised.

NEURECTOMY OF THE SECOND DIVISION OF THE
FIFTH NERVE

Anatomy. — The superior maxillary nerve "commences at the middle of
the Gasserian ganglion, and, passing horizontally forwards, soon leaves the
skull by the foramen rotundum of the sphenoid bone. The nerve then crosses
the sphenomaxillary fossa, and, taking the name of infraorbital, enters the
infraorbital canal of the upper maxilla, by which it is conducted to the face"
(Fig. 48).

"In the sphenomaxillary fossa an orbital or temporo-malar branch ascends
from the superior maxillary nerve to the orbit, and two sphenopalatine branches
descend to join Meckel's ganglion; while the nerve is in contact with the upper
maxilla it furnishes the superior dental or alveolar branches; and on the face
are the terminal branches" (Quain).

When the neuralgia is limited to the facial distribution of the nerve, the
following operations may be performed:

(A) Locate the infraorbital foramen at the junction of the inner and middle
thirds of the inferior rim of the orbit and about half an inch below it. It is
on a line drawn from the supraorbital notch to a point between the two bicuspids.
Make a curved transverse incision parallel and close to the lower margin of the
orbit. Divide the orbicularis muscle in a direction parallel to its fibres. Expose
the nerve as it leaves the infraorbital foramen (Fig. 49). Seize the nerve in
forceps, and by traction and torsion extract as much of its trunk from its bony
canal as is possible. In the same fashion extract as much of its terminal twigs
as possible from the soft structures in which they run. It is extraordinary how
much of the nerve can be removed in this manner if patience is exerted. This
operation does not destroy the alveolar branches of the nerve. In an endeavor

NEURECTOMY TIC

to prevent recurrence one may plug the bony canal with a bone peg, silver screw,
rubber tissue, or amalgam.

(B) Expose the nerve as in Method A, Opposite the infraorbital foramen
make a vertical incision (a) through the soft parts joining the horizontal incision

ophthalmicus
supramaxiUaria
sphenopatai
For. oval.

iframaxillarit

Fig. 48. — {Esmarch and Kowalzig.)

at right][angles (Fig. 50). Divide the periosteum along the lower margin of the
orbit. Separate the periosteum covering the floor of the orbit from the bone.

Fig. 49. — Evulsion infraorbital nerve.

If this IS done, no orbital fat should be seen. With a flat retractor lift the orbital
contents upwards (Fig. 51). With a narrow chisel cut through the bone all

TIC DOULOUREUX

round the infraorbital foramen and remove it until that part of the osseous canal
which is covered by a thin shell of the bone forming the orbital floor, is exposed.
With the chisel cut away the bony roof of the infraorbital canal to its posterior
extremity. This can generally be accomplished without opening the antrum of

Fig.
Figs. 50 .and

ii. — Excision infraorbital nerve.

Fig. 51.
(Esmarch and K owalzig.)

Highmore. Lift the nerve from its bed and excise it. Close the wound with
sutures. Dress. The scar left by the operation is trifling. Several operations
have been devised to excise the superior maxillary nerve and Meckel's ganglion
by the antral route. Any operation in which the antrum of Highmore is opened

is undesirable on the score of uncleanliness,
and the advantages of such methods are
more fully obtained by the operation
about to be described.

Ptery go -maxillary Operation. (Braun
and Lossen's Modification of Lucke's
Operation.) — Step 1. — Expose the infra-
orbital nerve at its exit from the bone.

Step 2. — Beginning at a point just be-
hind and below the external angular proc-
ess of the frontal bone, make an incision
backwards and downwards to near the
tragus. From the same starting-point
make another incision downwards and
forwards to the lower margin of the
zygoma. Reflect downwards the triangu-
lar flap of skin and subcutaneous tissue
thus outlined. With a finger saw, chisel,
or Gigli wire saw divide the zygoma in
front and behind. Rose recommends that before the zygoma is divided holes
be bored on each side of the line of section so that everything may be ready
for wiring the fragments in position on the completion of the active part of
the operation. Separate the temporal fascia from the upper edge of the zygoma
and turn the bone downwards. Retract the tendon of the temporal mus-
cle backwards. The pterygo-maxillary fossa is exposed, with its fat and plexus

Fig.

;2. — Excision superior maxillary
nerve. {Farabeuf.)

NEURECTOMY TIC 69

of veins. If one now pushes the fat back with a blunt retractor, one at the
same time keeps the venous plexus and internal maxillary artery out of the
way. Demonstrate the posterior orbital fissure with a probe or strabismus
hook and distinguish the superior maxillary nerve and its accompanying
vessel (Fig. 52). The course of the nerve from its exit from the skull is down-
wards, forwards and outwards. The artery runs inwards, forwards and
upwards.

Step 3. — Tie a ligature round the nerve for the purpose of traction. Divide
the central end of the nerve as close to the foramen rotundum as possible.
By traction and torsion pull the peripheral end of the nerve out of its bony
canal. By this operation the whole trunk of the nerve is excised from the
foramen, rotundum to the cheek.

Step 4. — Attend to hemostasis. Replace the zygoma and fix it in position
by wire or chromicized catgut sutures. Provide drainage. Close the skin
wound. Dress.

NEURECTOMY OF THE THIRD DIVISION OF THE FIFTH

The inferior maxillary or third division of the fifth nerve leaves the skull
through the foramen ovale and divides into an anterior, motor and a postel
rior division. The latter, almost entirely sensory, divides into the auriculo-
temporal, the lingual, and the inferior dental. The lingual and the inferior
dental are of surgical importance, and as they are generally both involved,
if either of them is affected by neuralgia, their excision may be considered as
part of one operation. (See Fig. 48.)

The Operation. — Shave the temple. Clean the side of the face and the
external auditory meatus, and plug the latter passage with a little gauze or
better with non-absorbent cotton.

Step I. — Beginning about the middle of the zygoma cut backwards and
slightly downwards to a point a little below the tragus, then continue the in-
cision downwards along the posterior margin of the ascending ramus to the
angle of the lower jaw. From this point cut forwards along the inferior edge
of the horizontal ramus for about ^ inch. The cut only involves the skin
and subcutaneous tissue. Reflect the skin-flap, outlined as above, forwards.
The flap, consisting of skin alone, leaves the branches of the facial nerve un-
injured. Note carefully the position of Stenson's duct and of the anterior
lobules of the parotid gland. Make a transverse incision parallel to and below
Stenson's duct, directly down to the bone, at a point about 3^2 inch below
the sigmoid notch. Any portions of the parotid gland which may be in the
way must be retracted backwards uninjured. With a periosteal elevator de-
nude the outer surface of the ascending ramus of the jaw for a distance of one
inch or more below the sigmoid notch.

Step 2. — Apply a ^-inch trephine to the outer surface of the bone, the upper
edge of the trephine being not more than }/i inch below the edge of the sigmoid
notch (D, Fig. 53). With the trephine perforate the ascending ramus and
remove the button of bone. With rongeur forceps remove the bridge of bone

70 TIC DOULOUREUX

(C, Fig. 53), separating the trephine hole from the sigmoid notch. The result
of the above manoeuvres is to deepen the sigmoid notch while the coronoid
and articular processes are left in uninterrupted connection with the rest of
the jaw.

Step 3. — Retract the tendon of the temporal muscle forwards. With two
pairs of dissecting forceps pick away any fat which may be in the way and
demonstrate the external pterygoid muscle, which passes transversely across
the wound from the outer surface of the external pterygoid plate to the articular
process of the lower jaw. Note also the fibres of the internal pterygoid run-
ning downwards and backwards from the pterygoid fossa to the inner surface

of the lower jaw near its angle. Retract upwards
the lower fibres of the external pterygoid and thus
expose both the lingual and inferior dental nerves,
which, resting upon the internal pterygoid muscle,
come out from under the external pterygoid and run
downwards. The lingual nerve lies a little internal
and anterior to the dental. Tie a ligature, for

purposes of traction, round each nerve. Trace the
Fig. 5?. — Excision inferior . ^1 r 1 j j- -j .1

dental nerve. nerves up to the foramen ovale and divide them

there. Trace the nerves downwards and either di-
vide them or by torsion and traction tear away as much of their peripheral
portion as can be extracted. It is easy to remove more than an inch of the
nerves.

Step 4. — Attend to hemostasis. Close the skin-wound Drainage may or
may not be used. Dress.

In certain cases of very painful cancers of the tongue relief may be secured
temporarily, at least, by section of the lingual nerves.

Leriche (Lyon. Med., Jan. 18, 1914) agrees with Hayem that besides aeroph-
agy due to a reflex having its origin at the level of the stomach certain cases
are due to a primary hypersalivation. In one case of the latter after various
regimes had failed to relieve, he divided both lingual nerves and the right
auriculo-temporal nerve. The desired result was obtained; there was no longer
hypersalivation, the aerophagy and its consecutive gastric disturbances disap-
peared. The patient was satisfied but complained of an impediment due to
the lingual anaesthesia.

The simplest method of exposing the lingual nerve is through the mouth.
Open the mouth widely. Pull the tongue forcibly to the opposite side so as to
make the nerve stand out in relief below the mucous membrane of the tongue
behind the last lower molar tooth. Make a 3^-inch incision along the course of
the nerve and after picking it up with a blunt hook excise as much as desired.
The wound in the mucosa requires no sutures.

The auriculo-temporal nerve may be exposed by a ^^-inch vertical incision
midway between the tragus and the condyle of the jaw at the level of the posterior
root of the zygoma. The nerve is posterior and parallel to the superficial tem-
poral artery.

Inferior Dental Nerve. Transmaxillary Neurectomy.

Step I. — From the angle of the lower jaw make an incision for about 1}^^

NEURECTOMY TIC 7 1

inches forwards along the lower border of the horizontal ramus. With an
elevator separate the masseter from the bone. If necessary continue the
incision upwards along the posterior border of the ascending ramus for about
^'4 inch. Expose the greater part of the external surface of the ascending
ramus.

Step 2. — Note the line of the free border of the teeth of the lower jaw and
continue this as an imaginary line across the ascending ramus; on this line choose
a spot midway between the anterior and pos-
terior borders of the ramus and at this spot
apply a Doyen's bur (about i6 mm. in di-
ameter) and bore a hole sufficiently deep to
expose the inferior dental canal and the
nerve in it. The bur is a better instrument
to use than a trephine as it is not so liable
to injure the nerve.

Step 3. — The nerve is seen lying in the
depth of the wound (Fig. 54). Pick up the "'^^^^7::

nerve in a forceps and evulse it after the fig. 54.— Excision inferior dental
manner of Thiersch. Pack the bone canal n^^^^e. {Lemrmant.)

with rubber tissue, hard paraffin, amalgam or some such material.

Step 4. — Close the wound.

The author has found this operation very satisfactory.

All the operations of neurectomy which have been described give at least
temporary relief, but too frequently the tic returns after the lapse of a year or
two. Occasionally the patient does not seem to get immediate relief from
his pains. The author has in mind one case in which he removed portions
of the inferior dental and lingual nerves. The patient suffered from neuralgia
for one or two djiys after the operation. The pain was at once relieved on
the removal of bloody fluid which had collected in the deep wound. Had
the wound been efficiently drained, the temporary trouble might have been
averted.

None of the operations of neurectomy for tic douloureux which have been
described here are dangerous when performed by an experienced surgeon,
but they are not a proper field for invasion by a tyro in surgery. In almost
all the operations the wounds while large, are so situated as to cause but little
deformity from scar, especially if the subdermal suture is used in closing
them.

HARTLEY-KRAUSE OPERATION

It has been shown that tic douloureux almost always recurs after even
the most extensive excision of the nerve-trunks involved. It has also been
shown (Keen and Spiller) that in the Gasserian ganglion very marked degen-
eration is present. When neurectomy fails to give permanently good results, it
is most logical to attack the Gasserian ganglion. This has been done in many
cases with excellent effect. The Gasserian ganglion may be exposed either

TIC DOULOUREUX

from below or from above. The former method has been thoroughly studied
by Rose, Andrews and others. Their route entails temporary resection of
the zygoma and the coronoid process, the use of the inferior maxillary nerve
as a guide to the foramen ovale, exposure of the base of the skull beside that
opening, the removal of a button of bone from the exposed portion of skull
with a trephine, and lastly a rather haphazard removal of the ganglion when
it is reached. Anyone who has had occasion to operate in the neighborhood
of the foramen ovale can appreciate the difficulties of the operation. Hartley
and Krause almost simultaneously devised a method of reaching the Gasserian
ganglion by an intracranial route.

Fig. 55. — {Frazicr, Jour. A. M. A.)

Position of Patient. — Frazier places the patient in the sitting posture (special
operating chair) claiming that less ether is required, that there is less venous
bleeding and that as the plane of the floor of the skull is level with the surgeons
eye he may stand erect and look directly at the structures on which he is
working.

Pussep (Russki Wratsck, 191 2, No. 2. Zentfur. Chir., 191 2, No. 24) advises
that the patients head be placed hanging down and somewhat to the side so
that the weight of the brain acts in place of a retractor. (See Bogojawlensky's
position.)

Anesthetic. — Ether. Deep anesthesia is not required and after the root is
divided the anesthetic may be discontinued.

The Operation. — The shortest route to the ganglion is from the middle of the
zygoma.

GASSERIAN GANGLION

Step 1.— Make and reflecl forwards the skin flap shown in Fig. 55. This
avoids injury to the upper division of the facial nerve. Make and reflect liack-
wards and forwards the temporal musculo-aponeurotic flaps as shown in Fig. 55.

Fig. 56.— (/'Vc/c/o-, Jour. A. M. A.)

Fig. S7 -—(Frazier, Jour. A. M. A.)

Attach all these flaps by sutures to the drapings around the operative area and
thus avoid the use of retractors. Control hemorrhage as described in Cushing's
subtemporal decompression.

TIC DOULOUREUX

Step 2. — A short distance above the zygoma ojien the skull with a suitable
bur. Enlarge the opening with rongeurs until it is about 4 cm. (i3^ in.) in
diameter. The lower margin of the opening extends to the base of the skull.

Step 3. — Separate the dura slowly from the temporal bone and the base of
the skull following the middle meningeal artery to the foramen si)inosumr Plug

^FiG. 58. — {Frazier, Jour. A. M. A.)

the foramen with a twisted bit of moistened cotton or with bone wax, and
divide the artery (Fig. 56, ). Continue the separation to the foramen ovale.
Step 4. — Note the dural reflection on the mandibular division of the nerve
as it enters the foramen ovale (Fig. 57). Open this reflection and enlarge the
opening until the upper surface of the ganglion is stripped of its dural covering.
Follow the ganglion upwards until at the apex of the petrous bone the sensory
root is seen (Fig. 58).

Ophthalmic division .

Superior Maxillary
division.

Hutchinson's line of section.
Casseriati Cati^lion.

Middle Meninjeal Arfety.

MecKal's Canglii

Ifif trior Maxillar/ division.
Fig. 59. — Left Gasserian ganglion exposed from the side.

Step 5. — Isolate the sensory root; pick it up on a small blunt hook and by
gentle traction sever it from its central attachment.

Step 6. — Close the wound.

During the operation a proper retractor provided with an electric light
(Fig. 57) is valuable. To avoid keratitis Frazier advises the use of goggles for
a year after operation when the patient is out of doors.

GASSERIAN GANGLION 75

Jonathan Hutchinson, Jr., advocates division of the sujicrior and inferior
maxillary nerves and removal of the corresponding j)ortion of the ganglion
leaving intact the ophthalmic division and its i)ortion of ganglion (Fig. 59).

THE ABBfi OPERATION

Abbe, to avoid the dangers of hemorrhage, shock, and prolonged operation,
has given up attempts to formally resect the Gasserian ganglion. He performs
an intracranical neurotomy or, preferably, neurectomy, and then prevents
reunion of the divided nerves by interposing a layer of thin rubber tissue,
sterilized by immersion in corrosive sublimate solution, which is washed ofif
with salt solution. To lesson hemorrhage from the middle meningeal artery
Abbe ligates the external carotid just above the thyroid.

'*Ligate the external carotid; make a straight incision in the temporal
fossa above the zygoma; split the temporal muscle, scraping it widely from the
bone, and enter the skull by a small trephine opening, rapidly enlarged by
rongeurs to one and one-half inches in diameter. Expose the second and
third branches from the Gasserian ganglion to the foramina. Seize each at
the foramen by a narrow clamp, cut it, and resect a half-inch or tear it from
the ganglion; push back the dura well beyond the foramina; arrest bleeding
by a moment's pressure, and spread over the bone a piece of sterile rubber
tissue, enough to more than cover both foramina, one inch wide by an inch
and a half in length, which must be pressed upon the bone by a strip of gauze
packed over it for a couple of minutes. When this is removed, the rubber
tissue lies in close contact with the skull and the dura is allowed to settle down
to its place upon it. The wound is then closed by a few fine catgut sutures
and drained for a day at its lower angle." ("Trans. Am. Surg. Assoc,"

1903-)

G. R. Fowler has used Crile's plan of temporary occlusion of both common

carotids and found it useful. In one case a tape passed round the carotid

and secured by a clamp, pressed against the internal jugular vein and caused

much venous oozing during the operation.

When should one practise excision of the Gasserian ganglion? In cases
of intolerable tic douloureux one should try the milder operations of neu-
rectomy, as they give at least temporary relief, and so permit the strength of
the patients to be built up. This is important, as the sufferers from tic doulour-
eux are often much reduced from their long-continued agony. Surgeons are
coming more and more to favor excision of the ganglion as the primary operation
and with this change of opinion the author is in sympathy.

V. Pleth (Am. Jour, of Surg., May, 19 19) reports uniformly good results in
fifty cases of Tic in which he performed cervical sympathectomy with or with-
out deep and superficial injections of alcohol. Apparently it is the superior
ganglion which he attacks. In some cases alcohol injections are used to obtain
immediate results as the full benefit from the sympathectomy is not obtained
until three months or more have elapsed.

EXTERNAL EAR

CHAPTER V
PLASTIC OPERATIONS ON THE EXTERNAL EAR

The external ear when very large or very projecting may be operated on
for cosmetic reasons.

Macrotia. — The pinna is uniformly enlarged but does not project out-
wards unnaturally. Make the incision AB (Fig. 60) through the whole thick-

ness of the pinna. Pull the upper segment of pinna over the lower segment
to see how much tissue must be removed in order to correct the deformity
(Fig. 61). Make a cut from D to B and remove the overlapping triangle

N'-'

Fig. 63.

of tissue DEC. The edge of the pinna at D does not correspond with the
edge of the pinna at A, therefore cut away a wedge-shaped segment of pinna
DEB (Fig. 62) and so permit the point D to be brought out to the point A.
With sutures introduced alternately from the outer and inner side of the ear,
unite the edge DEB to the edge AB. Instead of lengthening the wound edge
DB, it might be possible to shorten the edge AB by cutting out the wedge
of tissue XYZ (Fig. 62).

SYNECHIA EAR

(A) Plastic Restoration of Lobule.— The lobule of the ear may be absent
congeni tally or may have been removed by accident or for disease. If removed
for disease it may be replaced at the primary operation or later.

GaveWs Operation. — Step i. — Freshen the stump of the lobule. Apply
pressure with a hot pad to stop bleeding. Retract the stump upwards.

Step 2. — Reflect, and fold on itself the flap ABC (Fig, 63). With sutures
keep the two raw surfaces of the flap together.

The flap or new lobule must be one-third larger than the normal lobule;
this to allow for shrinkage.

Fig. 64. — {Laurens.)

Fig. 65. — {Laurens.) Fig. 66. — {Lauretis.)

Step 3. — Suture the upper edge of the new lobule to the vivified stump of
the old lobule.

Step 4. — Close the wound in the neck either by sliding of skin or by grafts.

(B) Coloboma of Lobule. — A part of the lobule may be absent either
congenitally or as the result of accident, usually the result of necrosis follow-
ing piercing of the lobule with dirty instruments. Nelaton's method of
operating will be easily understood by glancing at Figs. 64, 65, 66.

SYNECHIA OF LOBULE

Occasionally, instead of hanging in the normal fashion the lobule is adherent
to the body through its whole length. The deformity may be annoying.
The following method is suggested for correction of the synechia: Mark the
line along which the lobule ought to be separated. In front of the ear raise
the flap X (Fig. 67), having its base corresponding to the above-mentioned
line and attached to the ear. Behind the ear elevate the flap Y, having its
base or pedicle attached to the neck (Fig. 68). Divide the lobule along the
line AB. Attend to hemostasis. With the flap X cover the wound now

EXTERNAL EAR

existing on the new inner edge of the lobule. With the flap Y cover the cor-
responding wound in the neck. Fix the flaps in position with sutures.

Fig. 67.

Fig. 68.

Fig. 69. — {Laurens.)

Fig. 70. — {Laurens.)

PROMINENT EARS

Instead of lying parallel to the head the auricles may stand out more or
less at right angles to the head. The deformity, especially when the ears
are large, is considerable and may have an injurious influence on the patient's
career. There are several methods of correcting the deformity.

Method A. — The deformity is not of high degree. There is little or no
macrotia, there may be, as in Bacon's case, some microtia. Remove the whole
thickness of the skin from the area abed (Fig. 69). Take away more skin
from the auricle than from the mastoid region. Suture the edge adb to the
edge acb (Fig. 70).

PROMINENT EAR

Method B. — A portion of the skin and an ellipse of cartilage may be removed
(Fig. 71), and the wound closed (Fig. 72). The result is, however, not satis-

FiG. 71. — {Payr.

Fig. 73. — {Payr.)

Fig. 74. — {Payr.)

factory. Payr recommends the excision of a sickle-shaped portion of cartilage
(Fig. 73). This gives better results.

EXTERNAL EAR

Fig. Ts.—{Payr.)

Fig. -je—iPayr.)

Fig. 77. — (Payr.)

PROMINENT EAR

Fig. 78.-
Antihelix.

Helix.
Fossa

Method C {Payr's Operation). — Payr found ("Archiv fur klin. Chir.,"

Ixxviii, 918) that the results from Method A were good at first but that the

spring-like action of the cartilage of the ear caused stretching of the scar and

some recurrence of the deformity. In cases of great

deformity he operates as follows:

Step I. — Remove the skin from the areas I and II

(Fig. 74). Make the incisions a-a, b-b, c-c, down to,

but not into, the cartilage. Reflect the flaps abab and

aacc.

Step 2. — From the most prominent part of the concha

posteriorly make two parallel incisions about % inch

apart, through the cartilage out to the free margin of

the auricle. Do not injure the skin covering the anterior

surface of the cartilage. Elevate and turn back the

flap of cartilage (Fig. 75). From the cartilage above

and below the transverse wound remove sickle-shaped

portions of cartilage (Fig 75).

Step 3. — With sutures close the wounds in the carti-
lage (Fig. 76).

Step. 4. — In a convenient location make two parallel antihdix

incisions through the mastoid periosteum and elevate a

bridge of periosteum. Pull the flap of cartilage under the periosteal bridge and

suture it there (Figs. 76 and 77).

Step 5. — Close the wounds aa, bb, cc with sutures (Figs. 74 and 77).

Unite the edges of the denuded area I to
the edges of the denuded area II (Figs.
74 and 77). This operation corrects both
the inacrotia and the malposition. If
the ear is not much enlarged and there
is marked malposition the anchoring flap
of cartilage may be made narrow and
the sickle-shaped resection of cartilage
may be omitted.

Method Z>.— Luckett C'Surg., Gyn.,
Obst.," June, 1910) considers that in
prominent ears the deformity is due to
absence or insufiicient development of
the antihelix (Fig. 78), the cavity of the
concha being continuous with that of the
helix. To form an antihelix Luckett
operates as follows:

Step I. — On the inner or posterior
surface of the auricle make a crescentic
incision through the integument opposite

the line of the intended new antihelix. Remove the inscribed integument.

Dissect the edges of the skin free from the cartilage and retract them.

Remove a similar crescentic segment from the cartilage. The amount of

^■■^t*!crr. j

Fig. 79. — {Luckett, Surg., Gyn., Obslet.)

82 EMPYEMA OF THE ANTRUM OF HIGHMORE

cartilage removed depends on the extent of the deformity. Do not buttonhole
the skin on the anterior or external side of the ear when removing the cartilage.

Step 2. — Close the wound in the cartilage by Lembert sutures so as to
invert the edges (Fig. 79) and form an antihelix.

Step 3. — Close the skin wound with horse-hair sutures.

Hematoma Auris. Othematoma. Cauliflower Ear. — Don H. Palmer
(Northwest IMed., Dec, 1913) operates with good results in this deformity
as follows: Sterilize the external ear and surroundings by any good method
without iodin. Plug the external auditory meatus with cotton. Make an
incision over the most prominent part of the swelling into the hemorrhagic
cavity. With curette or fine gouge remove all clots, new-formed cartilage
or bone. Gently scrape the anterior surface of the old cartilage until it is
smooth. Close the incision except for a small opening which will just admit a
Eustachian catheter connected with a small Pynchon pump. With the pump
remove all accumulated blood; the suction compels approximation of the skin,
perichondrium and cartilage. Dry the skin. Put a fresh, dry plug of non-
absorbent cotton in the external auditory canal. Apply sterile vaseline gen-
erously to both surfaces of the ear and to the surrounding parts. Place a card-
board mould around the ear and fill it with plaster-of-Paris cream so that the
ear is completely encased in the plaster through which the Eustachian catheter
projects with the connected pump working continuously.

As the plaster hardens rotate the catheter sufficiently to permit its easy
removal. As soon as hardening is complete remove the catheter; the track
left by its removal, permits drainage. Hold the plaster cast in place by
bandages. After about ten days remove the cast by fragmentation.

CHAPTER VI
EMPYEMA OF THE ANTRUM OF HIGHMORE

INTRANASAL OPERATION

Cocainize the lower meatus of the nose. Seat the patient with his head
well thrown back. Introduce a stout, curved trocar and cannula through the
nostril to a point immediately under the inferior turbinated bone, i.e., to a
point in the highest portion of the inferior meatus of the nose. Before this
can be done it may be necessary to remove part of the inferior turbinate bone.
Turn the trocar so that its point touches the outer wall of the nose (inner wall
of the antrum) at right angles. Push with steady force, outwards so as to
make the trocar enter the antrum. Wash out the antrum with warm water
or a mild antiseptic. Do not use peroxide of hydrogen; it may spread infection.
Remove the trocar. No dressings are required. The trocar used ought
to be large enough to leave a more or less permanent opening.

Alveolar Route. — Provide a drill about the size of a No. 16 French sound.
Provide one or more metal drainage tubes about % to i inch long, provided
with a flange to prevent their slipping into the antrum. Provide a nozzle
which can slip into the drain and permit of irrigation.

friedrich's operation 83

Examine the teeth. If a carious tooth is found it is probably the cause
of the empyema, and must be extracted. (The teeth at fault may be the first
premolar or the first or second molars.) Through the tooth socket drill a
hole upwards and backwards (never inwards) into the antrum. Remove
the drill, substituting a drainage tube. Irrigate daily through the tube.

Never sacrifice a healthy tooth to gain access to the antrum by this route.
The drainage tube used ought to fit the drill hole snugly and so have no
tendency to fall out.

Radical Operation. — This method is based on the obsolete method of
drainage through the canine fossa. Administer a general anesthetic.

Step I. — Retract the upper lip upwards and outwards. Make an incision
to the bone from the maxillary tuberosity to a point immediately below the
nares, high up above the line of the reflection of the mucosa from the alveolus
to the cheek. Attend to hemostasis by temporary pressure. Pull the upper
edge of the wound upwards with a retractor.

Step 2. — With a periosteal elevator expose the whole outer wall of the an-
trum. Do not injure the infraorbital nerve. Open the antrum with a chisel, en-
large the opening with rongeur forceps. Cleanse out any pus and blood which
may be present. Attend to hemostasis by temporary packing gauze.

Step 3. — Explore the antrum. If the disease is catarrhal merely wash
the cavity. If granulation tissue is present in quantity remove it by scraping
it away with pledgets of gauze or with a curette used gently. If necrosed
bone is present remove sequestra and diseased bone. Occasionally sinuses
leading through thg alveolus to the mouth require excision (Laurens) through
a vertical cut reaching from the primary incision to the alveolar margin. Ex-
amine the inner wall of the sinus carefully behind the normal opening into
the nares, because ethmoidal disease may cause necrosis here, and unless
the ethmoid trouble is treated a cure may be prevented.

Step 4. — Provide permanent drainage for the sinus as follows:

With chisel, forceps, etc., remove the lower ^^ of the nasal wall of the sinus.
This means removing the lower turbinate bone as well. Bleeding will be
free but is easily stopped by gauze pressure. Be sure that no crest of bone
remains between the nasal and antral floors (Laurens). Pack the cavity with
gauze brought out through the nostril.

Step 5. — Close the wound in the mouth with sutures.

Remove the pack in twenty-four or forty-eight hours. After this keep the
parts as clean as possible without greatly disturbing the patient.

P. L. Friedrich's Radical Operation. — Make an incision down to the bone,
skirting the ala of the nose in the natural groove of this region. Expose the
outer and lower angle of the pyriform opening. With the elevator separate
the soft parts and periosteum together from the outer surface of the superior
maxilla; it may be necessary to make an incision to the bone from the middle
of the primary incision downwards and outwards for about three-fourths
of an inch. With the elevator separate the muco-periosteum of the outer
wall of the nose from the edge of the pyriform opening backwards for about
one inch. A fair area of both the facial and nasal walls of the lowest portion
of the antrum are exposed by the above means. With chisel and rongeurs,

OSTEOPLASTIC EXPOSURE OF THE ORBIT

beginning at the lower and outer angle of the pyriform opening, cut away the
bony walls (both facial and nasal) of the antrum. In doing this, part of the
inferior turbinate bone is removed.

Friedrich's operation gives very free access to the antrum and permits
proper treatment both of the antrum and of any fistula leading from it.

The intranasal and alveolar methods of treating empyema of the antrum
are suitable in cases of catarrhal inflammation, or where dental disease is the
primary cause of the trouble. When the disease resists drainage for two or
three weeks the probabilities are that osteitis, necrosis or some granulomatous
condition is present and only the radical operation will avail.

CHAPTER VII
OSTEOPLASTIC EXPOSURE OF THE ORBIT

Frankes' Modification of Kronlein's Operation. — This operation is of value
in the exploration of, and removal of tumors from, the orbit when it seems possi-
ble to preserve the eye.

Step I. — Below the level of the eyebrow make an incision corresponding to
the external half of the upper margin of the orbit. Continue the incision
downwards along the outer margin of the orbit to a point near the lower orbital
margin. From this point cut backwards on the malar to the middle third of
the zygoma.

Fig. 8o. — Osteoplastic exposure of the orbit.

Step 2. — (a) Subperiosteally divide the zygoma near its middle, {b) Be-
ginning at the upper and outer part of the orbital rim, subperiosteally divide
the outer orbital rim backwards and downwards to the inferior orbital fissure
(Fig. 80). This is best done with a chisel, (c) Beginning at the lower and
outer part of the orbital rim, subperiosteally divide the malar backwards to
the inferior orbital fissure and to the origin of the masseter.

Step 3. — Reflect the bone flap thus formed. Remove any portions of the
external orbital plate which obstruct, and so expose the orbital fat.

Step 4. — Do whatever may be necessary to the orbital contents.

Step 5. — Replace the bone flap. Suture the skin. Suture of the bone is
unnecessary.

EXCISION OF UPPER JAW 85

CHAPTER VIII
EXCISION OF UPPER JAW

Resection of the Alveolus, Schlange's Method. — This is usually called for be-
cause of tumors. Small tumors may be removed by the methods recommended
in excision of the alveolus of the lower jaw. When much of the alveolus is
involved and perhaps part of the palate, Schlange operates as follows: Provide
three or four gouges with blades i to 2 inches wide. Tampon the nostril on
the affected side. If necessary in order to obtain free access, split the cheek
by a curved incision running upwards and outwards from the angle of the
mouth. Open the jaws widely with a gag. Retract the cheek and upper lip
thoroughly. Beginning posteriorly and as remote as possible from the disease
drive the gouges one after the other vertically upwards through the alveolar
and palatal processes into the antrum. Leave each gouge undisturbed in situ;
this is of great importance because removal of the instrument would at once be
followed by serious bleeding. ''When the horizontal portion of the superior
maxilla has been thus divided by three gouges the part to be removed is held in
place merely by the anterior wall of the antrum. With the fourth gouge quickly
divide this connection and exerting slight leverage on the chisels remove them
and the separated bone together. Before the gaping wound has time to bleed
pack it with a tampon or large sponge which has been
held in readiness. The operation can be carried out in a
few minutes and with almost no loss of blood." When
much of the alveolus is removed from a young and
growing patient great deformity of the jaw and teeth
may be expected unless the defect is properly filled by
a suitable prosthesis.

Many incisions have been devised to expose the
superior maxilla. Probably the best are those of Weber
(A, B, C, D, Fig. 81) and Velpeau (V, P, Fig. 8i).

Weber's Incision. — Beginning immediately below '' X

the inner angle of the eye, make the incision B, C, D, „,^,^^-,^^.-~.A' ^' ^' P'
^ •' ' . ! J 7 Weber s incision; P, V,

which skirts the ala of the nose and divides the upper Velpeau's incision.
lip in the middle line. From the point B (Fig. 81)

make the curved incision (B, A, Fig. 81) which follows the lower margin of
the orbit. Reflect outwards the flap outlined by the complete incision.

Velpeau's Incision. — This incision is very similar to that of Syme. Be-
ginning at the angle of the mouth, make the incision, P, V (Fig. 81), through the
whole thickness of the cheek. The cut runs obliquely upwards and outwards
from the angle of the mouth for such a distance as will permit of exposure of the
superior maxilla by reflection of the cheek upwards and inwards. This incision
is not as good as Weber's.

Separate the periosteum covering the floor of the orbit from the bone.
Gently lift the orbital contents upwards with a flat retractor. With a bone

EXCISION OF UPPER JAW

forceps or Gigli saw divide the malar bone and with it part of the orbital floor
at the point Z (Fig. 82). In the same manner divide the nasal and prbital
processes of the superior maxilla at the point X. Open the patient's mouth
and with a knife make an incision through the muco-periosteuni of the hard
palate, parallel and close to the middle line. Continue this incision forwards
and then upwards through the muco-periosteum covering the alveolus to
the nasal aperture. With bone forceps, Gigli or finger saw divide the hard
palate and alveolus along the line of the mucoperiosteal incision. With knife,
or better with scissors, separate the soft palate from the hard palate on the
side being excised. Seize the superior maxilla with lion-jawed forceps and

forcibly remove it with a twisting motion.
Any undivided strands of tissue may be
severed with scissors. The internal
maxillary artery will generally be found
bleeding vigorously in the depth of the
wound. It should be seized with forceps
and ligated. Oozing is stopped by pressure
with gauze pads wrung out of very hot
water. Pack the wound with iodoform
gauze. Replace the flap of soft structures
over the packing and suture it in position.
The after-treatment consists in having
the patient lie on the side operated
upon or sit up in bed or a chair as early
as possible. This is to avoid danger of
pneumonia. The mouth must be kept
clean. Closure of the wound usually takes
place rapidly. When recovery has taken
place, consult a good dentist with regard
to the use of an artificial palate.
Keen notes that sarcoma of the upper jaw often extends through the
infundibulum into the frontal sinus. This extension must be looked for
and removed. Extend the incision C, B (Fig. 81) upwards to the nasal
side of the inner canthus over the frontal sinus. Remove with a smaller
rongeur the anterior wall of the infundibulum and of the frontal sinus; wipe
away the tongue-shaped process of the sarcoma with a gauze pad.

W. J. Hearn, Matas, and others always ligate the external carotid before excis-
ing the jaw. The former surgeon finds in doing so that he always exposes
some enlarged glands which require removal. Matas emphasizes the impor-
tance of ligating the external carotid high up, well above the bifurcation, other-
wise there is danger from cerebral embolism.

A. H. Ferguson's operation, suitable in cases where the skin is not involved.

1. Place the patient with head hanging over a sand-bag.

2. Make an incision about one-half inch long over the nasal process of the
superior maxilla; through this, with an osteotome, divide the bony process.

3. Repeat Step 2 over the junction of the superior maxilla and the malar
and divide the bone.

Fig. 82. — Excision of upper jaw.

X, Y, Z. Usual lines for division of bone.
P, Q. Sectipn may be made here instead of
at Z, when disease is extensive.

EXCISION OF UPPER JAW 87

4. Cut through the alveolar process and the hard palate. Save as much
of the soft palate as possible.

5. With elevator or forceps evulse the jaw and pull it out through the
mouth. Pack the cavity with iodoform gauze.

BARDENHEUER'S OPERATION FOR PARTIAL EXCISION OF THE
UPPER JAW AND IMMEDIATE PLASTIC REPAIR

By means of the incision A, B, C (Fig. 83) the flap C, E, D is reflected
and the jaw and tumor exposed. By means of saw, bone forceps, and scissors

Fig. 83. — {After Bardenheuer.) Fig. 84. — {After Bardenheuer.)

the jaw is partially excised, the object being to remove the tumor and with
it a safe margin of healthy bone. Bleeding is arrested by ligature, hot water
and sponge pressure. The incision F, G, H (Fig. 84) outlines a skin-flap
(hairless) in the pedicle of which is a portion of the skin of the upper eyelid
as well as the whole eyebrow. The flap is turned (epidermis inwards) into
the position F, I, H, and there sutured. The flap C, E, D is now turned back
into its old position and there sutured. Most of the wound F, G, H is covered
by Thiersch's grafts. After the lapse of two weeks the pedicle of the flap
F, H, I is divided and the eyelid and eyebrow contained in it returned to their
normal position. The wound left where the pedicle was divided must be
trimmed and closed. The result is seen in Fig. 85.

EXCISION OF SUPERIOR MAXILLA WHERE THERE IS TUMOR
INVOLVING BOTH THE BONE AND THE SKIN

Make the incision A, B, C (Fig. 86). Isolate the tumor from the rest of
the skin by the incision D, F, E, which joins A, B and C at the points D
and E. Reflect the flap A, D, E, C towards the opposite side of the body
(Fig. 87). Reflect the skin at B towards the ear so as to expose the zygoma
and the frontal process of the malar. Divide the bones as shown in the dotted
lines in Fig. 87. Remove the tumor and superior maxilla as in the classical

EXCISION OF UPPER JAW

operation for excision of the upper jaw. Pack the wound with iodoform
gauze. Replace the flaps and suture them in position.

Fig. 85. — {After Bardenheuer.)

Fig. 86. — Author's method of excising upper
jaw for disease involving the skin.

EXTENSIVE EXCISION OF UPPER JAW

The younger Konig in very extensive disease of the upper jaw necessitating
removal of the floor and outer wall of the orbit recommends the following
operation:

I. Ligate the external carotid between the origin of the superior thyroid
and lingual arteries. This step is simple, harmless, and very useful.

Fig. 87. — Author's method of excising upper jaw for disease involving the skin.

2. Expose the bone by Velpeau's incision. Remove the disease.

3. Recognize and expcse the temporal muscle in the outer part of the
wound. At the level of the coronoid process and about i}4, finger-breadths
from its anterior margin split the muscle upwards and downwards. With
a chisel divide the ascending ramus of the lower jaw along the line in which

RODENT ULCER

the muscle was split. The result of the above is to provide a flap, consisting of
temporal muscle and bone, attached above to the skull and free below {¥ig. 88).

Fig. 88. — F. Konig's operation.

Fig. 89. — Author's method of excising
rodent ulcer.

4. Turn this flap inwards and unite its free extremity to the remains of the
frontal process, so that a firm floor is provided for the orbit and the eye is kept
in place.

5. Complete the operation by closure of the skin-wound and packing with
iodoform gauze.

RODENT ULCER

As a t)^e of operation for rodent ulcer an example may be taken where
the disease involves the malar, the superior maxilla, and to a moderate extent
the orbit.

Fig. 90. — Author's method of excising rodent ulcer.

1. Make an incision around the disease, and distant from it 3^ inch (Fig. 90).

2. Leaving the diseased tissue undisturbed, reflect the soft parts all around
it from the bones so as to lay bare to touch the upper margin of the orbit,
the external angular process of the frontal bone, the temporal process of the
malar (Fig. 90), the external anterior surface of the superior maxilla above the
alveolar process, and the nasal bone on the afifected side. As hemorrhage occurs,
it must be arrested at once.

EXCISION OF UPPER JAW

3. With bone forceps or chisel cut through the bones as shown in Fig. 91,
Bone incision A (Fig, 91) penetrates the antrum of Highmore.

4. Separate the orbital contents from the roof of the orbit and divide the
optic nerve.

It is now easy to remove the disease surrounded by a fairly large zone of
healthy tissue. The cavity is packed with iodoform gauze. After the lapse
of about ten days endeavors may be made to lessen the deformity which has
been produced. As the cavity is largely lined by mucous membrane, it is proper
that an endeavor should be made to provide its new covering with an epidermal
surface internally.

Fig. 91. — Excision rodent ulcer.

Fig. 92. — Plastic repair after excision rodent
ulcer.

T)rpe of Operation to Repair the Deformity.— On the hairless forehead make
the incision A, B, C, Fig. 92, so as to obtain a flap, A, C, D, of size and shape
suitable to provide an epidermal outer and anterior wall to the cavity left by
operation. The base (A, C) of the flap is a little above the orbit and ought to
extend beyond the orbit on one side or the other so as to have plenty of nourish-
ment. The flap is now turned down so that its epidermal surface faces inwards,
its raw surface outwards. The edges of the flap are stitched with catgut in
the position A, C, D (Fig. 92). From the neck the flap E, F, G is dissected up
and sutured in the position F, E, H, I. The raw surfaces A, B, C and E, F, G
are lessened in size by sliding their edges centripetally and there suturing them.
Any parts not covered by skin are now grafted by Thiersch's method.

After the lapse of two weeks, if everything has gone well, the pedicles of
the flaps A, D, C and H, I, E are divided and their remnants turned back into
their old positions. A certain amount of trimming and suturing must be done
at the margins of the now repaired deformity.

OSTEOPLASTIC RESECTION 9I

Note. — In the original operation when the bone incisions are being made it is wise to
divide the nasal bones last, so as to avoid the entrance of blood into the nose. The com-
plete dissection of the soft parts before attacking the bones ensures that most of the bleed-
ing will have been attended to before any of the facial cavities have been opened. Should
the patient's strength warrant, the reparative work might be done at the same sitting, but
the disease generally affects the old and debilitated.

Osteoplastic Resection of Upper Jaw (Kocherj. — Suitable for Ihe removal of
nasopharyngeal and retropharyngeal neoplasms— e.g., sarcomata, etc.

Preliminary ligation of both external carotid arteries may or may not be
practised. Place the patient in Trendelenburg's position. This renders pre-
liminary tracheotomy unnecessary.

Step I. — Split the upper lip near the middle from the nostril to mouth.
On each side divide the buccal mucosa at its line of reflection from cheek to
alveolus. Only divide the mucosa sufficiently to permit the performance of
Step 2.

Step 2. — With a chisel divide the anterior-external wall of the antrum from
the nose outwards and backwards above the alveolus. This opens the antrum.

Step 3. — With a wide chisel (better osteotome) of thin steel divide the
alveolus and hard palate close to the middle line. With strong sharp hooks
pull the halves of the upper jaw apart, pushing the vomer to one side and
dividing any nasal mucosa which hinders. If necessary divide the soft palate.
Remove any of the turbinated bones which obstruct.

Step 4. — Free access to the base of the skull is now possible. Remove the
tumor secundum artent, using the cautery if necessary.

Step 5. — Replace the halves of the jaw and fix them by a suture (wire or
silk) penetrating the alveolus. Suture the soft palate if it has been divided.

Step 6. — Apply iodoform gauze packs to the bed from which the tumor
was removed bringing the ends of the pack out through the nose.

Partsch's Method. — (Beitrage z. klin. Chir., xci, 555). — Place the patient
on a table which is slightly inclined to one side and has its lower end moderately
elevated. The patient's neck is supported on the edge of the table (not hanging
as in Rose's position). A general anesthetic is administered through a tube.
The external carotid arteries may be ligated or hemorrhage may be lessened
locally by the use of adrenalin.

Make an incision above the alveolus of the upper jaw from the second molar
on one side to the second molar on the other side. Retract the soft parts up-
wards and open the nasal fossae by freeing the mucosa at their anterior orifices.
With a thin chisel divide the septum nasi along the floor of the nose. Divide
the anterior and external walls of the antrum of Highmore at the level of the
antral floor. Do this on both sides as far back as the maxillary tubercles.
The alveolus and the palatal vault can now be pushed dowTi as a flap the hinge
of which corresponds to a transverse line passing through the posterior extremi-
ties of the maxillary body. This gives very free access to the nasopharynx w^ith-
out interfering with the palatine arteries. When the operation is finished the
flap is easily replaced and secured by some stitches through the mucosa.

Reinhardt ("Zentralblatt fiir Chir.," May 9, 1908) has collected fourteen
cases in which this operation has been performed without a death.

LOWER JAW— RESECTION

Exposure of the Base of Skull by Temporary Resection of the Palate. — C.
Hofmann's method ("Zentralblatt fiir Chir.," 1910, No. 24).

Step I. — Make an incision through the mucosa of the palate from the pre-
molar tooth on the right side to a corresponding point on the left side. Nearly
at right angles to the above incision make a cut immediately to the inner side
of the alveolus (on the right or left side of the palate, according to the location
of the tumor in the nasopharynx). This incision extends backwards to the edge
of the soft palate dividing the muco-periosteum covering the hard palate and
the whole thickness of the soft palate.

Step 2. — With a chisel divide the bone of the palate corresponding to the
incision made in Step i. With an elevator raise the palate and reflect the flap
of bone and soft parts, fracturing the bone in the pedicle of the flap. While
this is being done the nasal septum must necessarily be either fractured or
divided.

Step 3. — After removal of the tumor from the nasopharynx replace the flap
and fix it with a few sutures. Hofmann states that the flap tends to stay in
position and that the whole operation is easy.

CHAPTER IX

LOWER JAW-RESECTION

I. RESECTION OF THE .ALVEOLAR PROCESS

Incise the muco-periosteum around the portion of bone to be excised. If
the portion to be excised is small, its removal may be effected with rongeur
forceps or with the chisel and mallet. In using the chisel the surgeon should
hold the instrument in one hand, support the jaw with the other, and let his
assistant manipulate the mallet. When the excision is to be more extensive,

one may with a finger saw make a vertical
incision through the alveolar process in
front of, and another behind, the portion
to be removed, and join the lower ends of
the vertical incisions by a horizontal one
cut with a chisel or a saw operated by a
surgical engine.

II. PARTIAL RESECTION OF THE
HORIZONT.AL RAMUS

Make an incision through the skin
down to the bone along the inferior edge
of the jaw. Separate the soft parts from
the inner and outer surfaces of the jaw. If the operation is done for necrosis,
preserve the periosteum; if for tumor, sacrifice it. Divide the jaw by
vertical incisions made with the Gigli wire or the finger saw, in front of
and behind the disease. If teeth are present at the lines of vertical
incision, they must be removed before the saw is applied. Remove the
segment of bone between the vertical cuts. Whenever the nature and extent

RESECTION LOWER JAW 93

of the disease permit, it is important to leave the lower edge of the jaw in
situ (X, Y, Fig. 93), as then the continuity of the maxilla is maintained.
To accomplish this, the vertical bone incisions do not completely divide
the jaw, and the excision is completed with the chisel. It is difficult to
use a saw on the lower jaw. To cut accurately with a chisel is no easy
task and the bone is very liable to fracture. A good method to secure pre-
cision and safety is as follows: After incising the muco-periosteum at a safe
distance from the tumor, bore a series of holes about 3^ inch apart all around
the portion to be removed. When this has been done it is easy to complete
the excision with rongeur forceps or chisel. If possible, suture the mucous
membrane of the floor of the mouth to that of the cheek. Close the cutaneous
wound after providing for drainage.

III. RESECTION OF ONE-HALF OF THE INFERIOR MAXILLA

Transfix the tongue with a stout thread for purposes of traction. Make
a vertical incision in the middle line through the chin, beginning a little below
the edge of the lower lip and ending on the lower edge of the jaw. Do not
include the margin of the lower lip in the cut unless compelled to do so by the
size of the tumor.

From the lower end of the vertical incision make a cut along the inferior
edge of the jaw to its angle. If necessary, continue the cut up the posterior
edge of the ascending ramus of the jaw to a point not less than one finger-
breadth below the lobe of the ear. Before the facial artery is divided it should
be ligated.

With periosteal elevators, scissors, and knife separate the soft parts from
the outer side of the bone to be removed. If the operation is for the removal
of a tumor, sacrifice the periosteum. Choose the line in which to divide the
bone anteriorly, extract any teeth which may be in the way, and divide the
bone with the Gigli wire or finger saw after the soft parts have been separated
from both sides of the bone along the line of section. Pull the jaw down-
wards and outwards and separate the soft parts from its inner surface (my-
lohyoid, geniohyoid, and internal pterygoid muscles, submaxillary gland, etc.).
Pull the jaw downwards, expose the coronoid process, and divide its attach-
ments to the temporal muscle. It may save time and be easier to cut through
the coronoid process with bone forceps than to separate the temporal muscle
from it.

By blunt dissection separate the masseter muscle and the parotid gland
from the ascending ramus. With a twisting movement directed downwards
and outwards tear the head of the bone out of its bed and the active part of
the operation is completed. Attend to hemostasis. If possible, suture the
mucous membrane of the floor of the mouth to that of the cheek. Close the
external wound after providing for drainage.

The after-treatment consists in endeavoring to keep the mouth clean by
means of frequent washing with mild antiseptic solutions, in nourishing the
patient, and in encouraging him to sit or walk about at as early a date as
possible.

94 LOWER JAW — RESECTION

When, after any operation in which one-half of the inferior maxilla or a
segment of it is removed, deformity results and the teeth of the lower jaw no
longer articulate with their fellows above, some surgeons or dental surgeons
have managed by a long and painful process to push the fragments of the lower
jaw back into their normal position after healing has taken place and have
maintained the position by means of a plate or of bridge-work.

Sinclair White ("Brit. Med. Journ.," Nov. 27, 1909), in removing two
inches of the lower jaw for a tumor preserved the periosteum of the lower
edge of the excised segment. "The resected surfaces of the lower jaw were
pierced with a drill to the depth of ^ inch. The drill hole in the body was hori-
zontal and placed near its lower margin, so as to miss the teeth roots; that in the
ramus was vertical and somewhat posterior to the mandibular foramen. The
ends of a suitable length of stout silver wire were jammed tightly into the drill
holes, and the wire completely covered by suturing together the mucous
membranes of the cheek and the floor of the mouth over it. The diagram
(Fig. 94) indicates the position and curve of the wire.

Fig. 94. — Metal splint used after resection Fig. 95. — Metal splint used after resection
lower jaw. {Sinclair White.) lower jaw.

A small drain tube was placed in the neck end of the wound and retained for
forty-eight hours, and the mouth was rinsed frequently with hydrogen peroxide
solution. A little pus formed in the track of the tube, but the wound in the
mouth healed quite kindly.

"At the present time, except for the skin scar, there is absolutely no external
deformity. He can open his mouth almost to the full, and when the jaws are
closed the teeth on the right side meet accurately those in the corresponding side
of the upp er jaw. He is able to bite soft things, and has to be restrained from
attempting greater masticatory feats."

Partsch,* after removing a segment of the lower jaw, keeps the ends of the
bone in correct position by means of a perforated metal plate united to the bone
by a couple of wire stitches. (See Fig. 95.) The metal plates are protected
with rubber tubing, and the mucous membrane of the floor of the mouth and
of the cheek are sutured together below the metal plate so that the latter lies
exposed in the oral cavity. As soon as a proper dental apparatus or plate can be
made and properly fitted, the temporary metal plates are removed. Berndt, in
cases where half the inferior maxilla has been removed, replaces it with an ap-
paratus of celluloid. After the bone has been removed he sutures the mucous
membrane of the floor of the mouth to that of the cheek, packs the wound, and
lays silkworm-gut cutaneous sutures in position but does not tie them. After
the lapse of about ten days he takes a celluloid ring pessary, softens it by boiling,
*"Archiv f. klin. Chir.," Iv, 746.

REPAIR LOWER JAW 95

moulds it to the proper shape, and puts it into the wound so that one end is in
the glenoid cavity while the other rests against the sawed surface of the remnant
of the lower jaw. He next closes the skin-wound and ties the sutures already in
place, thus completely covering the celluloid apparatus. Berndt reports that
slight suppuration often takes place anteriorly from irritation to the sawed sur-
face of bone, but that if a small portion of the celluloid is then cut away by
forceps, a little fibrous tissue forms between the bone and the foreign body, and
the wound heals. One patient* seven months after operation claimed to have
celebrated Christmas by cracking nuts with his jaw, one-half of which was cellu-
loid, and to have suffered no ill consequences.

By an incision made through the skin below the jaw Macewen has im-
planted a piece of rib between the fragments of jaw. Of course no communica-
tion existed between the site of implantation and the mouth. The implanted
bone was obtained from a rib near the axilla. The result was perfect.

(Stillman.)

Macewen's method has been successfully carried out by a number of surgeons.
Clarence McWilliams found that if the transplant was entirely deprived of
periosteum it became absorbed. This does not agree with Macewen's observa-
tions. Stanley Stillman ("Annals Surg.," July, 1912) uses Murphy's silver-wire
girder (Fig. 96) to hold the remnants of the inferior maxilla in good position
until healing has advanced far enough to permit bone implantation. He finds
the silver cannot be left in situ permanently but that when it is removed the
scar tissue keeps the bones in a useful position — so useful that the patient may
prefer not to have the transplantation made.

H. Nimierf gives an admirable description of Martin's prosthetic apparatus

*"Archiv f. klin. Chir.," Ivi, 210.

f'Traite de Chir." Delbet and Le-Dentu, v, 793.

LOWER JAW — RESECTION

suitable for use after even very extensive excision of the inferior maxilla. He
says: Provided with a segment of maxilla formed out of hard rubber, moulded
in advance to represent the bone to be excised, the surgeon cuts and fashions
it so as to fit between the remaining portions of the bone and to reestablish
the exact shape of the inferior maxilla. Two small platinum plates at each
end of the apparatus are attached to the bones by screws, and, acting as fish-
plates between the bone and the substitute for bone, keep the latter in position.
If much of the ascending ramus has been removed, the anterior portion of
the apparatus is fixed to the remnants of the coronoid process, while that
portion corresponding to the articulation is left unattached. To assure solidity
in such cases it is necessary to attach the apparatus to the palate by a moulded
J plate. On the upper edge of the appa-

ratus a band of hard rubber roughly
simulates the teeth. It is necessary to
disinfect the tissues in which the foreign
body is implanted, and for this purpose
the apparatus is perforated in various
directions, so that irrigation is easy. Fig.
97 shows apparatus used after an almost
complete excision of the lower jaw. The
above description applies to the implanta-
tion of a temporary splint. When cica-
trization is complete, a permanent one
Art^ficiii replaces it. The permanent apparatus is

lower jaw." 4. Fish-plate uniting remnants of ^yip^plv a mnrp plahnrfltP pHitinn of the
bone to the apparatus, s- Fish-plate uniting "lereiy a more eiaoordie euiuon 01 LUC

tuberforlrrigation^^ apparatus, c. System of temporary. In cases of extensive excision

the apparatus may be introduced in two
parts, which are then united by fish-plates and screws.

Such extremely ingenious and complicated prosthetic devices will rarely
be available when required, and if available, must rarely be serviceable. The
tissues do not tolerate foreign bodies well for any length of time, and especially
mobile bodies, such as described above. They have been described here more
as examples of surgical ingenuity than as practical aids.

Fractures of the Mandible or Lower Jaw. — Few recent fractures of the
mandible require operative treatment. Malunion and non-union usually de-
mand operation. When there is little or no loss of substance, wiring or plating
is usually suitable. When there is considerable loss of substance, some form
of bone grafting is essential. In cases of malunion with great deformity, cor-
rection of the deformity is impossible without penetrating the mouth. Under
such circumstances the mobilized fragments should be wired together in spite
of the inevitable infection. With the above exception all operations should be
performed with the most painstaking aseptic care and without penetrating the
mouth. The ideal is ' knife and fork ' operating, no finger touching the wound.

I. Wiring and Plating.— V . P. Cole (Brit. J. Surg., July, 1918) writes "cases
suitable for wiring are those in which there is little or no loss of substance. As
has been pointed out, these fractures occur in the neighborhood of the angle.
The posterior fragment is left free. The anterior fragment, if not edentulous,

Fig. 97.

I. Articular process lower jaw
rubber ridge representing teeth

FRACTURES LOWER JAW

is splinted in correct alignment. When the lower jaw is edentulous, no splint
is used. Cases have been treated in this way with consistent success."

As a preliminary to operation, splinting ought to be fitted and put in place
(p. 98).

Expose the bone by a suitable incision. Remove tissues interposed between
the fragments. Vivify the ends of the bone. Perforate each fragment with a
drill. Wire the fragments together. To do this requires free exposure of the
deep surfaces of the bone and thus involves danger of penetrating the mouth.
If a metal plate is used, denudation of the deep surface of the bone is unneces-
sary, but it is imperative to hold the fragments in accurate apposition while
the plate is being applied. To avoid these troubles Cole combines the plate
and wire method.

Fig. g8.— {Cole, Brit. J. of Surg.)

Fig. 99. — (Cole, Brit. J. of Surg.)

2. Bone Grafting.

A. Free or N onpedunoulated Graft. — When there is much loss of bone sub-
stances, there are commonly much loss of soft parts, much scar tissue and often
fistulae. Before any grafting may be attempted various plastic operations are
essential. Cole's description of a concrete case is a model of clearness.

"Fig. 98 shows the condition of a patient immediately before the plastic
operation was undertaken. A suitable splint was adapted to retain the frag-
ments in correct position. A wide exposure of the area was then obtained by
free reflection of the soft parts. The ends of the fragments were exposed, and
the mucous membrane of the floor of the mouth was dissected up and united
to the mucous membrane of the cheek. Under cover of this the bone ends were
shut off from the buccal cavity, and between them was inserted a piece of
decalcified bone. The soft parts on the outer aspect of the bone were brought
together in such a way as to raise the corner of the mouth. Counterdrainage
through a stab wound was established. The parts healed uneventfully. Nu-
trition was promoted by radiations and massage, and the patient is now ready

LOWER JAW RESECTION

for the insertion of the graft (Fig. 99). In order to eliminate the possibility
of infection from latent sources of sepsis, an interval of three months is allowed
to elapse in such a case before the grafting operation is undertaken.

"The technique of this operation is as follows: Two or three days previously,
upper and lower cast-metal cap-splints are cemented in place. These splints

Fig. 100. — {Cole, Brit.\ J.
of Surg.)

Fig. ioi.— {Cole, Brit. J. of Surg.)

are provided with bilateral overlapping threaded flanges, which, when fixed
together by screws, determine the position of the fragments in correct alignment
(Fig. 100) . When the patient is on the operation table these screws are removed ,
allowing the mouth to be freely opened for the passage of the intratracheal

^^.

Fig. 102. — {Cole, Bril. J. of Surg.)

catheter. As soon as the catheter is passed, the screws are replaced. It will
be noticed that the jaws so disposed are in the open bite position. This position
is essential, if intratracheal methods are employed. The anesthetist is then
isolated from the operation area. A curved skin incision extending well into
the neck is now made, and a flap turned up to expose the site of the fracture

COLE S OPERATION

(Fig. loi). Bleeding vessels are ligatured and towels clipped to the skin margins.
The ends of the fragments are then exposed, cleared, freshened, and shaped
for the reception of the graft. The graft, taken as a rule from the tibia, is
now cut, the length and shape being determined by the use of calipers and a

Fig. 103. — {Cole, Brit. J. of Surg.)

pattern cut in sheet lead. The plates are screwed to the graft before the
detaching cross-cuts are made (Fig. 102). The graft with detached plates is
then transferred to its destined site and fixed in the gap by two screws attach-
ing each plate to the corresponding fragment of the fractured mandible (Fig.

Fig. 104. — {Tainter, Jour. A. M. A,)

103), and the wound sewn up. A similar technique is adopted when rib is
employed." The graft may be obtained from any convenient bone such as
the tibia or a rib. No particular attempt need be made to preserve the perios-
teum. Grafts from 2}^ to y}^ cm. (i to 3 in.) in length have been used.

lOO

LOWER JAW RESECTION

B. Pedunculated Grafts. — Cole's ()|)C'ration. (P. P. Cole, Brit, J. Surg.,
July, 1918, B. M. J., Jan. 18, igiq. Tainter, Journ. A. M. A., Oct. 25, 1919.)

Fiu.

lainia-, Jour. .1. .1/. .1.)

Before operation have the dentist prepare a proper splint from impressions
taken in sections and assembled on a proper articulator. V^ery carefully con-
trol the posterior fragment and put it in proper relation to the anterior fragment

I'lc. io(>. — (Tdinlcr, .Jour. .1. .1/

and the upper jaw. Figs. 104, 105, 106, and 107 sufficiently describes the
operation.

The Birmingham Operation (Billington, Parrott, Round, B. M. J., Dec. 21,
1918). — Preparatory treatment, often prolonged, is necessary to secure com-

THE BIRMINGHAM OPERATION

lOI

plete healing of the wounds. It consists in removal of dead bone, in provision
for drainage, in correction of displacements by means of dental splints, etc.,
and lastly in building up the general health. Unlike Cole the Birmingham
surgeons remove all splints immediately before ojjcrating and do not replace
them until the operative wound has healed after which the case is treated as a
simple fracture.

Step I. — Choose a point on each side of the bony defect i inch behind
the extremity of the posterior fragment, i inch in front of the fractured end of
the anterior fragment and about i% inch above the lower border of the jaw.
Join these two points by a curved incision, which crosses the neck about an
inch below the jaw. Turn up the flap thus outlined and with it all the soft
parts covering the jaw for a distance of i inch from the fracture. If the mouth
is penetrated completion of the operation must be put off until the wound has
healed.

Fig. 107. — {Tai liter, Jour. A. M. A.)

Step 2. — Remove all scar tissue between the fragments. With bone forceps
remove a shell of bone from about i inch of the outer surface of each fragment.
Attend to hemostasis and temporarily pack the wound.

Step 3. — Make an incision from the anterior superior iliac spine backwards
along the iliac crest. With a saw, excise a segment of the crest 2 inches longer
than the gap to be filled. (If a greater curve in the graft is necessary the bone
between the Ant. Sup. and Ant. Inf. spines may be used.) Close the wound.

Step 4. — With forceps bevel the ends of the graft so that they can lie flatly
on the prepared outer surfaces of the jaw. Place the graft in position and retain
it by careful suturing of the soft parts over it. Close the skin wound with a
few interrupted sutures. No drainage tube is used. Serum can escape between
the sutures. Apply dressings but no splints.

The wound is usually sufficiently healed in two weeks to permit the use of
dental splints. "Firm osseous union occurs in from two to four months, but

I02

LOWER JAW RESECTION

it is inad\'isable to fit the final dentures until at least four months have elapsed
and it is perhaps wiser to allow an interval of six months."

Undeveloped Lower Jaw. — When there is a marked want of development of
the lower jaw there is not only present a disfiguring recession of the chin but
the patient may be unable to open the mouth more than one-eighth of an inch.

,t'.i-»*

Fig. io8. — {Eisenstaedt, Surg., Gyn., Obst.)

V. P. Blair ("Journ. A. M. A.," July 17, 1909), has twice successfully operated
as follows:

Step I. — Make an incision about 3^ inch in length in front of the lobe of
each ear and retract the parotid backwards.

Step 2. — Pass a curved needle with thread through the incision, under the
ramus and out through the cheek. By means of the thread pull a Gigli saw
round the ramus and divide the bone horizontally.

Fig. 109. — {Eisenslaedl, Surg., Gyn., Obst.)

Step 3. — Forcibly stretch the muscles of mastication.

Step 4. — Pull the body of the jaw forwards if possible until the lower in-
cisors are in front of the upper. Wire teeth of the lower jaw to teeth of the
upper until sufficient fixation is obtained.

Prognathism. — The lower jaw extends forwards beyond the upper so that
proper articulation of the upper and lower teeth is impossible. In adolescents

ANCHYLOSIS I03

orthodontic appliances are capable of greatly improving or curing the deformity;
in adults the aid of operative measures becomes necessary for a cure. The
surgeon must always have the aid of a good dentist or orthodontist.

Harsha and Eisenstaedi's Method (Surg., Gyn., Obst., July, 1912). — Have
plaster-of-Paris models of both upper and lower jaws prepared, also skiagraphs.
Make careful measurements to ascertain the shape, size and location of the
wedge of bone which it is necessary to excise on each side of the lower jaw to
permit proper articulation with the upper jaw. If it is necessary to extract
any teeth do so long enough before operation to permit of healing and to ren-
der submucous resection possible.

Cardboard models of the lower jaw should be made on which to carry out
experimental operations, as it is desirable to alter the angle of the jaw as well as
to shorten the horizontal ramus. Make an incision about 2)^ inches long
beneath the border of the jaw. Through this separate the periosteum and muco-
periosteum from the bone completely around the segment of bone it is desired
to remove. Do this, if possible, without entering the mouth. With forceps and'
saw cut out the desired segment of bone. Unite the bone wound with wire
sutures or Lane's plates. Close the skin wound, if necessary providing drainage.
Carry out a similar operation on the opposite side. If necessary reinforce the
union of the bone by interdental splints and wiring the teeth of the lower to
those of the upper jaw (Figs. 108 and 109).

ANCHYLOSIS OF TEMPORO-MAXILLARY JOINT

The usual procedure for the operative treatment of bony anchylosis of the
temporo-maxillary joint consists in mere excision of the condyle of the lower
jaw. Helferich, having had poor results from the above operation, modified
it slightly. His modification is founded on the fact that interposition of the
muscle between the fragments is a common cause of non-union in fractures.

Helferich's Operation. — Make a vertical incision ij^ to 2 inches in length,
one finger-breadth in front of the ear. Ligate the temporal artery. Push the
parotid gland aside; expose the condyle and neck of the lower jaw. The
temporo-maxillary joint may be indistinguishable because of anchylosis. With
a chisel divide the neck of the bone at a point about J-^ inch below the site of
the joint. Do not preserve the periosteum. Excise the condyle and neck of
the jaw above the point of section, taking away the periosteum with them. If
only one joint is anchylosed, the mouth can now be easily opened. If necessary,
enlarge the skin-incision upwards. Reflect a long flap from the temporal mus-
cle, about one inch wide and with its base below. Turn the flap downwards
so that its free end can be tucked into the defect left by the excision of the
condyle. To turn the flap down and put it in position requires that a portion
of the zygomatic arch be removed. This is easily done with rongeur or bone
forceps. Fix the muscular flap in position by a few sutures of catgut. Close
the wound without drainage. Apply dressings. The result obtained from
Helferich's operation was most happy. Murphy's experience seems to show
that a flap of fat is preferable to muscle in the above operation.

104

LOWER JAW — RESECTION

J. B. Murphy's Operation (Journ. A. M. A., June 6, 1914.) — This operation
will be best comprehended by a study of the accompanying figures. Figure no
shows the L-shaped incision which gives good exposure but avoids injury to the
facial nerve. The internal maxillary artery is shown passing inward behind

* If '

, uUl [^■■ll i«

Fig. 1 10. — L-shaped skin incision above the zygoma and in front of the ear, so placed to
avoid injury to the facial nerve. Note the relation of the external carotid, the temporal,
and internal maxillary arteries to the field of operation. The last-named vessel in passing
inward behind the neck of the mandible lies close to the bone and must be carefully protected
from injury during the operation, especially at the time when the neck of the mandible is
divided. {Murphy.)

and close to the neck of the mandible where it is liable to injury unless well
protected during the operation. Figure in shows the neck-of the bone exposed
and being divided with a Gigli saw while the internal maxillary artery is pro-
tected by means of two curved periosteal elevators.

ANCHYLOSIS

lOS

In Fig. 112 the neck of the bone has been divided, the cut ends of the bone
have been separated by traction during which time the protecting curved ele-
vators were kept in situ. A flap of fat and fascia is dissected from the temporal
region and is turned downwards and inwards between the divided end of
the mandible where it is securely anchored by tacking stitches.

Fig. III. — Dividing the necli of the mandible with the Gigli saw. (In actual operation
the saw is not allowed to make so acute an angle as shown in the illustration, because of its
great tendency to break when sharply bent.) (Murphy.)

The after-treatment consists in keeping the mouth open by means of a
wooden block until healing is complete.

How to know which side is anchylosed is important. Murphy's rules for
this are:

I. There is flattening of the jaw on the tmaffected side, most pronounced
near the tip of the chin.

io6

LOWER JAW — RESECTION

2. When the patient attempts to open his mouth, the teeth move from }^q
to Koo iiich downwards and deviate a little in the direction of the anchylosed
side, because of a slight sliding forwards of the mandibular articulation on the
unafifected side as the muscles of the neck are put on tension in the effort made
to open the mouth.

Fig. 112. — The pediclcd fascia and fat flap is dissected out Irom the temporal fascia, and the
free end of the flap is turned inward between the divided ends of the mandible and sutured
securely in place with tacking stitches. {Murphy.)

3. A sliding motion on the unaffected side can be felt by the palpating fin-
gers, and the muscular activity on that side is very much greater on attempted
opening of the mouth than on the anchylosed side.

4. The muscles on the anchylosed side are more atrophied than those on
the unaffected side.

L. W. Arlow* finds that in severe cases of temporo-maxillary anchylosis
the pathological changes are by no means limited to the joint, but that osteitis

* Ref. Centralblatt f. Chir., 1903, No. 28.

ANCHYLOSIS

107

alters the form, size, and relations of the articular process, the coronoid process,
the incisura semilunaris, the zygoma, etc. As a consequence simple division
of the articular process is insufficient to give motion, and even when combined
with osteotomy of the coronoid it often fails and resection of a part of the full
width of the upper portion of the ascending ramus becomes necessary. Facial
paralysis is more common as a result of tearing and distraction than of acci-
dental division with knife or chisel. Recurrence is avoided by extensive removal
of bone, by the implantation between the fragments of muscle or even of metal
plates, and by early passive and active motion. Monod and Van verts strongly
recommend osteotomy of the ascending ramus as being easier than resection
of the neck of the bone, as efficient, and not liable to cause injury to the facial
nerve. Rochet's method of operating is as follows:

Step I. — Make an incision bordering the angle of the jaw. About one inch
of this incision runs along the lower edge of the horizontal ramus, and about

Figs. 113 and 114. — Rochet's operation. {After Monod and Vanverts.)

one inch along the posterior edge of the ascending ramus. Through this expose
the inferior insertion of the masseter and detach it from below upwards with
an elevator. This exposes the outer surface of the bone. In the same way ex-
pose the inner surface of the bone by separating the insertion of the internal
pterygoid.

Step 2. — With chisel, forceps, or Gigli saw divide the bone along the lines
marked in Fig. 113, and remove the bone between the lines of section. The
amount of bone should be as great as possible, to permit wide range of motion
subsequently.

Step 3. — From the deep surface of the masseter dissect a flap about i3^
inches long, with its pedicle above, consisting of about half the thickness of the
muscle. Pass the free end of this flap through the breach in the bone and suture
it to the pterygoid (Fig. 114). Should the flap from the masseter be insufficient
for the purpose, a subsidiary flap may be taken from the pterygoid.

Step 4. — Close the wound.

Io8 ODONTOMATA

CHAPTER X
ODONTOMATA

Odontomata are tumors arising from teetli germs or teeth still in process of
growth. Bland-Sutton described seven varieties of this tumor besides the sim-
ple dental cyst which develops at the root of a dead tooth. The odontomata
are often called dentigerous cysts. The chief importance of these tumors is that
they are rarely recognized prior to operation, that they are often wrongly diag-
nosed as malignant neoplasms and the whole jaw needlessly extirpated. The
tumors are non-malignant and are readily removable.

Bland-Sutton writes: "In the case of a tumor of the jaw, the nature of which
is doubtful, particularly in a young adult, it is incumbent on the surgeon to
satisfy himself before proceeding to excise a portion of the mandible or maxilla
that the tumor is not an odontome, for this kind of tumor only requires enuclea-
tion." The following operation performed by the author explains the principles
of procedure. Incision through muco-periosteum over the prominence of the
tumor. With chisel, trephine, or bur cut through the shell of bone (about two
lines in thickness). In the posterior part of the tumor a cavity was found con-
taining a perfect premolar tooth with thick mucous membrane attached all
round its neck. Tooth removed. The mucosa was attached to a purplish,
soft, round, grape-like mass which filled the anterior part of the tumor or bone
cavity. This was easily shelled out. The cavity left was the size of a hen egg,
was smooth and lined with mucous membrane. The root of the first molar
projected into the cavity. Extracted this tooth. Partly closed wound and
packed with gauze. The tumor was a typical odontoma. After many weeks
the cavity closed completely.

A more rapid closure would have been obtained had the operation been per-
formed as follows:

1. Free incision of muco-periosteum over the growth.

2. Reflection of muco-periosteum from over the whole external of the promi-
nent surface of the tumor.

3. Penetration of the bone and removal of the contents of the bone cavity.

4. Removal of all the external wall of the cavity and destruction of the
mucous membrane lining the rest of the cavity.

5. Application of the reflected muco-periosteal flaps to the bottom of the
cavity. Application of dressings to keep the flaps in position.

EXCISION OF THE CHEEK I09

CHAPTER XI
EXCISION OF THE CHEEK

If a tumor is located on the buccal surface of the cheek, is not extensive, and
does not involve the skin, it may be excised through the mouth by an elliptical
incision and the wound closed by sutures. Should the amount of mucous mem-
brane and subjacent tissue removed be great, then, when healing has taken
place, there may result fibrous anchylosis of the jaw. To prevent this contrac-
tion, one must fill the defect by means of a graft covered with epithelial tissue.
Of course, when the anchylosis is the result of an old burn or similar lesion one
must excise the scar tissue before implanting the graft.

The Operation. — The tumor or old scar tissue has been excised through the
mouth, leaving the defect a, b, c (Fig. 115). On the neck trace the flap D,E,F,

Figs. 115 and 116. — Repair of buccal mucosa.

the distal portion of which consists of hairless skin large enough to more than
fill the defect. Dissect free the fiap outlined. Be sure that the pedicle is wide,
thick, and so placed that when turned into position its vessels will not be injuri-
ously twisted. Make an incision (X, Fig. 115) through the cheek into the
mouth. Through this incision pass the flap D, E, F, and suture its edges to the
margins of the defect a, b, c. After the lapse of ten days divide the pedicle of
the flap at X and replace its remnant in its normal position. Close the wound in
the cheek. Close the wound in the neck partly by sliding the edges towards
each other and partly by skingraf ts. [This closure of the wound in the neck may
properly be attended to at the original operation.]

When it is impossible to remove the tumor through the mouth, although the
skin is not involved one may make the incision A, B (Fig. 116) through the skin
alone, reflect the skin-flaps X, Y (Fig. 117), and thus expose the mucous mem-
brane and tumor (T, Fig. 117). Next excise the tumor and fill the resulting de-
fect by the flap (C, E, D, Fig. 118) taken from the neck (or forehead). Replace
the flaps X and Y and secure with sutures.

EXCISION OF THE CHEEK

Shelton Horsley (Journ. A. M. A., Jan. 30, 1915), if necessary, provides an
epithelial lining for the mouth by means of a flap turned up from the neck or
from the tongue. The flap to replace the skin defect is taken from the forehead

Figs. 117 and 118. — Repair of buccal mucosa.

i[,>rjlcy. J,',:

and instead of being provided with the usual pedicle, transplantation of the
anterior temporal artery is practised according to the method published by
Monks (Boston Med. and Surg. Journ., 1898) but of which Horsley was ignorant
at the time.

PLASTIC REPAIR

III

The Operation. Anesthetize preferably by the rectal method.

1. Prepare the cheek by trimming away the scar tissue around the defect and
by undermining the skin slightly. If it is necessary to replace the mucosa do so
by implanting the flap A, B, C, D (Fig. ii8).

2. Outline the flap E, F, G. Make the straight incision G, H along the
line of the anterior temporal artery. Expose the artery, but do not injure it or
grasp it with forceps. Dissect the artery free along with a considerable amount
of surrounding tissue so as to preserve the nerve supply of the vessel. Make the
incision H, I through the skin alone and prepare a bed for the artery. Complete
the mobilization of flap E, F, G and place it in the defect in the cheek. Place

Figs. 120 and 121. — Plastic operation on cheek. {Monod and Vanverts

the artery, which of course runs into the flap E, F, G into the gutter prepared
along the line H, I and suture the skin over it. Unite the flap E, F, G by dijew
stitches to the defect. As the drainage of the flap and not its blood supply is
liable to be faulty, plenty of opportunity for escape of blood and fluids must be
provided, hence few stitches are used. "By the second day the flap is swollen
and becomes a dark purple color. If it is too tense, every few hours a sharp
knife can be inserted along the edges of the flap to scrape it a little so as to pro-
mote bleeding and relieve the tension. After a week the swelling begins to dis-
appear and new capillaries drain away the blood."

Bardenheuer has devised some excellent and ingenious methods of repairing
defects in the cheek, defects left after the removal of disease or of scar tissue
which gave rise to fibrous anchylosis. Fig. 120 represents a case in which the
mucous membrane was replaced by a flap of skin taken from the forehead and
provided with an enormously wide and reliable pedicle; the skin was replaced by
a flap of skin taken from the neck. After healing was secured the pedicles were
divided, the wound trimmed, and all raw surfaces on forehead or neck covered

112

EXCISION OF THE CHEEK

by skin-grafts. Fig. 121 represents a case in which Bardenheuer brought a
skin-flap down from the forehead. The flap was nourished through a narrow
flap which contained the supraorbital artery. The defect in the skin was cov-
ered by a flap taken from below.

The above operations are described as suggestive types for the repair of de-
fects in the cheek. The operations of Kraske and Israel are also good types
(Figs. 122, 123, 124, 125, 126).

Figs. 122 and 123. — Kraske's operation. {Esmarch and Ko'iiolzig.)

Figs. 124, 125, 126. — Israel's operation. (Esmarch and Kowalzig.)

W. D. Gillies (Surg. Gyn., & Obst., Feb., 1920) uses a postauricular flap in
closing defects of the cheek. When insufficient skin is available from over the
mastoid, he includes some skin from the posterior surface of the pinna (Figs.
127, 128, 129, Gillies).

In cases where part of the lower jaw has been removed and where there is a
corresponding loss of substance in the cheek Sonnenburg ("Archiv fiir klin.
Chir.," Ixxviii, 820) makes an incision along the corresponding side of the tongue
(Fig. 130) and so obtains a flap of tissue covered with mucosa. This flap Sonnen-
burg sutures to the freshened upper edge of the defect in the cheek (Fig. 131.)
The oral side of the defect being filled as above, the outer or skin side may now be
covered by an appropriate flap from the neck.*

PLASTIC REPAIR CHEEK

113

Figs. 127, 128, 129. — Post auricular flap for cheek replacement. {Gillies, Surg., Gyn. b'Obst.)

Drawn by S. Hernswick.

Figs. 130, 131. — (Sonnenburg.)

114

EXCISION OF THE CHEEK

Hotchkiss' Operation, — Planned for cases of extensive cancer of the cheek
with involvement of the jaw.

Fig. 132. — {Hotchkiss, Annals of Surg.)

Fig. 133. — {Hotchkiss, Annals of Surg.)

Step I. — Make the incision i, 2, 3, 8, 4 (Fig. 132), through the skin, and
reflect the flaps outlined so as to expose the lower border of the inferior maxilla,

Fig. 134. — {Hotchkiss, Annals of Surg.)

Fig. 135. — {Hotchkiss, Annals of Surg.)

the platysma overlying the submaxillary gland, and the deep structures of the
neck.

LOWER LIP

115

Step 2. — Free the anterior border of the sternomastoid exposing the chain
of glands extending from the submaxillary space to below the level of the cricoid
cartilage. From below up remove en masse the entire lymphatic chain along
the internal jugular vein and beneath the sternomastoid muscle until the bellies
of the digastric come into view when the contents of the submaxillary space
(both salivary and lymphatic glands) must be dissected free and retracted
upwards in one piece (Fig. 133). Doubly ligate and divide the external jugular
and facial veins and the external carotid artery.

Step 3. — Expose the outer surface of the lower jaw and prepare it for section.
Protect the neck wound with gauze. Make an incision all around the disease
on the face and at a safe distance from the disease (i, 2, 10, 9, Fig. 132). This
incision penetrates the mouth. Divide the lower jaw with a Gigli saw well in
front of the growth. Retract the divided jaw. Divide the floor of the mouth
along the groove of the tongue severing the mylohyoid and hyoglossus muscles.
Pull the lower jaw and attached structures outwards, and if the disease involves
the upper jaw remove the affected bone. Disarticulate and remove the lower
jaw along with the diseased tissues. (Fig. 134).

Step. 4. — In Hotchkiss' cases " the mucous membrane at the side of the tongue
was united to the cut edge of the hard palate, the tongue thus being elevated
as a sort of wedge against leakage from the mouth. The edges of the cut
mucous membrane in front and behind this were united by suture and the cut
edge of the mylohyoid muscle was brought up over this line of union of the
mucous membrane, and the skin-flap shown in Fig. 135 was then sutured up to
fill in the defect in the cheek. A portion of the incision in the neck was left un-
sutured and filled with loose gauze packing extending up to the glenoid and tem-
poral fossae" ("x'Vnnals Surg.," Oct., 1908).

CHAPTER XII
LOWER LIP

Epithelioma is the most common cause for removal of the lower lip. The
classical method of removing labial cancers is by a V-shaped incision. This
method is applicable to cases in which not more than two-thirds of the width of
the lip is involved. The resulting deformity is slight.

The operation is performed as follows: A general or local anesthetic having
been administered, an assistant controls the coronary arteries with his fingers
and thumbs; the surgeon rapidly cuts through the whole thickness of the lip on
each side of the tumor. The two cuts thus made meet at an angle below the
tumor, which is now removed. Before the assistant relaxes his control of the
coronary vessels the surgeon applies silk or silkworm-gut sutures, either through
the whole thickness of the lip or with the exception of the mucous membrane.
The sutures are tied and form, a sufficient guard against hemorrhage.

When performed as above, the operation is very speedy; so speedy, in fact,
that the surgeon may inadvertently make his incision approach a little too close
to the tumor. In such operations there is usually nothing to be gained and

ii6

LOWER LIP

much may be lost through great speed. A sHght modification in operating
leads to greater deliberation and hence greater thoroughness.

The surgeon seizes the tumor and lower lip between the finger and thumb
of the left hand, and pulls them forwards and upwards in such a way as to guard
against blood entering the mouth. Beginning on the lip margin, at least one-
fourth of an inch from the growth, a curved incision is made downwards until the
lower limits of the tumor are passed. This incision is made to but not through
the mucous membrane. Bleeding vessels are caught up with hemostats. A
similar incision is made on the opposite side, and only after bleeding is stopped is
the mucous membrane divided and the growth removed. The wound is closed
as in the previous operation. Many surgeons prefer to stitch the mucous mem-
brane with catgut and close the rest of the wound with silk or silkworm-gut. As
a matter of routine, the glands through which the lymphatics of the lip drain
should be removed even if not enlarged. He would be a bold fool who would
say a field had no seed in it because no sprouting verdure was visible. Experi-
ence seems to show that it is unnecessary to remove the lymphatics leading from
the tumor to the lymph nodes, although theoretically such ought to be removed.

Collectors 0/ tipfier Up ending in
submaxillary nodes

Collectors of lower Up ending in
same nodes

Vessel passing to node of internal
jugular chain

Fig. 136. — The lymphatics of the lips. {Morris After Dorcndorf.)

For the sake of obtaining aseptic healing of the wound made in removing the
lymph glands this part of the operation may be performed through a separate
incision which is closed before the primary disease is attacked. "The capillary
plexuses of the skin and mucous membrane are continuous at the free border
of the lips. The ducts of the upper lip, of which there are about four on each
side, pass to the submaxillary nodes. From the lower lip the trunks from near
the angle of the mouth pass to the submaxillary nodes, while those from the cen-
tre of the lip pass to the submental nodes. There are from two to four subcu-
taneous ducts and from two to three submucous ducts on either side. The
collecting trunks passing to the submaxillary nodes do not anastomose, and
the same is true of the submucous ducts of the lower lip. The subcutaneous
ducts, on the other hand, passing to the submental nodes, anastomose freely —
an important fact in connection with the extension of cancer of the lower lip."
("Morris' Human Anatomy") Fig. 136.

The submental nodes ought, therefore, to be removed on both sides. Re-
member that some lymph nodes are closely attached to the submaxillary sali-
vary glands and hence these glands should be excised on the afifected side. A

REGNIER S OPERATION II7

continuation downwards of the incision for the removal of the tumor, the V
incision being converted into a Y, and elevation of the skin on each side of the
cut give excellent access to the structures requiring removal.

Bloodgood found that excision of the lip and glands, when there was no ap-
parent glandular involvement, resulted in twenty cures among twenty-one cases,
while the same operation gave six cures out of twelve cases when metastasis was
demonstrably present in the glands. In the six cases in which recurrence
took place it was local in one and in the cervical glands in five.

When there is palpable glandular involvement in the neck the operation
becomes similar or practically identical with that required in cancer of the
tongue. (See Butlin's, Crile's, Maitland's methods described in chapter on the
Tongue.)

Very superficial cancers of the lip may be removed by a curved, more or less
horizontal incision, the mucous membrane and skin being subsequently sewed
together.

A large number of methods for the removal of cancers of the lower lip and
for remedying the resulting deformity will be found sketched at the end of this
article.

Figs. 137 and 138. — Regnier's operation.

Regnier's Operation. — Step i. — The tumor and the whole of the lower lip,
from one angle of the mouth to the other, are removed by a curved incision. In
making this incision it is well to have all bleeding arrested before the mucous
membrane is divided and the mouth is penetrated.

Step 2. — The skin and mucous membrane at the edge of the wound are
united by sutures (A, Fig. 137).

Step 3. — From the lower edge of the middle of the upper lip measure down-
wards to the lower edge of the middle of the lower jaw {e.g., call the distance
2^ inches). From the middle of the wound (A, Fig. 137) measure downwards
and mark a point the same distance below A as the mental process is below the
edge of the upper lip (in our example, 2}/^ inches). Take a point, B, in the
middle line, ^'4 inch lower than the above {i.e., in our example, 3 inches below A).
In the submental region or in the neck, as the case may be, make a curved inci-
sion parallel to the wound in the lower lip, and having the point B as its centre.
This curved incision must be from 5 to 6 inches in length.

ii8

LOWER HP

Step 4. — Through the incision at B dissect the skin-flap, A, B, from the sub-
jacent tissues in such a way as to enter the mouth at the line of reflection of the
mucous membrane from lip or cheek to gum. In this way a vizor-shaped or
double-pedicled flap is formed and can be slid over the lower jaw to re-form the
lower lip. The lower edge of this flap is sutured to the periosteum at the lower
edge of the jaw (Fig. 138).

Step 5. — A space, C, is left in the submental region through which any en-
larged glands may be removed. Ogston maintains that, when the submaxillary
gland is enlarged and even slightly adherent to the bone, the bone is probably
already involved in the disease and ought to be removed. If this is the case,
then it is quite feasible to remove the whole thickness of the bone involved,
along with the gland, though the triangular space C. The skin of the neck
being very lax and mobile, it is a simple matter to cover at least a large part of
the space C with skin. Any uncovered portions may be grafted according to the
Thiersch method.

Dressings. — Iodoform gauze should be loosely packed between the newly
formed lower lip and the upper part of the external surface of the lower jaw.
Externally the usual antiseptic dressings may be applied. The mouth should
be frequently washed with a weak solution of permanganate of potash and the
dressings changed as required.

JRegnier's operation is capable of being modified to meet man}' conditions,

and very great deformities may often be
/^^%\ avoided by its means. To the writer it

has given great satisfaction.

DOWD'S OPERATION

Step I. — iSIake the incisions A, B and
C, D below and parallel to the lower jaw.
Be careful to leave the point X (Fig. 139)
attached to the jaw. Expose and remove
the fatty and lymphatic tissue of the
whole submental and submaxillary region.
Remove also the submaxillary salivary
glands. If the lymphatics above men-
tioned are visibly and palpably enlarged,
continue the incisions backwards and expose the carotid packet of vessels.
Remove the lymphatic glands in this region whether they are palpably
enlarged or not.

Step 2. — Remove the disease by means of the incisions A, E, F; C, G, H; A,
C. These incisions should be }4 to ^ inch distant from the disease.

Step 3.— Make the incisions I, E and G, K (each two inches or more in
length), down to but not through the buccal mucosa. Divide the mucosa along
lines at least ^i inch higher, so as to form a flap which may be stitched to the
skin and serve as mucous membrane for the new lower lip.

Step 4.— Unite the raw surface A, E to C, G with sutures. The wedge-
shaped incisions L and M may aid in the approximation of the new lower lip.
Step 5.— Close the wounds A, B and C, D, after providing for drainage.

Fig. 139. — Dovvd's operation.

SUTTON S OPERATION II9

Trendelenburg's position ought to be used throughout the operation. In
operating on cancer of the lip it is a good rule, where possible, to begin by dis-
secting out the lymphatics which may be diseased. It is, of course, imperative
to remove all evidently involved lymphatics, but it is prudent to go further
and remove the apparently unaffected ones next in order. For example : the sub-
mental and submaxillary group of lymphatics appear healthy, or but very
slightly diseased: remove them and then excise the primary disease of the lip as
well as perhaps the fatty connections between the primary and the secondary
foci of disease; again, the submental and submaxillary group are evidently dis-
eased; expose the carotid group of lymphatics, excise them, as well as the sub-
maxillary, etc. One great reason for beginning with the lymphatics is that by
so doing the mouth is not penetrated until the difl&culties of the operation are
practically ended.

Fig. 140. — Sutton's operation. (Sutton.)

W. S. Sutton devised an ingenious and successful method of removing
tumors involving both upper and lower lips at the angle of the mouth ("Jour.
A. M. A.," Aug. 20, 1910). Fig. 140 is self-explanatory. Grant's operation is
sufficiently explained by Figs. 141 and 142.

Nelaton and Ombredanne recommended the two following operations as the
methods of choice in cancers of different extent.

Method A .

Step I. — Excise the cancer by a V-shaped incision. From the apex of the V
make one or if necessary two incisions parallel to and a finger's breadth below
the border of the lower jaw, outwards to the line of the carotid artery (Fig. 143).
Excise the lymphatics extensively.

120

LOWER LIP

Step 2. — Close the wound by suture, after providing for drainage (Fig.
144). Closure of the wound produces a very ugly deformity of the upper lip.
To correct this make an angled incision E, B, C (Fig. 144) on each side of the
mouth. Suture the cut surface E, B to the cut surface B, C. This restores
the upper lip. Along the line E, D, C unite the buccal mucosa to the skin.
This gives a presentable lower lip (Fig. 145).

Fig. 141. — Grant. {Bryant's Op. Surg.)

Fig. 142. — Grant. (Bryant's Op Surg.)

Method B. — For very extensive lesions.

Step I. — Excise the tumor, preferably by incisions which form a triangle
with its apex below, so that a cut may run down from the apex to expose the
lymphatics beneath the jaw.

Step 2. — On each side proceed as follows: From the angle of the mouth make
an incision (A, B, Fig. 146) directed towards the inferior border of the tragus.

s?^> y_ ^ ^(^Sife^

Fig. 143. — {Nilalon and Ombridanne.)

Divide the skin only. Open the mouth. Mucous membrane exists under the
anterior portion of the cut A, B. Divide the mucous membrane parallel to but
about }/s inch above the skin incision. (By suturing the mucosa to the skin a
red border is provided for the new lower lip.) Make the skin incision B, C
parallel to the wound made in the excision of the disease. The lower end of the
cut B, C, is about a finger's breadth below the lower border of the lower jaw. In
making the cuts A, B and B, C do not injure the parotid. Reflect the flap out-

NELATON-OMBREDANNE OPERATION

121

lined by the cuts AB, BC; to do this it is necessary to divide the mucosa verti-
cally along the the anterior edge of the masseter. Be careful not to divide the
facial artery where it crosses the border of the lower jaw, but separate it, with the
flap, from the jaw.

Step 3. — Clear away the lymphatics and the submaxillary glands but care-
fully preserve the facial artery; if necessary, the facial vein may be sacrificed.

^•^^^ y_ V ^^^^

Fig. 144. — {Nelaton and Omhredanne.)

Step 4. — Suture the mucosa to the skin on the upper edge of the flap (see
Step 2) so as to form a red border for the new lower lip (X, A, Figs. 147 and 148).

Step 5. — Suture the lower edge of the mucous membrane of the new lip to
the cut edge of the mucous membrane on the lower jaw (L, L, Figs. 147 and 148).

^^^^ j_ V ^^^^

Fig. 145. — (Xelaton and Omhredanne.)

This forms the line of reflection of the mucous membrane between the lip and the
jaw. The rest of the operation is sufficiently explained by Figs. 148 and 149.

Clark Stewart's operation ("Jour. A. M. A.," Jan. 15, 1910) gives good
exposure of the submaxillary lymph nodes and permits of the excision of the
lymph nodes, submaxillary glands and the tumor in one piece.

122

LOWER LIP

"The first incision extends just below the jaw from one angle to the other
and cuts the skin and platysma muscle, which are then carefully dissected down

Fig. 146. — {Nilaion and Omhredanne.)

Fig. 147. — {Nilaton and Ombridanne.)

Fig. 148. — {Ndlaton and Ombridanne.)

Fig. 149. — (Nilaton and Ombridanne.)

to the level of the thyroid cartilage (Fig. 150). All tissues down to the muscles
are then sectioned at this line and a clean dissection is made elevating all loose
connective tissue, lymph nodes, etc., in a flap which extends laterally to the great

STEWARTS OPERATION

123

vessels on each side. The facial artery and vein are ligated and the submaxil-
lary glands are loosened and raised in the flap on each side. Incisions are now
made at each side of the epithelioma far enough away to include all infiltrated
tissue, and these are carried down to the cross-section already made.

Fig. 150. — {Stewart, Jour. A. M. A.)

The lateral flaps are now dissected free from the jaw, keeping close to the
skin at the lower part to avoid lymphatics, and finally the intervening central
mass is loosened from the jaw and removed. This contains the tumor and a
fan-shaped mass of skin and the deeper tissues attached to the lympth nodes of

the neck, and the submaxiUary gland by a loose flap of tissue which contains the
connecting lymphatics.

The submaxillary glands should always be removed, not because they are
infected in early cases, but because there is regularly a lymph node attached
to each which is one of the first to be involved. In cases in which not over
three-fourths of an inch of the vermilion edge of the lip has been removed,

124

LOWER LIP

simple suture of the wound with drainage of the submaxillary fossae completes
the operation. In cases in which the mouth must be extended on account of
more extensive removal of the lower lij), the procedure shown in the drawings is
convenient.

The mouth is broadened by a straight incision outwards at either or both
angles, and this incision is carried down to but not through the mucous mem-
brane; the latter is then cut one-half inch higher and stitched to the raw surface
of the new lip (Fig. 151). To avoid puckering of the upper lip a triangle of the
skin is taken out of the cheek to allow of the smooth drawing together of the
lower lip (Fig. 152). The new chin should be sutured to the soft tissues over
the lower jaw to exclude mouth fluids from the neck wound."

Fig. 152. — {Stewart, Jour. A. M. A.)

Mayo's Operation. — Step i. — Make a collar incision through the skin and
platysma ^ inch below the mandible from one sternomastoid to the other.
Reflect the skin and platysma down to the hyoid bone and up to the mandible.
Remove all fascia and fat as well as the submaxillary salivary glands from the
submental and submaxillary triangles on both sides. Ligate the facial arteries
and veins but preserve the hypoglossal and lingual nerves.

As soon as the glands have been removed from one side have them examined
microscopically while those on the other side are being removed. If they are
innocent of cancer complete the operation by suturing the platysma and then
the skin after providing for drainage and proceed to the excision of the lip. If
the glands are cancerous further dissection is essential as described in Step 2.
If they are not cancerous proceed to Step 3.

Step 2. — Make an incision along the sternomastoid muscle, reflect the skin
and platysma sufficiently to expose the whole region of the sternomastoid on
that side of the neck from which cancerous glands were obtained. Divide the
sternomastoid at its lower end and from below up make a block dissection of all
the glands and gland-bearing fascia of the entire neck, including the anterior and

RESULTS

125

posterior deep jugular glands up to the mastoid process. Removal of the sterno-
mastoid is necessary to a complete dissection. lie very careful to clean out the
glands in the posterior part of the submaxillary triangle.

Fig. 153. — {Beckinan.)

Provide for drainage. Close the wound. Delay operation upon the lip
until danger from infection of the great cervical wound is past.

Results after Operation for Cancer of thf

Lower

Lip (Beckman, Mayo Clinic

, 1913)

Group

No. of No. op-
cases erated

Traced

^'ot r,,„H Not Inop-
traced 1 ^'^'^^'^ cured erable

Per
cent,
cured

I. Clinical diagnosis only

II. Primary radical operation . . .
Glands involved

III. Late radical operation

Glands involved

IV. Glands removed one side or
incomplete

V. Local excision only

126

s
18

126

25
12

99
18
20
12

19 2
27 83

S 14
4

1
1 2
3 II

23
16

6
8

,83.8

^0.0

70.0

33-3

40.0
73-3'

126 LOWER LIP

Step 3. — Figure 153 sufficiently elucidates the removal of the disease in the

lip.

CHIN AND JAW

Occasionally an operable cancer involves the soft parts of the chin, the floor
of the mouth, and a portion of the lower jaw. The following method has proved
useful in such cases:

Fig. 155.

Step I. — A stout thread is passed through the tongue so as to have command
over that organ.

Step 2. — An incision is made through the skin around the tumor. From the
lowest part of this a cut is made downwards through the skin of the submental
region and neck to a point A (Fig. 154). The cut A, B, is made through the

^ — ^

Fig. 156. — Author's operation for epithelioma of the chin and jaw.

skin. The incision around the tumor is deepened until the bone is reached, but
the mouth should not be penetrated until all bleeding vessels have been caught.
By proceeding thus, time is not wasted by the necessity of swabbing blood from
the pharynx.

Step 3. — The flaps A, C and B, D (Fig. 155) are reflected, giving easy
access to the bone. The horizontal ramus of the lower jaw is divided by a
chain or finger saw on each side of the tumor.

CANCER LOWER LIP

127

Figs. 157 and 158. — Bruns. {Esmarch and Kowalzig.)

Figs. 159 and 160. — Estlander. {Esmarch and Kowalzig.)

Figs. 161 and 162. — Dieffenbach. {Estnarch and Kowalzig.)

Figs. 163 and 164.— (a) Jaesche; (6) Trendelenburg. {Esmarch and Kowalzig.)

128

LOWER LIP

Step 4. — Posteriorly to the tumor and from below upwards the floor of the
mouth is divided in such a maimer that all bleeding is invited and arrested before
the scissors or knife enters the mouth.

Step 5. — It is now easy to remove all the diseased structures — chin, jaw,
floor of mouth, glands, etc., en masse.

Step 6. — If possible, the edges of the oral mucous membrane should be
united by silk or catgut sutures. The skin-wound is closed by silkworm-gut.

Figs. 165 and 166. — Burow. {Esmarch and Ko-d'ahig.)

Figs. 167 and 168.— Blasius. (Esmarch and Kowalzig.)

51 ' ( \

Figs. 169 and 170. — Langenbeck. {Esmarch and Kowalzig.)

Dressings. — The floor of the mouth should be lightly packed with iodoform
gauze. The external wound should be covered by an antiseptic dressing. Fre-
quent washing of the mouth with a weak permanganate of potash solution is
necessary. Food ought to be given through the stomach-tube, though the
patient may drink water if he so desires. It is important in all such cases to
encourage the patient to leave his bed as early as possible. This helps to avoid
the great danger in such cases, viz., septic pneumonia.

Should the first part of Step 6 of the previous operation be impossible owing
to lack of mucous membrane, then an attempt may be made to supply the de-
fect as follows: In the neck (where hairs are absent) trace out a flap of skin
(F, Fig. 156) in such a position and of such a size that, allowing for shrinkage it

UPPER LIP

129

can be made to fit into the floor of the mouth. Turn the flap F up and stitch
its distal or free end to the anterior portion of the mucous membrane wound.
The most posterior stitches unite the mucous membrane of the side of the mouth
near the root of the tongue to the raw edges of the flap near its pedicle. This
gives an epithelial lining to the floor of the mouth. The flaps A, C and B, D
(Fig. 156) are now sutured over flap F; both flaps, A, C and B, D, having been

Figs. 171 and 172.— Trelat. {Monod and Vanverts.)

Figs. 173 and 174. — Serre. {Monod and Vanverts.)

split (G) to permit the passage of flap F into the mouth. The wound left by the
transplantation of flap F is to be closed by sutures or by Thiersch's skin-grafts.
Of course, a secondary operation will be necessary to close the hole G and to
divide the pedicle of flap F.

Several well-known methods of excising the lower lip and repairing the defect
are illustrated by Figs. 157 to 174.

CHAPTER XIII

UPPER LIP

Excision of the upper lip is usually demanded because of malignant disease,
but scars resulting from infective lesions, burns, etc., may require excision and
repair.

As in other regions, when operating for malignant disease, it is necessary to
know the anatomy of the lymphatics as the lymph nodes into which the diseased
area drains must be thoroughly removed. The lymphatics of the upper lip
pass into the submaxillary lymph nodes but on their way they may pass through
certain facial nodes, viz., (a) the infra-maxillary and supra-maxillary nodes
resting on the lower jaw near where it is crossed by the facial artery, (b) the
anterior and posterior buccinator nodes, superficial to the buccinator fascial

I30

UPPER LIP

lying on a line connecting the lower margin of the ear and the angle of the
mouth.

The posterior nodes lie near where the parotid duct perforates the buccinator
muscle, the anterior nodes lie between the facial artery and vein (Fig. 175).
In excising malignant neoplasms from the upper lip remember that the mid-

■- Suborbital nodes

- Node of nasogenial fold

Buccinator node

- Supra-maxillary node

- Infra-maxillary node

Fig. 175. — The facial nodes. {Morris after Buchbinder.)

groove of the lip is of the same developmental origin as the columella nasi and
that disease may early pass from the former to the latter structure. Removal
of the diseased upper lip scarcely requires description; repair of the resulting
defect may be difficult.

Principles of Repair. — Union of the edges of the defect must be accomplished
without tension being exerted on the sutures; without too great puckering of

Fig. 176.

the lower lip; without disfiguring twisting of the angles of the mouth which
might give the expression of a fixed sneer; without displacement of the alee nasi
sufficient to interfere with the patency of the nostrils.

Method I, — The neoplasm is at or near the middle line and is not of great
size. Step i. — Make the vertical incision AB and A'B', Fig. 176, on each side
of and three-fourths of an inch distant from the disease. Cut through the^whole

REPAIR UPPKR LIP

131

thickness of the lip. Continue the incisions upwards curving around the alae
of the nose to the points D and D'. By a transverse cut join the points B and
B' thus separating the alse of the nose from the cheeks and upper Hp and divid-
ing the columella nasi. Remove the diseased segment of the lip. Attend to
hemostasis.

Step 2. — Everting the remnant of the lip on one side make an incision through
the mucosa to the bone along the reflection of the mucosa from the cheek to the
upper jaw. With blunt and sharp dissection separate the soft parts from the
bone to such an extent that the whole cheek is fully mobilized. Do the same on
the opposite side.

Step 3. — Try to approximate the cut surfaces AB and A'B'. If tension is
too great, mobilize the cheek more thoroughly. This mobilization may be very
extensive and without danger if the surgeon "hugs the bone" in carrying it out.
When AB is approximated to A'B' the cuts BD and B'D' often become puckered
and press objectionally against the alee nasi causing obstruction of the nostrils.
To avoid this excise the segments of cheek BED and B'E'D', Suture AB to A'B'
as in hare-lip. Suture the divided columella to the new upper lip. The upper
lip may be repaired in this fashion after three-fourths of it has been excised.

If there is much puckering of the lower lip resulting from the operation it
may be corrected by an operation the same as that described for the lower lip
(p. 120) the lines of incision being of course reversed.

Fig. 177.

Fig. 178.

During the operation the facial lymph nodes may be looked for and removed.
On completion of the operation remove the submaxillary nodes through a special
incision and if necessary remove other suspected cervical nodes.

Method 2. — ^Lenthal Cheatle's operation. At a distance of at least three
quarters of an inch from the tumor make the vertical incision AB, Fig. 177,
through the whole thickness of the lip. Continue the incision along the curved
line BCD a short distance lateral to the groove separating the ala nasi from the
cheek. On the opposite side of the growth make the corresponding incision
A'B'C'D'. From the point D make an incision along the ala nasi groove,
skirting the ala and cutting it off from the lip. Do the same on the opposite
side. Divide the columella nasi, sacrificing a part of its base. Remove the area
of lip and cheek between the incisions ABCD and A'B'C'D'.

To facilitate approximation of the edges of the wound make the two curved
incisions BE and B'E' about i}4 inches long, through the whole thickness of the
cheek. These incisions must not injure Stenson's duct which is easily seen in

1,32 UPPER LIP

the mouth and avoided. Through the incisions BE and B'E' look for the buc-
cinator lymph nodes and remove them if they are present. Suture the wound
AB to the wound A'B'. Close the curved incisions beside the alee nasi. Suture
the columella nasi to the new upper lip.

Method 3. — The disease is not extensive and is situated in the lateral portion
of the lip.

Lenthal CheatJe's Operation. — Three-fourths of an inch internal to the disease
divide the lip vertically from its margin up into the nostril or to the columella.
From the point A, Y\g. 178, three-fourths of an inch external to the disease, at
or near the angle of the mouth make an incision AB upwards and outwards to-
wards the external canthus of the eye. The upper end of the incision is on the
level of the upper end of the ala nasi. Make the incision BC down to the bone.
From the point C make an incision following the curve of the ala nasi to meet the
original vertical incision.

Remove the disease along with the tissues in the shaded area in Fig. 178.
Repair must be eflfected by bringing the opposite half of the upper lip over to
meet the edge of the wound AF. To do this without undue tension divide the
connections between the remnants of the lip and the jaw; cutting against the
bone, widely separate the tissues of the cheek from the bone on the healthy side
By incision separate the ala tiasi of the healthy side from the cheek and from the
lip. To avoid puckering of tissues excise the crescent of tissue DE, Fig. 178.
Divide the columella at its junction with the upper lip. If tension has been
sufficiently relieved the remnant of lip can now be brought near the wound AF.
To prevent puckering of the angle of the mouth and to relieve tension make the
incision AY outwards and downwards from the angle of the mouth, through the
whole thickness of the cheek. From the point F on the level of the nostril, make
the incision FZ through the whole thickness of the lip. From the point B make
the incision BX down to the bone. Reflect the flap ZFBX and excise the buc-
cinator lymph nodes. Suture the wound AF to the remnant of the upper lip.
Suture the wound BF to the ala nasi. Suture the columella to an appropriate
point on the new upper lip. Excise the submaxillary lymph nodes.

Method 4. — The disease is extensive. Excise the whole upper lip.

Nelaton-Ombredanne Operation. — Trace the flap ABCDE on each side of the
defect (Fig. 179). "The side AB is formed by the border of the defect and in
length is a little more than one-half the transverse diameter of the defect.
Perpendicular to this side, we trace the line BC slightly concave upwards and
shorter than the vertical diameter of the defect. The result of this will be that
the flap when transposed will be a little too long and not quite deep enough but
the elasticity of the skin will permit a sufficient gain in the depth at the expense
of the length of the flap when sutures are being inserted. Mark the point E,
2 to 23^^ cm. (3^ to I inch) horizontally outwards from the angle of the mouth;
between and equidistant from the points C and E choose the point D which
must be about i cm. external to an imaginary line uniting C and E. Join CD
by a line slightly concave externally. Join DE by a straight line. This
completes the tracing of the flap.

The cuts AB and DE penetrate into the mouth. The cuts BCD penetrate
to the bone. Divide the reflection of the mucous membrane between the jaw

ANGIOMATA FACE

^33

and cheek; and dissect the flap BCD from the bone. The flap ABC D is covered
with mucosa except at its point. Along the edge AB suture the mucosa to the
skin so as to form a red edge for the new lip, if necessary excising a few milli-
meters of skin to make the mucosa more prominent. Suture the edge BC to its
homologue on the opposite side (Fig. i8o) ; the incision BC being slightly concave

^> y_ I 4^^

^^"^^^ L . ^«3^^

Fig. 179. — {Nelaton and Omhredanne.)

Fig. iSo. — (Xelalon and Omhredanne).

its suture makes a little prominence on the free border of the new lip. When
inserting the sutures begin with those in the mucosa. The curve of the inci-
sion CD fits it well for its new position under the nose. In closing the resultant
defect DC'D'E do not try to unite the two sides of the rectangle which are
closest to each other; this would deform the new lip giving it a horrible fixed
sneer. Suture the point 5 to the point ^ so as to form a sort of star into the
branches of which a few sutures may be inserted.

ANGIOMATA OF THE FACE

Angiomata of the face when small may require no treatment; when larger
they may be treated by the application of "dioxide" snow or by excision; when
superficial and extensive their owner may treat them with resignation but when
pulsatile or very large, deforming and threatening to life, more active treatment
may be necessary. Excision is often too dangerous and disfiguring. Ligation
is inefficient. Injection of coagulating materials is commonly insufficient and
involves grave dangers from embolism. Morestin (Rev. de Chir., Feb., 1914) lias
injected solutions of formalin to kill or "fix" the diseased tissues but precedes
the injections by ligating the principal afferent and efferent vessels. The tem-
porary cessation or lessening of the local circulation lessens the dangers from
embolism and increases the efficiency of the injections. Morestin's formalin
solution consists of equal parts of formalin, 90 per cent, alcohol and glycerine,
of which any amount from i c.c. to 12 c.c. or more may be injected according
to circumstances. The injections may require to be repeated several times but
no new injection should be made until the reaction from the pre\ious one has
subsided.

The Operation. — A general anesthetic is necessary in the first operation; if
the injections require to be repeated the tissues are so altered that no anesthetic
is required in the later operations.

134 HARE-HP

Step I. — Ligation of the ]'essels. — According to the case ligation is practised
on one or both sides. Bilateral ligation is proper when the lesion is very exten-
sive, passes over the middle line and is pulsatile.

Make an oblique transverse incision whose center is on the anterior margin
of the sternomastoid muscle one finger's breadth below the angle of the jaw.
Retract the sternomastoid. Penetrate cautiously between the facial and ex-
ternal jugular veins. According to the site and extent of the lesion tie the facial
vein, or the facial and external jugular or even the internal jugular (this last of
course only on one side). It is best to place the ligatures around the veins but
not to tie them until after the arteries have been tied.

Recognize the external carotid artery opposite the tip of the greater horn of
the hyoid. Pass a ligature round the artery ; expose its principal branches (facial
superior thyroid, lingual) and tie them separately. Unless these branches are
tied, anastomosis is so quickly established as to render useless the ligation of the
main artery. Close the wound.

Step 2. — Charge a syringe with the fixative solution and arm it with a long,
fine needle. Introduce the needle through the skin at the periphery and
push it through the tumor mass. Slowly withdraw the needle at the same time
expressing the contained solution drop by drop. Do not inject any of the
solution close to the skin or mucous membrane, otherwise sloughing will occur.
Repeat the injection until the whole of the angioma has been injected (in some
very large tumors it is better to inject one segment of the tumor at a time).

Morestin writes: "In pulsatile angiomas the dose of solution must be large
even although it may cause massive sloughing; the dangers from the disease
justify the risk. When the integument is diseased it is difficult to obtain a cure
without greater or less destruction of the skin but in these cases it is preferable
not to attack the superficial parts of the disease at the first sitting, they may be
treated later."

"A few hours after operation swelling begins and increases to very large
proportions during three or four days, but there is comparatively little discolora-
tion. Pain as a rule is slight and ephemeral. General symptoms are usually
absent. After four or five days the swelling begins to diminish. The tumor
itself persists for a time as a hard mass but little by little this softens and the
tissues may become quite pliable."

CHAPTER XIV
HARE-LIP

Time to Operate. — On the whole, it may be taken that it is better to oper-
ate after the patient has passed the first two months of life than at an earlier
period, although many surgeons operate by choice within a week or two of
birth.

Position of Patient and Surgeon. — Chloroform having been administered,
the patient should be put in Rose's position. The shoulders being supported on
a pillow, the head is allowed to hang backwards over the end of the table. In
this posture the anterior nares are at a lower level than the entrance to the

PRINCIPLES OF OPERATION 1 35

trachea, and thus it is easier for blood which has gathered in the nose or pharynx
to escape through the nares than to be aspirated into the lungs. For the same
reason much trouble caused by the collecting of blood in the pharynx is obviated.
Trendelenburg's position has the same advantages. Ether may be administered
and blood and secretions removed by means of proper apparatus such as is used
in operations on the tonsils. The surgeon sits with his back to the window
opposite the patient's head. The first assistant stands beside the patient's
left shoulder.

Fundamental Principles of Hare-lip Operations. — i. Tension must be re-
lieved, so that the function of the sutures is practically merely to hint to the
edges of the cleft that they must stay in apposition.

2. The edges of the cleft must be freshened so that union can take place.

3. This freshening must be done in such a way that the edge of the upper lip
opposite the line of suture is made to project below the normal level of the lip.
The object of this is to avoid the occurrence of a notch on the lip after the wound
has shrunk when healing is complete.

4. The freshened edges of the cleft must be brought together and kept to-
gether.

To these fundamental principles James E. Thompson adds the following:

5. The red line of the lip must extend in a clean, unbroken curve from one
side of the newly formed lip to the other.

6. The depth of the mucous membrane must be equal on each side of the
line of suture.

7. The newly formed lip must not be too short, but must be lengthened so
that it will more than cover the gums.

8. The nostril must be reproduced so as to have exactly the same dimensions
as the sound nostril, and must consist of tissue of the same texture as the normal
nostril.

9. There must be no flattening of the nose or ala nasi on the afifected
side.

SINGLE HARE-LIP

Incomplete Hare-lip. — The cleft in the lip does not extend into the nostril;
it is often a mere notch. It may be unnecessary to relieve tension, though when
the cleft is at all extensive or wide this is necessary and must be done thoroughly.
Malgaigne's operation gives good results, but Nelaton's is the one usually recom-
mended. These operations and a few others will be easily understood by a
glance at Figs. i8i to i86.

In incomplete hare-lip, when the ala of the nose is pulled to the side and the
nostril much widened, C. H. Mayo relieves tension very thoroughly, separating
the ala of the nose from its deep connections; then he makes his denudation at the
floor of the nostril (Fig. 187, A, B), and by pulling the lip downwards and intro-
ducing sutures, converts the horizontal wound A, B into a vertical one (Fig. 188).
The rerult is obliteration of the notch in the lip and correction of the deformed
position of the ala of the nose.

136

HARE-LIP

Figs. i8n and 182. — Malgaigne. {Esmarch and Ko'xalzig.)

Figs. 183 axd 184. — Xelaton. (Esmarch atid Kowalzig.)

Figs. 185 and 186. — Mirault. {Esmarch and Kowalzig.)

Figs. 187 and \i

^/i////>/..f..A...

-C. H. Mayo's operation.

Fig. 180. — Relief of tension.

Fig. 190.

The dotted area represents the extent of dissection
that is commonly required for the rehef of tension.

COLLIS OPERATION

137

Complete Single Hare-lip. — Relief of Tension. — This is one of the most im-
portant steps of all hare-lip operations. Failure to relieve tension completely
is the most common cause of bad results.

The upper lip i" -verted and pulled upwards and outwards by the fmger
and thumb of the left hand (Fig. 189). The mucous membratne is incised at its
reflection from gum to lip, and divided from the premolar region on one side to
the premolar region on the other side, if necessary. Through this incision,
with knife or scissors, one separates the soft parts from the bones (keeping the
instrument close to the bone). Particular attention must be paid to the sepa-
ration of the ala of the nose from the bone (Fig. iqo).

To what extent must the soft parts be separated from the bone ? The answer
to the foregoing question is, until the edges of the cleft in the lip, when placed
together, show a tendency to lie in apposition, so that the sutures when intro-
duced may be tied without giving rise to tension.

Freshening of the Edges of the Cleft. — The methods of freshening the edges of
the cleft are legion.

/ JSmdce*

Figs. 191 and 192. — Collis' operation.

The Collis Operation for Single Hare-lip. — Tension having been relieved,
make the incision A, B (Fig. 191) along the line of junction between mucous
membrane and skin. Dissect the mucous membrane, corresponding to that
incision, from the subjacent tissues until the whole edge A, B of the cleft is raw.
The mucous membrane may be entirely removed or may be left as a flap (F,
Fig. 192) having its pedicle posteriorly. If the flap is left attached it forms,
when the operation is completed, a sort of valve
covering the posterior surface of the wound. In
a few weeks no trace of it will be found.

On the external edge of the cleft make the
incision C, E, D (Fig. 191) through the whole
thickness of the lip. At the point E divide the
flap thus formed by a horizontal incision. This
result? in the formation of two flaps, C e' and D
e (Figs. 191 and 192). Stitch the raw surface of
the flap C e' to the highest possible part of the
raw surface A, B. This brings the ala of the nose

into good position and provides an epithelial covered floor to the anterior
nares. Turn the flap D e (Fig. 193) downwards and stitch it to the lowest
possible part of the raw surface A, B. Stitch the point E (Fig. 193) to the
middle of the raw surface A, B. When all the sutures are in place and tied, the
wound line will appear as represented in Fig. 193.

Fig. 193. — Collis' operation.

138

HARE-LIP

This operation wastes no valuable tissue and gives a particularly long upper
lip. Fig. 194 to 202 suffice to illustrate some other well-known methods of
operating.

Sutures. — One or two deep sutures involving almost the whole thickness of
the lip must be inserted. The best material for these is silkworm-gut. Hare-lip
pins have been discarded, as they cause too much scarring. Usually the deep
sutures are inserted through the skin and give rise to considerable scarring a^
their points of entrance and emergence; a better plan is to introduce the deep
sutures from the mucous surface and not to involve the skin in their bite;

Figs. 194, 195 and 196. — Giraldes. {Esmarcli and Kou'alzig.)

Figs. 197, 198 and 199. — Konig. (Estnarch and Ko'walzig.)

Figs. 200, 201 and 202. — Konig. (Esmarch and Kowalzig.)

when this is done, these stitches must not be removed until healing is com-
plete, when they will generally be found to have cut their own way out. If the
surgeon endeavors to remove such sutures at the end of a week, he requires to
evert the lip, and thus jeopardizes the line of union. Several superficial cu-
taneous sutures must be introduced; the best material for these is horse-hair.
Horse-hair sutures, because of their elasticity, leave less scar than any others.
All cutaneous sutures (superficial and deep) may be removed by the seventh day.

DOUBLE UNCOMPLICATED HARE-LIP

When the deformity is not complicated by the central portion of the lip
being carried forwards towards the tip of the nose by the intermaxillary bone,
the following operation will generally be found satisfactory.

DOUBLE HARE-LIP

139

Make the incisions A, B, C and D, E, F (Fig. 203) through the whole thick-
ness of the lip. At the points B and E divide each of the flaps thus formed into
two. The edges of the central portion of the lip (Figs. 204, 205, 206) are
now to be pared. On each side there are now two flaps, an upper and a lower.

Fig. 203.

Fig. 204.

The raw surfaces of the upper flaps are to be sutured to the lateral raw surfaces
of G as high up as possible. Corresponding to the lower edge of G, the hori-
zontal incisions H ajnd I (Figs. 204 and 205) must be made through the whole
thickness of the lip on each side. This procedure permits the easy approxima-

FiG. 205.

Fig. 206.

tion of the edges of the cleft below the level of the central part (G). The two
lower flaps when their raw surfaces are sutured together form a prominence on
the edge of the new upper lip. The appearance of the wound when the opera-
tion is completed is represented in Fig. 206. Other methods of operating are
suflSciently illustrated by Figs. 207 to 215.

Figs. 207, 208 axd 209. — Maas. {Esmarch and Kon'alzig.

James E. Thompson ("Surg., Gyn., Obst.," May, 191 2) good-naturedly
laughs at many of the operations for hare-lip figured in this and other books
giving diagrams representing what the true results must be, alongside the time-
honored figures showing the results as imagined by the inventors of the opera-

I40

HARE-LIP

tions. To insure accuracy in making his incisions, Thompson uses sharp-
pointed compasses which can be fixed by a screw and with them makes all
necessary measurements and marks.

Thompson' s Methods. — I. Single complete hare-lip without much divergence
of the sides of the cleft. At A and A', Fig. 216, i, a projection or shoulder shows
the junction of the cleft and the nasal margin. With compass measure the
distance from Y (midway between A and A') to Z placed on an imaginary line
KL which represents the natural curve of the upper lip. FLx the compasses
so that their points will remain this distance (YZ) apart. Place one point of
the compasses at A and the other at B on the skin of the lip close to the red
line of the mucous membrane. Mark the point B, Fig. 216, 2, by pricking the
skin. In the same fashion find and mark the point B'. The line AB equals

Figs. 210, 211 and 212. — Hagedorn. {Esniarch and Kowalzig.)

Figs. 213, 214 and 215. — Simon. {Esmarch and Kowalzig.)

in length the line A'B'. Readjust the compasses and take the measurement
BC, the point C being on the free margin of the lip. The angle ABC is usually
about 60° and must always be less than 90° if a projecting prolabium is to result
from the completed operation. Mark the point C by pricking the mucosa.
In the same fashion find and mark the point C . The line BC equals in length
the line B'C Pass a retaining stitch of horse-hair "through each side of the
mucous membrane of the lip close to, but below, C and C." Suture A to A',
B to B', C to C, Fig. 216, 3.

II. The sides of the cleft are unsymmetrical. Fig. 216, 4, shows how the
same operation gives the same results provided that the cheeks have been well
mobilized as advised on p. 137.

III. Double hare-lip. In Figs. 216, 5, and 216, 6, "the shoulders marking the
margins of the nostrils are shown at A and E, and at A' and E'. The triangle
E'DE shows the line of incision by which the central piece of skin covering the
intermaxillary bone is pared. E and E' are placed on the inner margins of the
nostrils. The sides DE and DE' are usually equal in length to one another
and their length varies according to the depth of the central piece of skin. It

THOMPSON S METHODS

141

must never be greater than AB and is usually much less. The points A B
and C and A', B' and C are chosen as described previously in the operation
on single hare-lip. Fig. 216, 6, shows the final appearance of the lip when the
flaps have been cut and the parts approximated. The point A is in contact

with E, A' and E'; the apex D of the triangle E'DE lies somewhere along the
line AB; the point B is in contact with B', and C with C.

Two essential points must be emphasized:

I. Under no circumstances must the circumference of the nostril be en-
croached upon. The shoulders that represent the margins of the nostril must
be accurately approximated.

142

HARE-LIP

2. The points B and B' must be as close to the red line of the lip as possible,
and must always be on the skin (upper side) of this line."

COMPLICATED HARE-LIP
A. Single complete hare-lip. The alveolus is cleft and one side of the
cleft is much more prominent than the other. If possible push the protrud-
ing part into alignment with the rest of the alveolus. If this is not possible
introduce a mattress suture of wire as shown in Fig. 217,
divide the bone at A, push the mobilized bone into proper
position and fasten it with the wire.

B. Double hare-lip complicated by the presence of the
intermaxillary bone hanging at the tip of the nose.

Some surgeons advise that the misplaced inter-
maxillary bone be entirely removed. When this has
been done, it is very difficult to secure union between the
new-formed upper lip and the column of the nose. Un-
doubtedly it is wise to retain the bone and replace it in its proper position. An
incision (Fig. 218) is made through the muco-periosteum of the nasal septum, be-
ginning immediately behind the intermaxillary bone and extending backwards for
^ of an inch. A fine periosteal elevator or probe is passed through this incision
and the muco-periosteum raised on each side of the septum (Figs. 219 and 220)
from its edge up to the root of the nose. With a strong pair of scissors a
triangular piece of the septum (Fig. 219) is now excised. This permits the

Fig. 217.

Fig. 218.
(Esmarch and Kowalzig.)

Fig. 219.
{Esmarch and Kowalzig.)

Fig. 220.
{Esmarch and Kowalzig.)

intermaxillary bone to be easily pushed back into position. It is not
absolutely necessary to trim off the mucous membrane covering the inter-
maxillary bone and those portions of the superior maxilla with which it is
in contact, though it is advisable to do so, as union can then take place with
rapidity. If any developing teeth are encountered, remove such. Teeth which
appear later in bad position are to be treated by a dentist. Suture of the
bone in position is unnecessary. The cleft in the lip should be united at the
same sitting.

Sometimes instead of excising a wedge from the septum it is sufficient to
make a vertical cut through it and slide that portion of the septum anterior to
the cut back alongside the posterior portion (Fig. 220). Lane thoroughly dis-
approves of all these attempts to replace the intermaxillary bone.

AFTER TREATMENT

143

If the intermaxillary bone has been dislocated backwards by any of the
means described, Reich ("Zent. fur Chir.," 1911, No. 25) remarks that it forms
"a blunt and bull-dog nose." He has endeavored to overcome this error.

Reich'' s Operation. Step i. — Dissect the philtrum from the intermaxillary
bone and, in doing so, expose the edge of the cartilaginous septum immediately
above the intermaxillary bone. With straight scissors divide the nasal septum
obliquely upwards and backwards as high as possible (Fig. 221). This cut
divides the mucosa, periosteum and perichondrium, cartilaginous septum and
the perpendicular plate of the ethmoid and leaves in front of it, and separate
from the rest of the septum, a plate of bone and cartilage reaching from the
root to the tip of the nose, guaranteeing its profile.

Step 2. — Subperiosteally excise a wedge of the septum as in the preceding
operation but much farther back. Push the intermaxillary bone into correct
position.

Step 3. — Close the hare-lip in the usual manner, using the philtrum nasi to
form the cutaneous septum of the nose (Fig. 222).

Figs. 221 and 222. — i. Point of Nose. 2. Philtrum of nose. 3. Intermaxillary bone.
4. Oblique section of septum. 5. Wedge of septum removed.

DRESSINGS AFTER OPERATIONS FOR HARE-LIP

Should tension on the sutures be feared, a strip of adhesive plaster may be
placed from cheek to cheek across the upper lip, in such a way as to relieve
tension. If, however, the soft parts of the lip and cheeks have been sufl&ciently
separated from the bones at the beginning of the operation, then such a measure
is unnecessary and undesirable, as it simply irritates the already irritable patient.
It is not necessary to apply any dressing to the wound, as nature soon seals it
with dried blood-clot. Until the sutures are removed there should be as little
interference with the wound as possible. If it is going to heal, it wiU heal under
the scab, and the best-intentioned endeavors to clean the wound will merely
interfere with nature's work and do no good, as cleanliness can never be attained
in such cases. Care must be taken so to fix the little patient's arms that scratch-
ing of the wound is rendered impossible.

When it is desired to close the cleft in the palate, which almost invariably
accompanies extensive hare-lip, such closure ought to be effected either at the
same time as the intermaxillary bone is replaced or at a former operation.

144

CLEFT PALATE

CHAPTER XV

CLEFT PALATE

The proper time to operate for cleft palate is when the patient is under
three months of age; Brophy's method of operating is inapplicable in children
of over six months. Brophy has operated on 2u cases of cleft palate in babies
younger than six months without a single death, yet the operation is un-
doubtedly not without risk. The operation should be performed before the
closure of the concomitant hare-lip. Brophy gives the following reasons for
the above practice: (i) The existence of the hare-lip gives more room in which
to work. (2) ,There is less nervous shock after an operation on a child of a
few weeks of age than when the babe is older. (3) The
bones are soft. (4) After operation the child will be
better nourished. (5) The muscles of the palate are given
an opportunity to develop instead of atrophy, and the
patient does not get into the habit of articulating through
the cavern of the nose.

Before operating see that the patient's general health
is good and that no local conditions exist which might
interfere with repair. If adenoids are present, they must
be removed. For a few days prior to operation it is well
to cleanse the mouth and nasal cavity with a saturated
solution of boracic acid in glycerin.

Brophy's Operation. — Applicable in children younger
than three months; generally possible, though not so easy,
in children up to, but not beyond, the sixth month. The
only special instruments required are two of Brophy's
strong needle? (Fig. 223); a few strands of No. 20 silver
wire; lead plates No. 17, American gage. No special
mouth-gag is necessary, the assistant's fingers being sufficient to keep the
mouth open and the tongue depressed. Immediately before operating the
writer swabs the parts with adrenalin solution. This lessens hemorrhage.
During operation bleeding is easily controlled by pressure with pledgets of
gauze wrung out of hot water.

The Operation. — i. Anesthetize the patient. Place in Rose's or the Tren-
delenburg position. Pass a stout thread through the anterior end of the
tongue as a traction suture. This is a great convenience.

2. With a knife pare thoroughly the edges of the cleft in the hard palate,
cutting away a little of the bone itself to insure thoroughness. Either pare or
horizontally split the edges of the cleft in the soft palate. If split thoroughly,
the edges of the split retract and so a good raw surface is left without any loss
of .tissue.

3. Thread a Brophy needle with a strong silk or celluloid hemp. Raise the
cheek and pass the threaded needle through the superior maxilla from without

Fig. 223. — {Brophy,
^^ Dental Cosmos.")

BROPHY S OPERATION

145

inwards at a point just back of the malar process and high enough to be above
the palate (Fig. 224). When the needle appears in the cleft, pick up the thread,
which it carries, with hook or forceps. Withdraw the needle, leaving the loop
of thread in situ. Catch the ends of the thread in a hemostat. Through a
corresponding part of the opposite bone pass a loop of thread in the same
manner. Pass this second loop of thread through the first and pull the latter
out, carrying with it the former. We now have a loop of thread passing through
both superior maxillary bones above the palate, and when necessary through
the nasal septum. By means of this thread pull a strand of very strong silver
wire through the same track.

Fig. 224. — {Brophy, "Denial Cosmos.")

4. In the same manner introduce one or sometimes two other silver wires
through the anterior portion of the maxilla above the level of the palate (Fig,
224, A).

5. Pass the ends of the silver wire through holes in lead plates moulded to
fit the convexity of the buccal surfaces of the bones (one plate on each side).
Draw the wires tight and twist them together — i.e., twist the "right end of
the anterior wire to the right end of the posterior wire and the same on the
left side" (B, Fig. 224).

6. With the thumbs forcibly press the two maxillary bones together until
the cleft is completely closed. Twist the wire once more so as to hold the
bones firmly together.

7. Close the soft palate by sutures. The state of the patient may necessitate
this step being delayed until another day. Do not close the hare-lip until
the palate is completely closed and the patient has recovered.

Note. — If closure of the cleft by mere compression proves impossible, division of the
malar process may be practised. Make a very small incision through the mucous mem-
brane over the malar process of the superior maxilla. Through this divide the process hori-
zontally, i.e., parallel to the alveolar edge, either with a knife or a s mail chisel, such as
dentists use.

After-treatment consists in as great cleanliness of mouth and nose as can be
attained; in the use of stimulants, if necessary; and in feeding by means of a
spoon. The plates and wire sutures remain in place from two to four weeks.
10

146

CLEFT PALATE

Fig. 225.

In unilateral cleft palate the palatal process of one side has united with the
septum of the nose. In such cases the septum is often very much curved, and
its lower portion seems a continuation of the palatal process to which it is united.
If, in the course of operation, it is difficult to bring the edges of the two palatal
processes together, we may cut a groove in the septum at
the point X (Fig. 225) and bring the freshened edge of the
ununited palatal process (P', Fig. 225) into apposition with
it, thus using a part of the septum to close the defect.

Uranoplasty (Arbuthnot Lane's Operation). — For many
reasons the operation should be performed as early as possi-
ble after birth. Before the milk teeth erupt there is plenty
of material present to permit the closure of almost any defect no matter how
wide it may be. The large surfaces of bare bone left after Lane's operation
heal very rapidly.

Instruments required:

1. Lane's mouth-gags with sharp teeth which bite into the gums. These
are sold in pairs of proper sizes (Figs. 226 and 227).

2. Lane's needle holder with very small needles (Figs. 228 and 229). This
was originally devised for suture of the bile ducts.

3. One small strong knife. A Jones' teno-
tome will serve admirably.

4. Fine sharp-pointed scissors.

5. One strong hemostat with mouse teeth
at the point.

6. Fine strong silk or hemp.

7. A good mouse- tooth dissecting forceps
suitable for catching the tissues or the end of
a needle.

Type A. — The cleft in the hard palate is
unilateral. The septum is continuous with the
hard palate on one side. The alveolus and the
soft palate are also cleft.

Step I. — Formation of reflected flap. Make the incision 7, 5, 6, 8 through
the muco-periosteum to the bone (Fig. 230). In order to obtain plenty of tissue
that part of the incision represented by the line from 5 to 6 is made on the outer
surjace of the alveolus near the reflection of the mucosa from the alveolus to the
cheek. Make the incision through the mucosa of the soft palate, but do not
injure the musculature. Reflect the outlined flap 7, 5, 6, 8. The pedicle or
hinge of the flap corresponds to the edge of the cleft in the palate.

In separating the muco-periosteum from the bone as the posterior palatine
foramen is approached, an elevator pressed in between the flap and the bony
palate causes the posterior palatine vessels and nerves to protrude for a con-
siderable length in a tube of periosteum. This is readily grasped by an efficient
hemostat, which is left in place until hemostasis is assured.

That portion of the flap taken from the soft palate consists of mucosa and
submucosa. It is important not to injure the muscles of the palate. The

Fig. 226. — {Lane.)

LANE S OPERATION

147

reflected flap is formed on the side of the cleft which is not attached to the
septum.

Slep 2. — On the side of the cleft attached to the septum proceed as follows:
With forceps pull the uvula and soft palate forwards so as to expose its nasal
surface. Divide the mucosa along the posterior edge of the soft palate (4, 3,
Fig. 230). Continue the incision across the nasal surface of the soft palate to

Fig. 227. — {Lane.)

thd point where the soft and hard palates meet at the edge of the cleft (3,2, Fig.
230). Continue the incision forwards along the edge of the hard palate (2, i)
and across the alveolus (1,9). The part of the incision affecting the hard palate
and the alveolus penetrates the whole thickness of the muco-periosteum. The
part of the incision affecting the soft palate only penetrates the mucosa and
submucosa. Reflect the mucous flap (2, 3, 4) outlined on the nasal surface of
the soft palate. Introduce an elevator through the incision 9, i, 2 (Fig. 230)
and separate the muco-periosteum from the hard palate and to a slight extent
from the alveolus near the point 9. Divide the attachments of the soft
palate to the hard palate along the posterior edge of the latter, leaving intact
the mucosa on the oral side of the palate. During Step 2 the posterior
palatine artery remains uninjured.

148

CLEFT PALATE

Step 3. — Turn the flap 5, 7, 8, 6 so that its epithehal-covered surface
is directed towards the nose and its raw surface towards the mouth. Tuck
the edge of flap 5, 7, 8, 6 well under flap 9, i, 2, 3, 4, and fix it in position
by two rows of fine sutures (Figs. 231 and 233).

Type B. — The cleft is wide; the septum is not attached
to the palate; the alveolus is not cleft.

Step I. — Make the flap i, 2, 3 (Fig. 234) as in Type A.

Step 2. — On the opposite side make the incision 6 through
the muco-periosteum along the edge of the cleft. Make the
incision 7 and 8 on the nasal surface of the soft palate and
reflect a flap of mucosa from the soft palate as in Type A.
Separate the muco-periosteum from the hard palate and di-
vide the attachments of the soft to the hard palate along the
posterior edge of the latter, leaving intact the mucous mem-
brane on the oral surface.

Step 3. — Turn flap i, 2, 3 over, with its epithelial surface
directed towards the nasal cavity, so as to cover the cleft.
Tuck the free edge of this flap well under the flap 10, 6, 7, 8.
The triangular portion of this latter flap which was obtained
from the nasal surface of the soft palate assists greatly in
providing a thick new velum palati.

Step 4. — Suture the edge of flap i, 2, 3 to the base of flap
10, 6, 7, 8 (Fig. 235). Suture the edge of flap of 10, 6, 7, 8
to the raw surface of flap i, 2, 3 (Fig. 235).

Note. — If the lower or free edge of the nasal septum extends to the level
of the cleft, attach it to flap, 1, 2 and 3 in the following manner after com-
pleting Step 2 as described: Make an incision (4, Fig. 234) through the
mucosa and periosteum or perichondrium along the middle line of the
Fig. 228. {Lane.) septum with two small transverse incisions (5) at either end, and turn
down laterally the narrow flaps so formed, leaving the cartilage or
bone bared and exposed. By placing flap i, 2, 3 in correct position, the line along which
it will rest on the septal margin can be readily defined. Along the line of contact with
the septal margin denude the surface of flap i, 2, 3 with a sharp knife. By a series of sutures
perforating flap i, 2,3 and the margin of the septum if it be not too hard, or the flaps of muco-
periosteum if the edge be bony, securely fix the flap to the septum (i, Fig. 235). Proceed to
Step 3.

Type C. — Double cleft palate. Premaxillary bone (P, M,
Fig. 236) well in front of the alveolar arch and fixed to the under
surface of the nose; the mesial segment (L) of lip is fixed to the
anterior surface of the premaxilla. Operation by means of re-
flected and pivoting flaps. (The following description is in
Lane's own words.)

"The reflected flap is obtained by an incision extending from
I along the outer aspect of the alveolus, through 2, and on to 3,
when it bends inwards along the free margin of the soft palate to the uvula 4.
The pivoting flap is obtained by an incision from 5, along the outer aspect of
the alveolus, through 6, along the margin of the cleft in the hard palate from
7 to 8, along the upper surface of the soft palate 9, and then to 10.

Fig. 229. —

(Lane.)

lane's operation

149

Fig. 230. — Lane's uranoplasty.

Fig. 231. — Lane's uranoplasty.

Fig. 233. — Lane's uranoplasty.

I50

CLEFT PALATE

Fig. 235.— (/.awe )

lane's operation

I =51

Fig. 236. — (Lane.)

Fig. 237. — (Lane.)

I>2

CLEFT PALATE

"The area of mucous membrane corresponding to the triangle 8, 9 and 10,
is raised and reflected inwards. The area of muco-periosteum included in
5, 6, 7 and 8 is raised from the subjacent bone, except at the point of entry of
the posterior palatine vessels and nerves, which form the pivot on which this
flap rotates. The mucous membrane is striped from the premaxilla and trom
the free edge of the septum in the manner indicated by the dotted lines, showing
incisions in the diagram.

"Large flaps are cut from the portions of lip forming the edges of the cleft,
and great care is taken that they have an extensive attachment at their bases.
The mucous membrane covering the lateral and lower aspects of the piece of
lip lying in the front of the premaxilla is removed (L).

"The reflected flap is first put in position; the mucous membrane, where it
comes into contact with the under surface of the septum, having been rendered
raw, is secured to it by sutures. The pivoting flap is then moved inwards upon
the reflected flap, to which it is united firmly by a double row of sutures. Finally
the soft palate is closed in a similar manner. This is represented in Fig. 237.

Fig. 238. — (Lane.)

"After this the triangular areas of muco-periosteum which were reflected
from the premaxilla are fixed in position (see Fig. 240), where these are indicated
by Y. The flaps from the lips shown as F, F are arranged with their raw sur-
faces upwards. These are united to the raw surfaces of the flaps from the
premaxilla and of the reflected flap, and are also sutured by their margins to
one another and to the free edge of the pivoting flap (see Fig. 238).

"Lastly, the ala of the nose is cut away from the cheek on either side and is
displaced inwards where it is united by sutures to the septum, and is sewn to
the cheek in its new position. This I have attempted to indicate in the same
diagram. Having brought the edges of the lip into accurate position by
means of separate sutures, two sutures of linen thread are passed in the manner
indicated in Fig. 239. The needle perforates the lip from behind, and is
made to re-enter the anterior aspect of the lip through the same hole, and after
traversing the lip transversely it again emerges and enters through the same
hole, the needle passing directly backwards through the lip. When this thread
k made taut and tied the opposing raw surfaces of lip are held in accurate

lane's operation

Fig. 239. — (Lane.)

Fig. 240. — {Lane \

Fig. 241. — {Lane.)

154

CLEFT PALATE

position, and no scar whatever results from the presence of these deep sutures,
which can be readily removed when they have served their purpose. In Fig.
239 only one cleft in the lip is represented."

Type D. — Wide cleft of soft palate.

Step I. — Reflect the flap i, 5, 6, 7, 8 (Fig. 241) with its base at the edge of
the cleft.

The flap consists partly of muco-periosteum from the hard palate and
laveolus and mostly of mucous membrane from the soft palate and cheek.
The flap must be large enough to easily cover the defect. Do not injure the
musculature of the soft palate.

Fig. 242. — {Lane.)

Step 2. — From the nasal surface of the soft palate on the opposite side of
the cleft reflect the flap i, 2, 3, 4 with its base at the edge of the cleft.

Step 3. — Suture the two flaps together one over the other in an overlapping
fashion (Fig. 242).

After the milk teeth have erupted some modification of Lane's methods or
the following classical operation may be selected.

The patient having been anesthetized, placed in Rose's position, and a
traction thread passed through the tongue, a suitable gag is introduced. Of
the numerous gags invented, probably Lane's or Whitehead's is the best, but
the writer finds that a piece of wood about ^^ inch thick answers every purpose,
and consequently rarely uses anything else.

I. Denudation. — Seize the end of the uvula on one side with a sharp hook or
forceps (Fig. 243). With a sharp knife or tenotome remove a strip of mucous
membrane from the whole edge of the cleft. In cutting, do so obliquely, re-
moving rather more membrane from the oral than from the nasal side of the
palate. This gives a more extensive raw surface, which is a great advantage.
When the soft palate is very thick, its edge may be split instead of pared.
Repeat the process on the other side of the cleft.

URANOPLASTY

155

2. With a suitable periosteotome or knife divide the muco-periosteum along
the edge of the cleft in the hard palate. Separate all the muco-periosteum

from the hard palate up to the alveolar process (Fig. 244). For this procedure
Brophy's periosteotomes (Fig. 245) are convenient, but a suitable instrument
is easily extemporized from a dental spatula or even an aneurysm needle.
3. The soft palate may be said

to consist of three layers : (a) The

nasal mucous membrane; (b) the

tissues attached to the posterior

edge of the hard palate; (c) the

oral mucous membrane.

Leaving intact the oral mucous

membrane, which is continuous from

hard to soft palate, divide trans-
versely with fine curved scissors both the nasal mucous
membrane and the tissues attached to the posterior
edge of the hard palate. This is one of the most
important steps in the operation, allowing the muco-
periosteal flap obtained from the hard palate to drop
towards the mouth, and with it the soft palate
(Fig. 249). Repeat this procedure on the opposite
side. Commonly the raw edges of the flaps thus
obtained will come into apposition without tension.
If they do not, it is necessary to make a lateral incision through the muco-peri-
osteum parallel and close to the alveolus (Fig. 247) on one or both sides of the

Fig. 245. — (Brophy, "Dental
Cosmos.")

i=;6

CLEFT PALATE

mouth, and extending from the lateral incisor back to the posterior margin of the
hard palate. If this is insufficient to relieve tension, Billroth 's procedure may be
adopted as follows: Pass a fme chisel through the posterior angle of the lateral
incision, direct it obliquely inwards and upwards against the hamular process,
and with a light blow from the hand make it divide that bone. The dislocation
of the hamular process, increased if necessary by the use of an elevator, gives

Fig. 246.

Fig. 247.

Fig. 248.

perfect relaxation of the velum palati and does not injure its musculature.
Incisions through the soft palate dividing its muscles were formerly considered
necessary; now they are never admissible.

C. H. Mayo considers it important to make lateral incisions (Fig. 247) on
both sides. Outside the posterior palatine foramina, these do not merely relieve
tension, but permit the use of a relaxation tape. Having prepared the parts

Fig. 24g.
N. M. Nasal mucosa. H. P. Hard palate. O. M. Oral mucosa. S. P. Soft palate. S. Line of section.

for the insertion of sutures, and having made two lateral incisions close to the
alveoli, he introduces a narrow tape which surrounds the right and left muco-
periosteal flaps (Fig. 247). Traction on the ends of the tape brings the flaps
towards the operator, steadies them, and facilitates the introduction of the
ordinary sutures. When the sutures are in place and tied, Mayo crosses the
free ends of the tape and fixes them by tying a ligature around them at this

Fig.

point (Fig. 248), cuts off the superfluous portions of the tape, and lastly slides
the w^hole tape until that part fastened by the ligature lies in the nasal instead
of in the oral cavity. The tape fastened as above acts as an elflcient relaxation
suture or support; it also drains secretions from the nasal cavity into the mouth.
It is remarkable how this very simple contrivance facilitates the operation,
Harry Sherman smears the tape with Mosetigs bone wax and fastens its free
ends together by sutures.

URANOPLASTY

157

4. Suture. Many special needles have been devised to overcome the
diflSculties met with in closing palatal defects. Of these, the Deschamps
(Fig. 250) is perhaps the best, although it is usually made too large. The
writer finds that he can discard such special instruments by using very small,
full curved needles, grasped in a long-necked needle-holder, and passing each end
of the thread, armed with a needle, from the nasal to the oral side of the palate,
i.e., from within outwards. The usual method of suturing is to begin at
the uvula and work forwards, being careful to evert the edges of the wound when
the flaps from the hard palate are being united. Silk or waxed linen are the
materials used. If the soft palate has been split instead of pared, Sherman
sutures the nasal surface first (knots being on the nasal side) and then the oral
surface.

Fig, 251. — [Brophy, " Dental Cosmos.")

Fig. 252. — {Brophy, '' Dental Cosmos.")

Harry Sherman (Journ. A. M. A., Dec. i, 1917) as a preliminary measure
endeavors to narrow the cleft by means of pressure applied as follows:

From a point opposite the top of the ear apply a strip of adhesive plaster
on the cheek to a point on the upper lip just external to the side of the nose.
Do this on both cheeks. Have a hook on the outer surface of the anterior
end of each adhesive strip. By an elastic band uniting the two hooks it is
easy to compress the superior maxillae. Other surgeons, e.g., Brown (Oral Dis-
ease and Malformation) apply adhesive tape across the lip from cheek to cheek
and by this means obtain narrowing of the cleft and even reposition of the pro-
truding premaxillary bone in double cleft palate. As soon as elastic pressure
has caused the ends of the broken alveolar arch to overlap (single cleft palate)
Sherman considers the child ready for operation. He uses the Langenbeck
method for closure of the soft palate but splits instead of paring the edges.
The posterior half of the hard palate is closed by the Langenbeck method also,
but mattress sutures are employed so that the edges of the wound are turned

158

TONGUE

down into the mouth thus providing broad contact of raw surfaces. Lateral
incisions and a waxed tape relaxation band are used as already described. At
a later date the anterior part of the cleft is repaired by Lane's method.

Brophy puts in, as a preliminary, tension sutures of No. 22 silver wire,
fixing these on lead plates (Figs. 251 and 252). He claims that the use of
these obviates the necessity of lateral incisions, and that the lead plates act as
a splint, securing rest, and hence better results. The fact that numbers of
Brophy's cases have passed the supreme test of successfully reading aloud be-
fore professional societies makes his opinions and procedures worthy of the
gravest consideration. C. H. Peck recommends the use of a dental plate to

protect the united palate. The plate must of course
be removed frequently for the sake of cleanliness.

After-treatment. — ^Liquid or soft food is alone per-
missible. Antiseptic sprays may be used if not
annoying to the patient. The patient should get out
of bed, and in suitable weather, out of doors as soon
as possible. The sutures must not be removed earlier
than the seventh day after operation.

Partial Cleft Palate. — When there is a cleft of
the soft palate alone and the edges can be brought
together without tension, one is content to pare the
edges and apply sutures. When the cleft in the soft
palate reaches close to the hard or when the latter
is partially cleft, it is absolutely necessary to relieve
tension. This is done in the same fashion as in complete cleft palate by di-
viding the attachments of the velum to the hard palate and by separating the
muco-periosteum from the bone to as great an extent as may be necessary
(Fig. 253).

Z and 0. Line of separation
of attachments of velum to hard
palate. X, Y, Z, Q. Area in
which muco-periosteum (con-
tinuous with the velum) is
separated from the bone.

CHAPTER XVI

TONGUE

Butlin's Marginal Resection of the Tongue. — This operation is suitable
where the tongue is originally, or has become, too large for the mouth and
where its lateral margin in contact with the teeth shows dangerous or annoying
irritability. The effects of the operation are: (a) diminution in the size of the
tongue without impairment of mobility or speech, {h) the teeth, instead of being
in contact with an irritable papilla-bearing surface, now lie in contact with smooth
mucous membrane derived from the inframarginal surface of the tongue.

Butlin's operation (Burghard's Op. Surg. II, 209) has been modified by Samp-
son Handley (Brit. Journ. Surg. I, 42) so as to do away with the necessity of
laryngotomy.

An anesthetic should be administered exactly as in operating for cleft
palate.

Step I. — Transfix the tongue far back by a strong silk suture for purposes

butlin's operation

159

of traction and control. Seize the tip of the tongue with a volsellum and
pull it forwards.

Step 2. — On the dorsum make a more or less transverse incision parallel to the
end of the tongue and about i>^ inches long. On the undersurface of the

Fig. 254. — First stage of operation. (By permission from the British Journal of Surgery.)

tongue make a corresponding incision. Through these two incisions cut out
a wedge-shaped segment of the tongue but leave (Fig. 254) the segment attached
by its two ends to the tongue.

t, ^J\

Fig. 255. — Second stage. (By permission from the British Journal of Surgery.)

Step 3. — PulHng the mobilized segment away from the tongue, close the
wedge-shaped wound with sutures. This stops bleeding.

Step 4 — Step by step continue the wedge-shaped excision along the edge
of the tongue and apply sutures to stop bleeding. When the level of the last
molar tooth is reached finish the dissection on that side (Fig. 255). In similar
fashion resect the opposite side of the tongue.

i6o

TONGUE

The lower incision should be at the junction of the smootli mucosa of the
undersurface of the tongue with the papillary mucosa of the dorsum. The
dorsal incision must be made internal to the tissue it is desired to excise.
The smooth infralingual mucosa being preserved makes an excellent flap for
the reconstruction of the margins of the tongue (Fig. 256).

L^ J'

Fig. 256. — The operation completed. (By permission from the British Journal of Surgery.)

When a small tumor exists near the tip of the tongue, it may be removed
by means of a V-shaped incision.

Dieffenbach's Operation. — ^Local anesthesia usually sufi&ces. If a general
anesthetic is used, the mouth must be kept open during the operation by a
mouth-gag. Pull the tongue forwards by means of a volsellum or a stout

Fig. 257.

thread passed through its tip. At a point on each side of the tumor and about
^ inch from it, pass a long silk thread through the whole thickness of the
tongue in such a manner that the loop of the thread is under the tongue,
while its two free ends emerge from punctures on the dorsum (Fig. 257).

Excise the tumor and a wedge-shaped portion of the whole thickness of the
tongue by the converging incisions A B, A C (Fig. 257). The excision is most
easily effected with the scissors. The bleeding is now liable to be sharp.
Tighten and tie the suture which has already been introduced. This stops all
•hemorrhage. Introduce a few more stitches so that the wound is neatly
closed (Fig. 258).

EXCISION TONGUE l6l

The only after-treatment required is frequent cleansing of the mouth with
non-poisonous antiseptic washes.

Excision by Elliptical Incisions. — Small tumors of the tongue may be ex-
cised under local anesthesia by means of elliptical incisions surrounding them.
As soon as the neoplasm is removed, bleeding is stopped by the application of
a few sutures which at the same time close the wound.

The treatment of lingual thyroids is discussed on page 216.

COMPLETE REMOVAL OF THE TONGUE

As a preliminary to any operation for extirpation of the tongue it is necessary
to clean the mouth. The mouth, especially in cases of cancer, is a filthy cavern.
The teeth, usually decayed, are covered with tartar and other abominations.
The mouth should be thoroughly washed with antiseptic solutions, the teeth
vigorously brushed, or, better, cleansed by a good dentist, and loose teeth should
be removed. Very many methods of operating have been devised, but only
a few of them will be described.

I. Whitehead's Operation.— The following description is taken almost
entirely from an article by Whitehead:

1. The patient should be placed in a sitting posture; the head, firmly held,
should be inclined forwards so that the blood may escape easily. The light must
be good and have direct access to the mouth. The patient's mouth and the
surgeon's axilla should be at about the same level.

2. During the first stages of the operation anesthesia should be complete,
but afterwards only partial insensibility should be maintained.

3. A good gag is essential. It must be one which will not slip and will not
embarrass respiration. [Whitehead's gag, with the tongue depressor absent,
is probably the best.] With this the mouth is opened as widely as possible.

4. A strong ligature should be passed through the tip of the tongue for the
purpose of traction.

5. The tongue is retained within the mouth principally by means of the
frenum and the attachments to the anterior pillars of the fauces. These and
the reflection of the mucous membrane between the tongue and jaw must be
divided with scissors. Should any spouting vessels be seen, they must at once
be caught in forceps and twisted; general oozing of blood may be neglected,
because as soon as the main arteries are discovered and twisted all bleeding
ceases. "There is, in reality, no difficulty in determining the actual position
of the lingual arteries, as they are practically invariably found in the same
situation and it requires very little experience to seize them with a pair of for-
ceps before dividing them." The rest of the tongue may be cut away without
difficulty. Before completely removing the tongue it is wise to pass a Hgature
through the glosso-epiglottidean fold. This ligature may be left in place for
twenty-four hours, and permits one to pull forwards the epiglottis should
respiration be interfered with at any time. Traction on this ligature of itself
arrests hemorrhage and makes it an easy matter to secure any bleeding vessel.

6. Wash the wound with an antiseptic solution.
11

l62

TONGUE

7. Paint the wound with iodoform styptic varnish. The varnish is made
by substituting for the alcohol ordinarily used in the preparation of Friar's
balsam a saturated solution of iodoform in ether 9 volumes, and turpentine i
volume.

After-treatment. — Encourage the patient to sit up and move about even
as early as the day following the operation. Give liquid food by the mouth
as early and freely as possible. If necessary, supplement oral feeding by the
use of nutrient enemata. The mouth is frequently washed and the varnish
is reapplied daily.

In the hands of Whitehead this operation has had remarkable primary
results. Up to 1891 he had performed it 66 times with but three deaths.

When it is necessary to remove only one-half of the tongue, the operation
is practically the same as above, except that the organ is split in the middle
line and the diseased half alone excised.

n. Regnoli-Billroth Operation. — Step i.— Pass a stout thread through the

tongue for purposes of traction.

Step 2. — Make an incision through the
skin and subcutaneous tissue from the
anterior margin of one masseter muscle to
the anterior margin of the other masseter.
This incision follows the lower edge of the
lower jaw (Fig. 259). Reflect the skin-flap
thus outlined. The submaxillary region now
lies exposed. If more room is desired, the
posterior ends of the original incision may
be extended backwards to the angles of
the lower jaw.

Fig. 259. — Regnoli-Billroth operation. Step 3. — With scissors or knife penetrate
{Esmarch and Ko'^'dzig.) ^^^ mouth from below upwards immediately

behind the symphysis. Be careful not to injure the periosteum. Separate
the structures composing the floor of the mouth from the lower jaw
as far back as the anterior pillars of the fauces. Any bleeding vessels are
caught up by forceps and either twisted or ligated. The tongue with its trac-
tion thread is pulled out through the sub-mental wound and its posterior
connections divided with scissors.

Step 4.— If there is hemorrhage from the stump and it is not easy to
locate the bleeding point, hook the forefinger into the pharynx and pull
forwards. This simple manoeuvre brings the whole stump within reach and
the hemorrhage is easily controlled by forceps or suture, A few sutures of
silk-worm-gut judiciously inserted lessen the extent of raw surface.

Step 5. — Put an iodoform gauze drain in place and close the remainder
of the wound with interrupted silkworm-gut sutures.

During this operation all affected or suspected lymphatic tissue must be
removed from the submaxillary region.

m. Sedillot's Operation. — In cases of Ungual cancer where the floor of the
mouth and the jaws are not affected, Kocher ("Operationslehre," fourth

sedillot's operation 163

edition) strongly advocates Sedillot's operation. The only disadvantage of
the procedure is that excision of affected or suspected lymph-glands, etc.,
if done at the same time as the primary operations, leaves too large and
irregular a wound, so that infection can scarcely be
avoided. Kocher recommends that the glands be
excised at a second operation. Supposing that the
disease affects the edge of the tongue posteriorly
and has spread to its base, to the anterior pillar of
the fauces, the soft palate, and the lateral wall of
the pharynx, the operation is carried out as follows:
Median division of the lower lip, chin, and skin
in submental region as far as the hyoid bone (Fig. . ^ nn^ v\\
260). Hemostasis. Division of the lower jaw in \

the middle line. Separation of the divided halves Fig. 260. — Excision of tongue.
of the jaw with sharp hooks. Median division of

the geniohyoid and genioglossal muscles. By means of a traction thread
pull the tongue out and towards the sound side. Divide the mucous mem-
brane of the floor of the mouth backwards at the margin of the tongue.
This exposes the lingual vein, running backwards and outwards over the
lateral surface of the hyoglossus; also the lingual nerve near the border of
the tongue, immediately under the mucous membrane. The hypoglossal
nerve is exposed at the outer surface of the hyoglossus, over which it runs in-
wards and forwards. Between the hyoglossus and genioglossus lies the lingual
artery, easily recognized and tied. Divide the hyoglossus with the cautery
(Kocher divides all the muscles around the tumor with the cautery). Put
great traction on the tongue and, using the cautery, divide the mucous mem-
brane posteriorly, along a line remote from the disease. If the disease extends
to the palate and pharynx, divide the styloglossus muscle, and with it the glosso-
pharyngeal nerve. After dividing the mucous membrane in front of the tonsil
it can be lifted up by blunt dissection, even when diseased, until the internal
pterygoid muscle is exposed. Divide, with the cautery, the soft palate so far
as it is diseased, and with it the tensor and levator palati muscles. Now divide
the mucous membrane on the posterior wall of the pharynx as far as the longus
colli muscle and forwards to the base of the tongue. All this can be done under
full guidance of the eye. Lastly, with the cautery, divide the tongue itself,
remote from the disease, and sever its nerves, muscles, and vessels (after apply-
ing ligatures), or such of these as penetrate the neoplasm. Preserve as many
nerves and muscles as possible so as to interfere with deglutition to the minimal
extent. Ability to swallow is the greatest preventive against subsequent
pneumonia. Rub the wound with a small amount of xeroform. Wire the
divided jaw. Do not elevate the periosteum when drilling the bone. Close the
wound in the soft parts, providing for gauze drainage immediately in front of
the hyoid bone. If the patient is placed in the Trendelenburg position, the
operation can be done under a general anesthetic without any preHminary
tracheotomy. The operation is suitable for all cases except those in which the
jaw is affected.

164

TONGUE

After-treatment. — Until the patient is able to sit up, he should be kept in
Trendelenburg's position. On the day following the operation he should try
to sit up and attempt to swallow tea or wine with water. Nourishment must
be administered through an esophageal tube.

IV. Von Langenbeck's method of excising the tongue is very similar to
that of Sedillot, and thus requires no special description, except as regards the
incision. On the side corresponding to the disease make an incision from
the corner of the mouth vertically downwards to the border of the lower jaw,
and continue it downwards to the side of the hyoid bone (Fig. 260). The
upper portion of the cut divides the lower lip and gum, penetrating to and
exposing the lower jaw; the lower or submental portion at first penetrates only
the skin and superficial fascia. Through the lower part of the incision excise
all suspected glands (lymphatic and salivary) and ligate the lingual artery.
Divide the jaw along the line of incision after boring holes for subsequent
wiring. With strong hooks separate the segments of the jaw. The tongue
and floor of the mouth are well exposed by this procedure and can be dealt with
according to the principles already laid down.

V. Kocher's Method. — In certain cases of
extensive carcinoma, and always when the disease
involves the lower jaw, Kocher advises the following
operation:

Step I. — Put the patient in Trendelenburg's posi-
tion. Pass a stout thread through the tongue for
purposes of traction.

Step 2. — Beginning immediately below the sym-
physis of the lower jaw, make an incision downwards
to a point a little above the hyoid bone; from here cut
backwards to the anterior margin of the sterno-
mastoid. Once more change the direction of the incision and continue
it upwards along the margin of the sternomastoid to a point near the level
of the lobe of the ear (Fig. 261).

Step 3. — Reflect upwards the skin-flap thus outlined.
Step 4. — Excise, en masse if possible, all the enlarged glands under the upper
end of the sternomastoid and under the angle and horizontal ramus of the jaw.
Carefully dissect free the anterior border of the sternomastoid, exposing the
carotid packet of vessels and the great horn of the hyoid. Excise the glands
in this region.

Step 5. — If the cancer affects the floor of the mouth, the fauces, or
jaw, it is wise to ligate the facial vein and the external carotid artery.

Step 6. — Expose clearly the anterior belly of the digastric through its whole
length, and ligate the veins under it. From below upwards dissect free
the packet of glands exposed until the entire posterior belly of the digastric
and the stylohyoid muscles lie free in the posterior inferior part of the wound.
Detach the mass of glands (lymphatic and salivary) from the lower jaw.

Step 7. — At the posterior end of the great horn of the hyoid divide the in-
sertion of the hyoglossus muscle. This exposes the lingual artery. Tie the
artery, but preserve the hypoglossal nerve.

Fig. 261. — Kocher's
operation.

butlin's operation 165

Step 8. — The lower surface of the mylohyoid muscle now lies exposed and
on it the mylohyoid nerve. At the posterior margin of the muscle penetrate
the mouth (guided by a finger in the mouth) after once more noting the
extent and limits of the disease. Beginning at this opening, divide the oral
mucous membrane along a line remote from the disease. Attend to
hemostasis.

Step g. — Divide the lingual muscles at the hyoid and remove all infiltrated
tissue. It is easy to pull the tongue out through the wound as soon as the
oral mucous membrane has been divided.

If a preliminary tracheotomy has been done, the entrances to the larynx
should be packed with sterile gauze as soon as the pharynx is opened.

_ After-treatment. — 'Leave the lower part of the wound open so that the laryn-
geal pack may be changed frequently. Every time the dressings are changed
(and this must be done very frequently) administer plenty of nutritious food
by means of an esophageal tube. As long as the mechanism of deglutition is
seriously disturbed keep the patient in more or less of the Trendelenburg
position except when he stands or sits up. As long as deglutition is poor the
patient must not lie horizontally; he must either sit up or lie with his head and
shoulders low. The object of this care is, of course, to avoid pneumonia from
the entrance of secretions into the air passages.

The question as to whether the last-mentioned operation should or should
not be preceded by a tracheotomy is much discussed. Kocher and Jacobson
are strong advocates of this as a preliminary.

The advantages of tracheotomy are the possibility of easy anesthetization;
of plugging the pharynx with gauze, thus avoiding inspiration of blood, and
of greater freedom in operating.

Butlin advocates preliminary laryngotomy as a safe and convenient sub-
stitute for tracheotomy.

When removal of the whole base of the tongue is not necessary Crile passes
closely fitting rubber tubes through the nares into the pharynx, to a point
opposite the epiglottis, pulls the tongue well forwards and then closely packs
the pharynx with gauze. The two tubes after emerging from the anterior
nares are connected by a Y, of glass or metal, to a single tube and through
this the anesthetic is administered.

The opponents of preliminary tracheotomy believe that this operation,
while decreasing the danger of pneumonia from inspiration of blood, yet makes
the patient subject to a greater danger of contracting pneumonia from other
causes. If tracheotomy is decided on, it should be performed several days
before the tongue is attacked, to permit the patient to become accustomed to
the new conditions of respiration before his powers are taxed by the very
severe operation he is to undergo.

VI. Butlin's Method.* — (A) The disease does not involve the floor of the
mouth.

Perform a preliminary laryngotomy (p. 232).

Pack the pharynx to prevent blood gravitating into the larynx.

Step I. — By Whitehead's method or some modification thereof, remove the

*Butlin, "Op Surg. Malignant Dis.," second, ed., "Brit. Med. Jour.," Feb. 15, 1905.

1 66

TONGVE

local disease with ^i inch of apparently healthy tissues around it in every
direction. Where the disease is on the border of the tongue, it is best to remove
that half of the tongue to an inch behind the cancer.

After about nine days, when the patient is able to take plenty of liquid food,
proceed to Step 2.

Step 2. — Make an incision along the anterior border of the sternomastoid
from near the mastoid process to the sternoclavicular articulation. Make an
incision from the symphysis menii to meet the previous incision, just above
the thyroid cartilage. Reflect the two triangular flaps of skin thus outlined
and expose the platysma myoides and fat of the anterior triangle of the neck.

Step 3. — Beginning below, expose the sternomastoid and retract it back-
wards. Expose the carotid packet of vessels, dissecting from below upwards,
and separate from it every particle of fat, whether superficial or deep, anterior

Fig. 262. — Butlin's method for excision of the tongue.
Sketch indicating the position of the most important lymph nodes, all of which are supposed to have been
dissected out and removed, i. Location of submental group lymph nodes. 2. Location of submaxillary
group lymph nodes. 3. Location of parotid group lymph nodes. 4. Location of carotid group lymph
nodes.

or posterior. Be careful to remove the fat between the parotid and the vessels.
All this fat ought to be left attached to that of the rest of the anterior triangle,
otherwise the operation is liable to be incomplete (Fig. 262). Working from
the region of danger (carotid packet) and from below upwards, remove en
masse all the fat in the anterior triangle and with it the submaxillary salivary
gland, leaving the muscles quite bare. In the submental region complete the
dissection by searching between the geniohyoid muscles, lest a gland be over-
looked.

If the disease involves the contents of the carotid packet, these must also
be removed. The internal jugular vein more often requires removal than does
the carotid artery.

Step 4. — Place one strip of gauze in the submaxillary triangle beneath
the jaw and another between the parotid and the vessels. Bring the ends of

butlin's results 167

the gauze out at the lowest part of the wound. Provide tubular drainage also.
Close the wound. Damage to the parotid will permit a leakage of saliva, but
this ceases in a few days.

The principles of Butlin's operation are: (i) Operation in two stages is
much safer than in one. (2) The glands are involved very early in lingual
cancer, but the lymphatic vessels between the primary lesion and the secondary
seem to escape.

Mr. Butlin's results have been so remarkable that no apology is necessary
for reproducing the statistics of seventy cases in which he was permitted to
complete the operation in the manner he advocates. A study of Butlin's
specimens and drawings gives great encouragement in the treatment of cancer
of the tongue even when apparently advanced:

Analysis of seventy cases in which the contents of the anterior triangle
were removed:

Died of the operation 6

Lost sight of after operation i

Died of recurrence in the mouth 9

Died of recurrence, uncertain where (in one of these the glands could not be entirely re-
moved ; operation abandoned) 7

Died of recurrence in the glands (in one of these the submaxillary salivary gland was
left, and the disease recurred beneath it; in the other seven cases the glands were
enlarged at the time of their removal, and in five of these they were demonstrably

cancerous) 8

Died of cancer on the opposite side of the tongue i

Died of affection of glands on opposite side of neck 2

Died of other disease within three years i

Cases not countable (operation too recent) 11

Successful cases, , 24

Total 70

The successful cases are calculated on the seventy cases, after deducting
cases not countable (11), the patient who died within three years of another
disease (i), and the patient who was not traced after the operation (i), leaving
fifty-seven cases, with twenty-four successful cases = 42.01 per cent.

The age of the patients operated on showed that ten of them were over 65
years of age, and one over 70 years (77).

The causes of death from operation were:

Hemorrhage, etc. (both from mouth and neck in a badly alcoholic patient) i

Suffocation (from the sudden falling back of the root of the tongue some days after

operation) i

Septic pneumonia 4

Total 6

(B) The disease involves the floor of the mouth to such an extent that the
intrabuccal operation is impossible.

Remove the tongue by any of the methods abeady described, and according
to the condition of the patient remove the glands of the neck either at the same
or at a subsequent seance.

1 68

TONGUE

Whatever operation is chosen for removal of lingual cancer, it is always
of prime importance to remove en masse the whole of the related lymphatic
territory, even if the primary lesion appear trivial and the lymphatics show
no macroscopic involvement.

Crile ("Journ. Am. Med. Assoc," Dec. i, 1906) reports remarkably
favorable results from an operation similar to, but more extensive than Butlin's.

^^■i

^1^1

c m

/JIM

w^ " ^

.*L..
c

k.mi

Fig. 263. — [Crile.)
The entire mass of lymphatic gland bearing tissue is excised en bloc, and handled as little as possible
This dissection becomes easy when followed in the deep plane. The entire block of tissue is finally divided
above, including the vein. A, splenius. B, hypoglossus descendens. C, spinal accessory. D, elevator
ang. scapuii. E, pneumogastric. F. scalenus posticus. G, internal jugular. H. facial vein and artery .
I, submental. J, submaxillary. K, digastric. L, mylohyoid. M, sternohyoid. N, omohyoid. O,
thyroid gland. P, thyrohyoid. Q. carotid.

When lymph nodes are palpably enlarged, further metastasis is sure to be
irregular, therefore Crile removes the whole lymphatic-bearing tissue on the
affected side; when there are no palpably enlarged glands he only removes the
lymphatics next in order.

In operating on the former class of cases Crile temporarily compresses
the common carotid with his special clamp, doubly ligates and divides the
internal jugular vein low down in the neck and excises the vein along with
the lymphatic tissues, and the muscles of that side of the neck (Fig. 263).

maitland's operation 169

George E. Armstrong performs what is practically the Eutlin operation.
He begins by exposing the cervical lymphatic territory on both sides of the
neck, ligating both external carotid arteries and excising the lymphatics exactly
as does Butlin. After providing for drainage and closing the large cervical
wounds he immediately proceeds to excise the tongue. When only one lateral
half of the tongue is removed he finds it very advantageous to stitch the re-
maining half to the floor of the mouth. In this way nearly all the raw surfaces
are covered.

Vn. Maitland's Operation.— Maitland ("The Australasian Med. Gazette,"
Oct. 20, 1906, describes a thorough operation which has given him much satis-
faction and which he practises in all except very early and very late cases. Fig.
264 shows Maitland's incisions. The following paragraphs are copied from
the article to which reference has been made.

^^ Dissection of the Digastric Triangle. — A clean dissection is then made of
this triangle, beginning at the point of the chin and working outwards and
upwards, paying particular attention to the spaces between the outer edge of
the mylohyoid and the hyoglossus, as glands are easily overlooked in these
situations. The anterior layer of the outer portion of the deep cervical fascia,
which here forms a compartment for the submaxillary gland, is opened, the
glands pulled forwards, the facial artery tied and divided, the common facial
and anterior division of the temporo-maxillary veins having been previously
tied and divided. The dissection of this anterior portion of the digastric
triangle is then completed by carrying the dissection well up over the body of
the mandible, so as to remove the lower of the facial glands. That portion of
the digastric triangle posterior to the stylo-maxillary ligament containing the
parotid is next cleared and the lower portion of the parotid is removed. This
dissection is carried sufficiently deep to remove the deep parotid glands; this
step has been insisted on by Butlin. I have regularly carried it out for some
years.

^'Division of the Sternomastoid. — Before this step in. the operation is per-
formed the dissection of the anterior triangle is begun from before backwards
till the anterior border of the sternomastoid is reached. The muscle is then
divided at the level of the omohyoid, the lower portion being turned down.

^^ Dissection of the Anterior and Posterior Triangles. — The dissection of these
two triangles is then proceeded with from below upwards, cleaning all the
fascia off the vessels. The dissection is carried on right up beneath the parotid,
the dissection being completed by removing the sternomastoid muscle at its
insertion, together with the contents of the anterior and posterior triangles.
By this means the whole of the deep descending cervical chain of glands is
removed.

"Removal of Internal Jugular Vein. — This is done as the last step of the
operation; if it be done earlier in the operation much valuable time is lost in
stopping venous hemorrhage. I am firmly of opinion that only by removing
the sternomastoid muscle can the deep cervical chair of glands be thoroughly
removed. The internal jugular vein I do not always remove, as with the
removal of the sternomastoid muscle, as I suggest, the vein can be more thor-
oughly cleared both on its anterior and posterior aspects.

170

TONGUE

"r/te Effect of Removal of the Sternomastoid Muscle. — All the mo\-ements
of the head are, as I show you from these cases, thoroughly carried out by the
post-rotators, and the removal of the muscle practically in no wise interferes
with the head movements. The text-books advise preservation of the muscle,
because of the supposed interference with the movements of the head; but this
view I know to be erroneous.

"77/e Division of the Spinal Accessory. — This is done in nearly every case,
and only in two instances have I seen drooping of the shoulders; the third and
fourth cervical are sufficient to preserve the function of the muscle. "

VIII. A. P. C. Ashhurst's operation is sufficiently described by illustrations
264, 265 and 266 (Annals of Surg., Aug., 1915).

Fig. 264. — Maitland. {Australasian Med. Gaz.)

IX. Spischamy's Suprahyoid Operation. (Archiv flir klin. Chir., xcii,
p. 121 2). — Step I.— Make a transverse incision above the hyoid bone from one
sternomastoid to the other. If necessary enlarge the wound b)/ longitudinal
incisions along the sternomastoid muscle. Remove the lymphatic glands
and with them the submaxillary salivary glands, if the floor of the mouth is
affected. Ligate and divide both lingual arteries. Divide both hypoglossal
nerves.

Step 2. — Separate the root of the tongue from the hyoid bone and open the
pharynx in the angle between the tongue and the epiglottis (Fig, 267). All
the diseased structures (even, if required, the tonsils, pillars of the fauces and
floor of the mouth) can now be isolated under guidance of the eye.

Step 3. — Open the mouth and through it divide the anterior attachments
of the tongue. Remove the tongue.

Step 4. — Suture together the remnants of muscles attached to the chin and
the hyoid bone. Carefully reunite the digastric muscles to the hyoid. Close
the wound leaving a narrow canal to the pharynx for purposes of drainage.

Pass a soft oesophageal catheter through the nose into the oesophagus to
permit feeding during the first few days.

Spischarny states that preliminary tracheotomy is unnecessary if the opera-
tion is performed in Rose's position.

X. Vallas' Transhyoid Operation. — When cancer is limited to the base of
the tongue near the epiglottis, or when it affects the epiglottis, Vallas' operation
of transhyoid pharyngotomy gives good access to the parts. This operation is

FXCISION TONGUE

171

Fig. 266. — After removal of tongue, floor of mouth is covered partially by suturing mucosa
of cheek across alveolus to stump of tongue. A hemostat is on the right lingual artery in the
floor of the mouth. {Ashhurst, Annals of Surgery.)

Fig. 267.

172

TONGUE

also suitable for the removal of foreign bodies and the treatment of sj^ihiHtic
strictures. Preliminary tracheotomy is not essential.

The Operation. Step i. — Make a median incision through the skin and
subcutaneous tissue from the symphysis of the lower jaw to the superior angle
of the thyroid cartilage.

Step 2. — With blunt or sharp dissection separate, in the middle line, the
fibres of the mylohyoid muscles in such fashion as to expose the upper border
of the hyoid bone in the median line.

Step 3. — With scissors or bone forceps divide the hyoid bone in the middle
line. Retract the halves of the bone along with the fibres of the mylohyoid
muscle. This gives us a space i3^ inches in width.

Step 4. — The lower part of the wound is separated from the phar>'n.x by the
thyrohyoid membrane, the upper part by the mucosa. To reach the pharynx,
divide the thyrohyoid membrane; to reach the base of the tongue or floor of the
mouth, cut upwards. Access has now been gained to the seat of the disease.
It is unnecessary here to describe over again the removal of the neoplasm;
it must be done freely on the principles already enunciated. Having completed
the excision, close the wound, pro\'iding drainage at its lower end. No special
suture of the hyoid is required.

XI. Abadie's Operation. — The carcinoma afiFects the floor of the mouth
superficially — has spread to the tongue and to the alveolar mucosa anteriorly

Fig. 268. — {Journ. de Chir.)

the muscles of the floor of the mouth are not involved. Abadie's operation
may be valuable ("Arch, provinciales de Chir.," xx, 725; Ref. "Journ. de Chir.,"
April, 191 2). Fig. 268 shows diagrammatically a case suitable for the operation
and the lines of incision.

Step I. — Make an incision along the lower border of the inferior maxilla
from one masseter to the other. Dissect upwards so as to separate all the soft
parts from the front of the jaw until the mouth is freely opened along the line
of reflection of the mucosa from the jaw to the lips. Reflect upwards as a visor
the flap thus formed.

Step 2. — According to the extent of the lesion select the two extreme points
of the line of section of the bone (A and B, Fig. 269). At these points perforate

PAROTID TUMORS

173

the bone with a drill. With an amputation saw divide the bone along the line
AB. Pass a Gigli saw through the perforation at B and divide the alveolus
along the line BC. Do the same at perforation A.

Step 3. — Seize the mobilized segment of bone with lion-jawed forceps and
pull it upwards and forwards. With scissors cutting horizontally from before
backwards, dissect up the disease on the floor of the mouth, then cutting up-
wards and forwards excise the disease from the tongue along the lines shown in'
Fig. 268. Attend to hemostasis.

Fig. 269. — {Journ. de Chir.)

Step 4. — Close the wound in the tongue with sutures. Unite the mucosa of
the tongue to that of the lip. Replace the visor-shaped flap of lip and suture
the skin wound after providing for drainage. Before, during, or after Abadie's.
operation, the lymphatic territory ought, of course, to be cleared of its glands
and fat as in any other operation for cancer of the tongue.

CHAPTER XVII

PAROTID GLAND

From the standpoint of operative surgery tumors of the parotid may be
divided into two classes:

1. Those which are encapsulated inside the gland. This encapsulation
may not be perfect, but there is no general infiltration of the gland by the disease.
Such tumors are the adenomata and the mixed tumors of feeble malignancy.

2. Those tumors which filtrate the gland substance. Such are the sar-
comata and carcinomata.

The principles of operation which may be applied to both classes of tumors
alike are: (a) early operation; {h) free exposure of the growth by suitable
incisions; (c) careful hemostasis.

174

PAROTID GLANU

When the tumor is one of those encapsulated within the gland, it should,
if possible, be enucleated with its capsule, leaving the gland as little injured
as is practicable. When the capsule cannot be removed with the growth, it
should be removed afterwards as thoroughly as circumstances permit. The
facial nerve must be preserved. An incomplete operation often gives good
results, but completeness must always be the aim. When the tumor is of the
infiltrating type, the whole, gland with its fascial coverings or capsule must be
removed, and with it any adherent skin. Little attention may be given to the
facial nerve; its destruction is almost certain. T. Carwardine and Gunn have
each preserved the facial nerve in such operations. The necessary dissection
must take very much time and in feeble patients this constitutes no mean
risk. As in the case of cancers located elsewhere, too much rather than too
little must be done. If the surgeon believes that the whole growth cannot
be removed, it is better to abstain from operation. An incomplete operation
is worse than useless.

I. Enucleation of Parotid Tumors. — (A) The tumor is small, mobile
and apparently easily removed: Make a horizontal incision over the promi-
nent portion of the growth, parallel to the course of the fibres of the facial nerve
and of length sufficient to permit of removal of the tumor under guidance of
the eye and without bruising of the wound. Incise the gland substance so as
to expose the tumor, which must now be shelled out. Attend to hemostasis;
in doing this, suture-ligatures involving the gland substance should be avoided,
as they are liable to constrict branches of the facial nerve and salivary ducts.
Close the wound with or without drainage.

(B) The tumor is not large and not suitable for the simple procedure de-
scribed above:

Step I. — Beginning at the tip of the mastoid process, make an incision
downwards along the anterior edge of the sternomastoid, to the level of the
angle of the lower jaw; from this point cut forwards and upwards, in a curve,
over the ascending tamus of the jaw, until a flap is outlined which when elevated
will expose most of the tumor. The flap consists of skin and superficial fascia
alone; no deeper structures must be involved because of the facial nerve.

Step 2. — The growth of the tumor inevitably pushes aside and spreads
out the glandular tissue in which it lies. Examine the exposed surface for
that part least covered by glandular tissue. The tumor capsule will generally
be seen at once; if not, expose it by dividing horizontally any overlying glandular
substance. If the capsule is strong, proceed to do an extracapsular enucleation
by blunt dissection. Any bands of tissue passing to the capsule from its sur-
rounding must be doubly ligated and divided. First free the anterior border
of the tumor, then the posterior, and dissect free its deep surface /^-ow below
upwards so as to gain early control of the vascular supply. Proceeding in this
fashion, it is often possible to enucleate the tumor en masse, but often enough
some deeply seated fragments are left behind; such must now be removed
individually.

If the capsule is weak and the tumor soft, extracapsular enucleation is im-
possible. Under these circumstances freely incise the capsule, clean out its
contents, and remove the capsule bit by bit as thoroughly as possible. This

EXCISION PAROTID I 75

apparently very imperfect operation often gives excellent results. With re-
gard to enchondromata of the salivary glands Jacobson writes: "It is not
uncommon for branches of the facial nerve to be in relation with the capsule of
the tumor, and if this had been much handled, or treated by counter-irritation,
they may very likely be firmly adherent. In either case injury to the nerve may
be best avoided by slitting up the capsule and shelling out the enchondroma
first. The capsule should then be examined to see if any nerve branches are
adherent to it; after these have been separated, the capsule itself should be
removed. This should always be done to prevent any recurrence, as the
peripheral part of these enchondromata is often adherent to the capsule
itself.'' (''Operations of Surgery," i, 340.)

Step 3. — Attend to hemostasis. Close the wound by sutures. Drain dead
spaces. Dress.

II. Excision of the Parotid.- — Excision of the parotid is necessary in cases
of malignant neoplasms, such as carcinoma or sarcoma. As these tumors are
infiltrating in character, enucleation is impossible and
useless; the whole gland must be removed, whether
evidently affected or not.

Step I. — Make a h- -shaped incision (Fig. 270) of
sufl&cient extent, through the skin. Reflect the skin so
as to expose all the parotid covered by its fascia.

Step 2. — Mobilize the anterior edge of the gland
and tumor. Doubly ligate and divide the vessels
situated here and Steno's duct. Forceps may be used
instead of ligatures during the dissection. Separate the
gland from the masseter, working from before backwards. Fig. 270. — Excision of
doubly ligating all vessels before dividing them. P^^° ^

Step 3. — Separate the lower edge of the gland (submaxillary portion) from
its surroundings by blunt dissection, doubly ligating and dividing the vessels.
Step 4. — Expose the upper end of the anterior portion of the sternomastoid,
open its sheath, and retract the muscle backwards. That portion of the
sheath adherent to the fascia covering the parotid must be removed with the
tumor.

Step 5. — By blunt dissection, working from below upwards and elevating the
lower edge of the gland, expose the external carotid artery as it passes under the
stylohyoid and digastric muscles. Doubly tie and divide the artery. Mobilize
the tumor and gland up to the level of the styloid process.

Step 6. — Separate by blunt dissection all connections between the tumor and
the temporo-maxillary joint. Ligate and divide the temporal vessels at the
level of the zygoma.

Step 7. — Pull the gland, etc., backwards, expose the numerous veins which
run along with the internal maxillary artery, from behind the neck of the
lower jaw into the gland. Doubly ligate this leash of vessels and divide them.
Step 8.— Separate by blunt dissection the posterior and pharyngeal con-
nections of the gland, doubly ligating or clamping all vessels before dividing
them. In making this last dissection be on the lookout for and avoid
injury to the internal jugular vein.

176

PAROTID GLAND

Step 9. — Attend to hemostasis. Close the wound with sutures after
providing for drainage.

Any enlarged lymphatic glands near the parotid ought to be removed
along with the tumor. The operation is a difficult one, and ought not to be
attempted by the inexperienced.

Zarraga's Method. ("Journ. de Chir.," Sept., 1912). — i. From the tip of
the mastoid make an incision downwards along the anterior edge of the sterno-
mastoid to a point a little below the angle of the lower jaw. Continue the
incision forwards immediately below and parallel to the lower jaw until the
anterior border of the masseter is reached. Continue the incision upwards
along the anterior edge of the masseter to terminate on the zygoma.

Fig. 271. — (Jojini. de Chir.)

2. Reflect upwards the skin flap thus outlined. This exposes the sterno-
mastoid, the facial nerve, the parotid, the masseter and the lower jaw in front
of it, the facial artery, the zygoma.

3. With elevator and knife bare the bone of the lower jaw just in front of
the masseter and divide it with Gigli's saw. Divide the masseter at its zygo-
matic insertion. Divide Steno's duct.

4. Grasp the ascending ramus of the jaw with lion-jawed forceps and dis-
locate it outwards and backwards, at the same time dividing the internal
pterygoid muscle, ligating the inferior dental vessels and dividing the tendon
of the temporal muscle (Fig. 271).

5. Ligate the external carotid immediately before it enters the parotid;
ligate the internal maxillary as it passes behind the condyle of the inferior
maxilla. Ligate the superficial temporal and the posterior auricular arteries.

SALIVARY FISTULA 177

6. Remove the gland and the ascending ramus of the jaw together. One
at this time can see if the pharyngeal prolongation of the parotid is adherent
to the carotid packet and if necessary separate the adhesions.

Salivary Fistula.— A salivary fistula most commonly results from disease or
injury of Steno's duct. In some cases a stricture is present distal to the fistula
and if this is dilated, the fistula either closes spontaneously or after its orifice
has been stimulated by the cautery or revivified and sutured. When the above
simple treatment is inappropriate or has failed, operation becomes necessary.

I. The fistula is anterior to the masseter muscle.

(A) Von Langenbeck's Operation. — Make the proximal portion of the duct
(i.e., the segment of duct next to the parotid gland) prominent by passing a
probe into it, through the fistula. With a knife or scissors separate the fistula,
and duct from their surroundings, leaving them attached to the gland. In a
convenient location pass the knife from the wound into the mouth, perforating
the buccal mucosa. Pull the free end of the mobilized duct into the mouth
through the perforation in the mucosa and fix it there with sutures. Close the
external wound. When applicable, the above is the best operation for salivary
fistula, but unfortunately it is not often available, as the unnatural orifice is
usually far back near the origin of Steno's duct behind the anterior margin of the
masseter.

(B) Degiiise^s Operation. — From the fistula make two perforations into the
mouth, about }4. inch apart. Through these openings pass the two ends of an
elastic ligature, a piece of lead wire, or a stout silk suture. Fasten together
the ends of the ligature in the mouth so as to exercise pressure on the included

ft.

Figs. 272 and 273. — Deguise's operation.

tissues. Necrosis of the tissues follows and a permanent opening into the
mouth, is assured. Freshen the edges of the cutaneous fistula and unite them
by sutures. The elastic ligature or lead wire may best be introduced through a
cannula which is made to perforate the cheek from within outwards (Figs. 272,
273). A silk suture is best inserted from without inwards by means of a needle
at each end.

(C) Kaufmann's Operation. — Pass a cannula (about J4 inch in diameter)
from the fistula into the mouth and through it introduce a rubber tube or seton.
Remove the cannula, leaving the seton in place. Whenever the track of the
seton has become covered with epithelium, remove the seton and close the
cutaneous orifice of the fistula.

11. The fistula is situated in the masseteric portion of Steno's duct.
12

178

PAKOTID GLAND

(A) Either Kaufmann's seton or Deguise's method of double puncture may
be used, but neither the seton nor the constricting ligature must j)erforate the
masseter. The puncture or punctures must pass from the lisUila to the mouth
by tunnelling between the masseter and the skin.

(B) Von Langenbeck's method may be used if a sufficient length of duct
remains attached to the gland. In this method it is necessary to puncture the

masseter and pull the mobilized portion of duct through
the puncture into the mouth. Instead of being punc-
tured, the masseter may be divided transversely, and
if necessary a portion of the ascending ramus of the
lower jaw may be cut away with rongeurs so that the
defective duct may gain access to the mouth.

(C) Plastic formation of a new duct (Braun's opera-
tion): Make the incision A, B (Fig. 274). Mobilize the
fistulous orifice by dissecting it free from the skin.
The incision penetrates all the tissues of the cheek except the mucosa and
masseter. Retract the edges of the wound, exposing the outer surface of
the mucosa (Fig. 275). From the mucosa construct a flap with its pedicle at
the edge of the masseter, of length sufficient to reach from the masseteric edge

^'^r,

*/^

Fig 274. — Braun's
operation.

275. — Braun's operation.

to the fistula. Turn this flap back over the masseter; suture its free end to the
fistula; suture its upper and lower edges together so as to form a tube lined with
epithelium (Fig. 276). Close the skin-wound.

(D) Grouse's Operation. — This operation is very similar to that of Braun
but is simpler and of wider application.

270.

Step I. — Make a 3 cm. (i34 in.) incision through the skin and fat straight
downwards from a point 2 cm. below the zygoma and 2 cm. in front of the ear.
This avoids injury to nerves and vessels. Expose the fascia covering the parotid
and make a i cm. incision in it.

CROUSE S OPERATION

179

Fig. 277. — {Croiise, ^arg., Gyn. & Ubsl.)

Fig. 278. — {Crouse, Surg., Gyn. b" Ohsl.)

l8o PAROTID GLAND

Step 2. — Grasp the lip, turn the cheek out and reflect a flap of mucosa, about
]/i inch wide and thick enough (^g in.?) to be reHably viable, beginning near
the vermilion line of the upper lip and running back to slightly behind the
level of the second upper molar. The pedicle of this flap is posterior.

Step 3. — Introduce a curved hemostat through the external incision on the
cheek and pass it forwards hugging the surface of the masseter and force it into
the mouth just in front of the pedicle of the intra-oral flap (Fig. 277). Open the
forceps and dilate the tunnel. Grasp the end of the flap in the forceps and pull
it through the tunnel. Pass a No. o chromic gut suture in the Lembert fashion
through the mucous surface of the flap near its free end (Fig. 278) and through
the posterior edge of the incision in the parotid fascia. Tie the suture but leave
its ends long. Pass a fine forceps from the external wound through the tunnel
into the mouth and catch with it the middle of a ligature of No. 5 chromic gut.
Pull this thread through the wound and tie the long ends of the fine suture to
its loop leaving the long ends of the coarse ligature in the mouth. The mucosal
flap assumes a tubular form around the coarse ligature. Close the external
wound. Grouse has used his operation five times with success (Surg., Gnti.
and Obst., May, 191 5).

Anastomosis between the Parotid and Submaxillary Glands. — In cases in
which lesions of Steno's duct seriously interfere with excretion from the parotid
Ferrarini (Zent. f. Ghir., 13, June, 19 14) has shown the possibility of estabhshing
drainage through a parotid-submaxillary anastomosis.

Expose the submaxillary gland by an incision parallel to and below the
horizontal ramus of the lower jaw. Continue the incision back to, and around
the angle of the jaw so as to freely expose the lower part of the parotid. Open
the capsule of, and mobilize bluntly, the submaxillary gland. Isolate and
mobilize the lower end of the parotid behind the angle of the jaw. Make
incisions in or pare off corresponding portions of the two glands and suture the
raw surface of one gland to the raw surface of the other. Close the external
wound. This operation has been an experimental success but has not been
used clinically.

lanni (Internat. Abst. of Surg., ^lay, 1919) advises Leriche's resection of
the auriculotemporal nerve to prevent secretion from the Parotid in old cases
of fistula where plastic operation is improper. After the auriculotemporal
nerve has passed around the posterior surface of the neck of the lower jaw it
enters the substance of the upper part of the parotid and passes upwards in
front of the auditory meatus behind the temporal arterj^ and vein "in a fibrous
sheath which renders its exposure difficult and its isolation troublesome'*
(Poirier and Charpy). In this part of its course besides supplying branches
to the gland it gives off branches which anastomose with the superior terminal
branches of the facial nerve.

The Operation. — Beginning at the Zygoma make a vertical incision 3 cm.
(i^^ in.) long immediately in front of the tragus, and so expose the temporal
artery. Note the extra-glandular portion of the nerve parallel to and behind
the artery. Follow the nerve downwards into and through the gland tissue.
When it is fully isolated, the portion of the nerve trunk freed from its surround-
ings is about 4.5 cm. (1% in.) long and the small secretory branches which

INTRANASAL TUMORS l8l

Stimulate the gland are visible. Evulse the central end of the nerve. Secretion
ccmtinues for some days after operation.

Olivier (Lyon Chir., XVI, No. 2) had perfect results in three cases. He
writes that the operation is easy but that the resection must be extensive enough
to get all the parotid branches. These branches leave the nerve trunk
behind and a little internal to the neck of the condyle so that the dissection
must be deej).

CHAPTER XVIII

OPERATIONS UPON THE NOSE
EXCISION OF INTRANASAL MALIGNANT TUMORS

DENKER'S TRANSM AXILLARY METHOD*

Step I . — With blunt hooks pull the angle of the mouth and the upper lip
upwards and outwards. Beginning opposite the wisdom tooth on the affected
side make an incision through the gum of the upper jaw to a point near the
frenum of the upper lip. The incision should be slightly curved upwards. With
an elevator separate the soft parts from the upper jaw until that bone is exposed
nearly to the lower margin of the orbit and the pyriform aperture of the nose
is laid bare.

Step 2. — With a fine elevator or dissector, beginning at the pyriform aper-
ture, separate the mucous membrane from the outer wall of the lower and mid-
dle sinuses of the nose and partly from the floor of the nose. Continue this
separation backwards to the posterior limits of the antrum of Highmore. If
the lower turbinated bone is not involved in the tumor, remove it with strong
scissors. Temporarily pack with gauze for hemostasis.

Step 3. — With chisel and rongeur remove the external bony wall of the
antrum of Highmore. If the mucosa lining the interior surface of this wall is
healthy incise it freely so as to gain free access to the sinus; if it is involved in
the growth, extirpate it with the growth. With chisel and rongeur remove
completely the inner or nasal wall of the antrum, both the bone and the mucosa.

Step 4. — With scissors or probe-pointed knife remove the mucosa of the
outer wall of the nose (already separated in Step 2). If the tumor has arisen
from the middle sinus of the nose it generally will come away with the nasal
mucous membrane. Free access is now attained to the ethmoidal and sphe-
noidal sinuses which can be treated according to circumstances.

Step 5. — Pack the wound with gauze. Suture the oral wound. Keep the
mouth clean with washes. Remove the pack after three or four days.

The above operation is not suitable for cases of tumors arising from the
nasopharynx, retro-maxillary or pterygo-palatine fossae.

* "Aliinchener med. Wochenschrift," 1906, No. 20.

182

OPERATIONS UPON THE NOSE

RHINOPHYMA (ACNK HYPKRTROPHICA)

This deforming disease must be treated by ojjeration. If the tumors are
pedunculated their removal requires no special description, if they are extensive
and non-pedunculated proceed as follows:

Give a general anesthetic.

Step I. — Through the anterior nares introduce gauze strips and so plug the
posterior two-thirds of the nose, leaving the anterior portion free. This pre-
vents the inflow of blood. Plugging of the posterior nares will do as well.

Step 2. — Put the forefinger of the left hand into one nostril as a guide.
Make an incision down to but not into the cartilage, all round the growth from
the middle line outwards (Fig. 279).

Be sure to leave as much skin as possible near the opening of the nares to
avoid subsequent stricture.

js:
Figs. 279 and 280.

-Rhinophyma. (Laurens.)

Step 3, — Seize the median edge of the tumor mass with forceps and entrust
these to the assistant (Fig. 280). With knife or scissors shave off all the dis-
eased tissues within the circle of the incision. Attend to hemostasis with
forceps, ligature, pressure with hot pads or the thermo-cautery.

Step 4. — Repeat Steps 3 and 4 on the opposite side.

Step 5. — Remove the nasal plugs. Introduce short drainage tubes into
each nostril. Cover the wounds with rubber tissue, perforated oiled silk or
silver foil. Apply compressive dressings. Field (Journ. A. M. A., June 14,
1919) operates in two sittings — excising first one-half and later the other. He
uses skin grafts. The results in time are very good. Skin grafting is rarely
necessary. Major Seelig heartily condemns skin grafts as unnecessary and
the cause of subsequent disfigurement. He urges that the redundant tissue
be not shaved off too deeply, otherwise all sebaceous gland rests are removed
and no nidusus of epithelium left for formation of new skin.

Angioma of Nose. — Angiomata of the nose are not uncommon and may
require no treatment. Often, however, they are so disfiguring as to pre-
vent their possessors from earning a livelihood.

EPITHELIOMA NOSE

183

When small, angiomata may be treated by freezing (liquid air, carbon-
dioxide snow), by electrolysis, by application of nitric acid, by ignipuncture,
etc., but a large, pulsating tumor demands excision. In the patient shown in
Figs. 281 and 282 ("Lancet,'' March 23, 1912), Mr. Battle ligated the external
carotid, the superior thyroid and the facial arteries on both sides and then cut
away the nasal disease leaving the bony and cartilaginous framework of the
nose exposed. About three weeks later the central portion of the lip was excised
and later the nasal wound was covered by a flap taken from the forehead in
the Indian method. The result was gratifying.

Fig. 2&i.~{Bdtlle:)

Fig. 282.— [Battle.)

Epithelioma of Nose. — In order to excise not merely the tumor but at least
^ inch of apparently healthy tissue all around and in one piece with the
lymphatic nodes next in order Henry Curtis (Trans. Royal Soc. Med. Clin.
Sect., April, 1914) operated as follows: (The tumor w^as situated on the left
side of the tip of the nose, the submaxillary glands were small and hard); the
incision 1-6 (Fig. 283) was made. On the columella the cut penetrated to the
cartilage; elsew^here it reached the bone or penetrated the nose and mouth.
From the beginning of the original cut in the median line of the upper lip, a
second incision was made (1-7) just skirting the red margin of the lip to the
left angle of the mouth, and then vertically down (7-8) to reach the lower bor-
der of the mandible. The flap outlined by the cuts 8-7-1-2-3-4-5-6 included
the entire left nostril, the w^hole thickness of the cheek and exposed both the
nasal and oral cavities.

An incision penetrating the skin alone was now made between the points
6 and 8 and the cheek flap was removed with the lymphatics and glands en
masse. "Those removed consisted of the left maxillary glands, just below the
orbit, the lymphatic vessels (and ? glands) in the left buccinator region, both
submaxillary, salivary and lymphatic glands, both submental glands, and the

1 84

OPERATIONS UPON THE NOSE

left superficial and deep cervical glands." To expose the glands below the jaw
and to provide a flap to repair the defect in the nose and cheek the incisions
8, 5', 4', 3', 2' were made and the outlined flap was fixed by sutures into its
new bed. A split made in the flap (Fig. 283 insert 2'-2"-x) aided in fashion-
ing the new nostril. The wound in the neck was easily closed. The result
was satisfactory after some subsidiary patching operations had been done.

•.#

...r

Fig. 283. — Curtis' operation. {After Curtis.)

RHINOPLASTY

Rhinoplasty, or the reconstruction of the nose, is called for in cases where
the nose has been destroyed by disease or operation. The character of the
operative interference required varies with the location and extent of tissue
destruction.

I. The destruction is confined to the soft structures of the nose but the
osseous and a part of the soft structures of the nose remain.

A. A relatively small portion of the soft parts has been destroyed. Figs.
284, 285, 286, 287 sufficiently e.xplain the correction of this defect.

1. The defect is confined to one ala. Fritz Konig ("Berlin, klin. Woch.,"
1902, No. 7), after thoroughly freshening the nasal defect, implanted into it a
properly shaped segment consisting of the whole thickness of the concha of the
ear. The result was excellent.

2. The defect extends beyond the ala but is still lateral.

Langenbeck's Operation. — From the sound side of the nose reflect a skin-
flap, which has its base near the inner angle of the yee of the affected side
(Figs. 288 and 289). Suture the flap thus obtained to the edges of the defect,
which have, of course, been vivified immediately before. Cover the raw surface
left by the elevation of the flap with Thiersch's skin-grafts.

Nelaton's Operation. — This is similar to the preceding, but the flap is ob-
tained from the cheek (Fig. 290).

3. The septum is absent.

RHINOPLASTY

i8s

Dieffenbach's Operation.— Make a flap as outlined in Fig. 291, consist-
ing of the whole thickness of the upper lip. Freshen the distal end of the flap,

Figs. 284, 285, 286 and 287. — (Esmarch and Kowalzig.)

Figs. 288, 28Q and 2^0.— {Esmarch and Kowalzig.)

Figs. 291 and 292. — {Esmarch and Kowalzig.)

Figs. 293 and 294. — {Esmarch and Kowalzig.)

turn it forwards, and suture it to a vivified area on the anterior edge of the
nasal opening (Fig. 292). Close the wound in the lip.

Langenbeck makes a flap from the skin of the upper lip, leaving the deeper
structures intact (Figs. 293 and 294).

i86

OPERATIONS UPON THE NOSE

Both of the above methods are faulty in that use is made of very hairy
skin, and annoyance is sure to result.

Fig. 295. — Lexer's operation.

Lexer makes a flap from the mucous and submucous structures of the upper
lip, leaving the skin intact except for a perforation through which the flap is

Fig. 296. — Lexer's operation.

brought into position (Figs. 295 and 296). Hueter uses a flap of skin obtained
from the nose itself (Figs. 297 and 298).

Figs. 297 and 298. — Hueter's operation. {Esmarch and Kowalzig.)

4. Much of the end of the nose has been destroyed as well as the cutaneous
septum and much of the cartilaginous septum: The alae nasi are drawn up-

CABOCHE S OPERATION

187

wards meeting in a mass of scar tissue attached to the ends of the nasal bones.
(La Pr. Med. 23, Jan., 191Q.)

Caboche's Operation. — Slop i. — -Free the remains of the alas nasi by an
incision parallel to and about ^g i'"'ch from their lower or free margin
(Fig. 299), and penetrating the nasal cavity. Where the alae were ad-
herent to the nasal bones there is much scar tissue. Excise the scar tissue.

"wiTirrm'^

""'^Tnt^

Fig. 299. — {Cahoclie, La Pr. Med.)

The result is the formation of two alar flaps (Fig. 302,) with external
pedicles and a considerable wound due to the excision of all the scar tissue at
the level of the lower part of the nasal bones.

Step 2. — Formation of new septum: (a) Much of the cartilaginous septum
is present and on it is part of the cutaneous septum. Puncture the septum at
a point slightly behind the future pedicle (Fig. 300). From this puncture divide
the septum close and parallel to the floor of the nose until the vomer is reached

Fig. 300. — (Caboche, La Pr. Med.)

Fig. 301. — (Caboclie, La Pr. Med.)

as demonstrated by increased resistance to the passage of the Septotome.
Separate the cartilage from the vomer for a sulflcient distance by hitting the
handle of the costotome a few blows with the heel of the hand. Divide the
cartilage from a point near the nasal bones downwards and backwards to reach
the incision already made — meeting it at an angle of about 45 degrees (Fig. 300).

1 88 OPERATIONS UPON THE NOSE

Pull the point of the septal flap forwards and upwards and suture it to the peri-
osteum of the nasal bones.

(b) Only the bony septum is present. At the anterior inferior part of the
septum separate the muco-periosteum on both sides backwards for i cm. and
upwards for 2 cm. Continue the separation of this muco-periosteum from the
floor of the nose outwards as far as possible. This forms a submucous pocket
on each side of the septum, open anteriorly and bounded internally by the
denuded septum, inferiorly by the denuded floor of the nose. The postero-
superior external boundaries are formed by the mobilized muco-periosteum.
Divide the periosteum along its posterior line of adhesion to the floor of the
nose thus forming on each side of the septum a rectangular pedicle capable of
nourishing the vomer after it is mobilized. Divide the vomer from before
backwards along the floor of the nose for a sufficient distance. This is best
done with an electric saw. Divide the septum from a point near the nasal
bones to the posterior extremity of the incision already made parallel to the
nasal floor. Pull the point of the flap upwards and forwards (Fig. 301,)
to be inserted between the nasal bones which have been previously separated
from each other by a forceps. Perforate the nasal bones and end of septal
flap, introduce a wire suture and so fix them together (Fig. 301). As the whole
of the operation is very bloody it is wise to have the pharynx packed and to
provide for respiration and anesthesia by means of a preUminary laryngotomy
(Butlin's) or the use of a pharyngeal tube.

Fig. 302. — {Caboche, La Pr. Med.)

Fig. 303. — {Caboche, La Pr. Med.)

Step 3. — Make two flaps from the cheeks (Figs. 302 and 303,) sufficient in
size to more than cover the nasal defect. Usually the lower end of these flaps
will reach to the level of the angles of the mouth while their upper ends or
pedicles may be near the orbito-nasal angles. The upp^ portions of the flaps
should have as much subcutaneous fat on them as possible. Do not suture
the lower ends of the flap into position for some days. Do not insert any drain
or pack into the nose lest the- flaps be compiressed. Divide the pedicles after
about six weeks. Of course as in all rhinoplasties, one or more secondary or
modeling operations may be required.

B. Practically all the soft structures of the nose are absent.

I. Indian Method. — In this operation a pedunculated flap is taken from
the forehead and sutured to the nasal defect.

RHINOPLASTY 189

The Operation. — With oiled silk make a model of the flap required. Figs.
304 to 311 represent variously shaped flaps which have been used.

Step I. — Place the anesthetized patient in the Rose or Trendelenburg pos-
ture. Thoroughly freshen the edges of the nasal defect down to, but not
beyond, the points into which the new alae of the nose are to be inserted. When
considerable skin exists over the bridge of the nose, Step i may be modified
advantageously as follows: From the nasal bridge reflect the flap of skin A,
B, C (Fig. 313) and turn it down with its epidermal surface directed towards
the nasal cavity. Freshen or pare the edges of the nasal defect as already de-
scribed. When in Step 3 the forehead flap is turned down, its raw surface lies
in contact with the raw surface of the flap from the nasal bridge, an epidermal
lining is provided for the new nose, and thus shrinking is obviated.

Step 2. — Place the oiled silk model on to the forehead, in an oblique position,
and with its pedicle so placed as to include the angular artery. Guided by
the model as to shape and size, cut a flap from the forehead. The flap con-

FiG. 304. Fig. 305. Fig. 306. Fig. 307.

Fig 308. Fig. 309. Fig. 310. Fig. 311.

Figs, 304 to 311. — {Esmarch and Kowalzig.)

sists of all the structures down to the bone. With sutures lessen the size of
the defect left in the forehead; cover such open wound as may be left with
skin-grafts.

Step 3. — Turn the forehead flap downwards with its epidermal surface for-
wards, being careful not to twist the pedicle too severely. As this step is being
carued out it may be necessary to lengthen the lateral incisions which bound
the pedicle. Fig. 312 shows a well-designed pedicle. Attention to the pedicle
is of prime importance because too great torsion means interference with
the blood-supply, and more particularly with the drainage of the flap. It is
wise to make numerous shallow scratches through the epidermis of the flap;
these permit of lymphatic drainage. (See chapter on Plastic Operations.)
Fold on itself, laterally, that portion of the flap which is to form the new septum
of the nares and maintain this fold by one or two stitches (Fig, 314). Fold
on themselves the two lower angles of the flap which are to form the alae of the
nose and maintain the folds by means of mattress sutures.

Step 4. — Suture the raw edges of the new alae of the nose into their proper
position in the nasal defect. Do the same with the new nasal septum. Suture

IQO

OPERATIONS UPON THE NOSE

Fig. 312. — {Esmarch and Kowalzig.)

Fig. 313.

Fig. 314.

Fig. 315. — {Esmarch and Kowalzig

Figs. 316 and 317. — (Monod and Vanverts.)

RHINOPLASTY

191

the rest of the flap in position (Fig. 315). Do not use too many sutures near
the pedicle, and in attempts at esthetic effect do not jeopardize the vitahty of
the flap, which depends on the freedom of the pedicle. If the flap lives and
unites in its new position, any defects in the appearance of the root of the nose
may be safely attended to subsequently. Keep the newly formed nasal open-
ings patent by means of dressed rubber tubes or cigarette drains.

2. French Method. — In this operation pedunculated flaps taken from the
cheekb are used to repair nasal defect. Figs. 316 and 317 sufficiently describe
the operation as performed by Nelaton.

3. Italian Method. — Skin for the repair of the nasal defect is obtained
from the anterior and inner aspects of the upper arm.

Slep I. — Dissect from the upper arm a flap of skin, with its pedicle pointing
towards the elbow. Flex the shoulder and bring the free end of the flap in
contact with the vivified edges of the nasal defect. Unite the flap to the nasal
defect by means of sutures. With suitable apparatus (Fig. 318) fix the head
and arm so that they maintain a constant
relationship to each other until union has
taken place.

Step 2. — When the flap is firmly united
to the edges of the nasal defect, divide its
pedicle and complete the rhinoplasty by
forming the alae and septum of the nose out
of the lower portion of the flap.

II. The destruction of tissue involves
both the soft parts and the osseous and car-
tilaginous supports of the nose.

A. The tip of the nose with its alae and
septum are intact [Konig (see p. 200), Israel
(see p. 201)].

B. The tip of the nose has been destroyed. ^ „ /,r ^ ^ rr

. fiG. 318. — {Monod and Vanverts.)

Finger Operation. — The bony framework

of the nose is absent and the soft structures are more or less destroyed (Fig. 319).

1. By paring and splitting the tissues, vivify the edges of the nasal defect.
Preserve as flaps all tissues which may be of use in forming the new nose.
Vivify the bone at the root of the nose. Apply warm gauze to the wounds.

2. A. Make an incision through the skin on each side and the whole length
of the middle finger of the left hand, carefully avoiding injury to the vessels.
Reflect the skin forwards on the palmar side of the wounds for a short distance
so as to form a skin flap on each side of the finger. These flaps are reflected
only from the sides of the finger; the skin on the palmar surface of the finger
is left intact. Form similar flaps on the dorsal side of the wounds. Through
the original incisions excise the carpo-phalangeal articulation and divide the
flexor and extensor tendons as well as the ligaments of the excised joint, being
careful not to injure the vessels. Excise the finger nail. Remove the skin
from the tip of the finger. Cut off the distal end of the last phalangeal bone.

B. If there is a sufficiency of suitable tissue at the nasal defect to form an
epithelial lining for the new nose then, instead of the lateral incisions on the

192

OPERATIONS UPON THE NOSE

finger, make one median incision and from it reflect flaps of skin towards the
sides of the finger.

Fig. 319. — (McWilliams.)

Fig. 320. — {McWilliams.)

FIRM
^'ATTACHMENl
TO FRONTAL
BONt

Fig. 321. — {McWilliams.)

Fig. 322. — {McWilliams.)

3. Apply the cut surface of the bone of the distal phalanx to the vivified
bone at the root of the nose and fix it there with sutures.

A. If method A has been adopted in step 2, suture the palmar flaps, with
their epidermal surfaces directed towards the nasal cavity, to the deeper parts

RHINOPLASTY

193

of the skin flaps around the nasal defect. This forms an epitheHal lining to
the new nose. Suture the dorsal flaps to the edges of the skin flaps around the
nasal defect (Fig. 320). Support and immobilize the hand, arm and head with
plaster of Paris as shown in Fig. 322.

B. If method B, step 2, has been adopted, use the remnants of tissue around
the nasal defect to form the epithelial lining for the new nose and cover with the
skin of the finger.

4. After about two or three weeks ligate the vessels on one side of the base
of the finger through the existing lateral incision; a few days later ligate the
vessels on the other side of the finger (Mc Williams).

5. About four or six weeks after the first operation amputate the finger at
the base of the proximal phalanx. Trim the phalanx suitably, flex it and suture
its raw end to a bed prepared for it at the middle of the lower edge of the
nasal defect so that it now forms the columella.

Fig. 323. — (McWilliams.)

As some necrosis of the proximal phalanx often occurs after amputation it
may be wise to defer trimming and implanting it in the nasal defect until
viability is assured (Fig. 323).

6. After healing of the implants is complete it may be necessary to perform
a number of minor plastic operations to make the new prominence or proboscis
approximate the form of a human nose. Figs. 319 and 320 show a patient of
McWilliams before and after operation. Fig. 321 shows the position of the
phalanges in the same patient.

Nekton's Operation. — Ch. Nelaton has devised an ingenious method of
rhinoplasty which requires no description other than that afforded by Figs.
324, 325,326,327.

Ch. Nekton's Operation with Transplantation of Costal Cartikge. — Pre-
liminary Operation. — Step i . — With oiled silk make a model or pattern of the

194

OPERATIONS UPON THE NOSE

flap necessary to cover the new nose with skin. Lay the model on the forehead
and mark its outlines with silver nitrate. The best shape and position for
the flap are shown in Fig. 328.

^m JT "** v^^^B^t>

^^KT"^]^^

.^gH,

m'm: ■

W%\

^WiM^'-' . ..i

Figs, 324 and 325. — Nekton's operation. (Monod and Vauvcrts.)

Step 2. — Without injuring the perichondrium excise by sharp dissection rhe
whole cartilage of the eighth rib. Close the wound. With a knife pare about
one inch of one end of the cartilage (the rib end) until it is not more than 3^

Figs. 326 and 327. — N^laton's operation. {Monod and Vanverls.)

inch (3 mm.) thick. This thin portion is destined to form the new column
of the nose. Where the pared portion of cartilage joins the unpared portion
cut a notch nearly through the cartilage so that it may be later bent in fashioning
the nose.

RHINOPLASTY

195

Step 3. — At the middle of the distal end of the flap outlined with silver
nitrate on the forehead, make a cut down to the bone. With a director burrow
a tunnel under the periosteum from end to end of the flap (Fig. 328). Pass
the graft of cartilage into this tunnel in such fashion that its thin or pared
end lies subperiosteally near the skin wound and the notch at the junction of
the pared and unpared portions faces towards the skin. Close the skin wound.
Apply dressings.

After about two months the second stage of the operation may be under-
taken.

Second Stage in the Operation. — Step i. — Make an incision all round the
nasal defect except at its lower side (Fig. 328). This cut penetrates to the
bone. Reflect the soft parts between the incision and the nasal defect towards
the latter (Fig. 328).

Figs. 328 and 329. — Nelaton's operation. {Laurens.)

Step 2. — Reflect the flap which was outlined on the forehead at the pre-
liminary operation. (Of course the original marking has disappeared but the
model has been kept and the flap has been again traced out with silver nitrate.)
The implanted cartilage is an integral part of the flap. Model the distal end
of the flap as in Figs. 314 and 329. Gently twist the flap into position and fix
it by sutures as shown in Fig. 315.*

Schimmelbusch's Operation. — Practically as in the Indian method, make
a forehead flap to cover the defect in the nose, but here the flap consists of the
outer table of the skull as well as skin (Fig. 330) . Protect the flap with gauze
and close the forehead defect, preferably by sliding forwards and inwards large
flaps of the scalp, as shown in Figs. 330 and 331. Examine the reflected flap
of bone and skin. If the bone is not splintered, cover the whole raw surface at
once with Thiersch's grafts, protect the grafts with silver-foil or rubber tissue,
and apply gauze dressings. With bandages support the flap against the head and
wait untn the grafts have become mature. This period of waiting is of value
in that the flap becomes accustomed to receiving its nourishment through the
pedicle before the pedicle is disturbed by twisting, but as the flap inevitably

'In Fig. 315 the flap has been taken from a different part of the forehead.

196

OPERATIONS UPON THE NOSE

shrinks during the delay, it is very necessary that it be made at least one-sixth
larger than the defect to be filled. If on examination the bone in the flap is
found to be splintered, delay the skin grafting until any necrotic bone is thrown
off and the remainder is covered by granulations (four to eight weeks). When
the raw surface of the flap is satisfactorily covered with epidermis, make an
incision with a fine saw^ in the middle line through the bone in the flap, so that
the flap can now be bent into a A shape (Fig. 331). Mobilize the pedicle of the

Figs. 330 and 331. — Schimmelbusch's operation.

flap and twist the latter into position. With sutures unite the edges of the flap
to the freshened edges of the nasal defect. When freshening the edges of the
nasal defect, it is easy to form flaps of tissue which may be used to form a septum
for the nostril (Fig. 332).

E. Lexer's Operation. — As Schimmelbusch's operation is based on Konig's
so is Lexer's on Schimmelbusch's. Lexer ("Archiv fiir klin. Chir.," xcii, 749)
recognizes that after complete rhinoplasty it is most difl&cult to breathe through
the nose because of contraction of scar tissue. Before opera-
tion the disease causing the deformity (sj^Dhilis, tubercu-
losis) has caused much destruction of tissue and recovery
has taken place by the filling in of ulcerations and defects
with granulation tissue which has contracted until the
pyriform opening has become small and distorted and nasal
respiration is poor. Before attempting to form a new
external nose the freedom of the air passage must be
assured. The operation is performed in many stages.

First Stage. — Step i. — With knife, scissors and chisel
cut away all scar tissue which deforms the pyriform open-
ing and obstructs respiration.
Step 2. — From the skin around the opening, from remnants of the alae of
the nose, etc., form pedunculated flaps and with these cover the defects resulting
from the excision of scar tissue (Fig. s^s)- These flaps may be held in place
by gauze tampons until they become united to their new beds. No flaps may
be taken from the root of the nose above the aperture; the skin here must
be preserved intact for use later.

Fig.

332-

RHINOPLASTY

197

Second Stage — Preparation of Flap from Forehead. — This procedure is
identical with that of Schimmelbusch except that Lexer at once covers the bone
in the flap with skin by folding the flap on itself (Figs. 334 and 335). The
wound in the forehead should be covered by Thiersch or Wolf skin grafts.

Third Stage. — (Three or four weeks Xdiitx .)— Step i. — Formation of pedicle
for the forehead flap.

Fig. 2,^2,-— {Lexer.)

Fig. 334.— (Lexer.)

The flap on the forehead formed in stage 2 was provided with a broad
pedicle whose base was on a level with the eyebrows (Fig. 334)- Lexer, in
several sittings, gradually step by step continues the cuts which outline the
forehead flap downwards until they reach on one side the inner angle of the
eye, on the other side the nasal opening (Fig. 336). From the latter incision
he separates the skin of the root of the nose from the bone until the middle
hne is reached (Fig. 337) and it becomes possible to twist the pedicle and bring
the flap into position without tension.

Fig. 2,3$-— {Lexer.

Fig. 336. — {Lexer.)

Fig. 337. — {Lexer, Archiv fiir
Klin. Cliir.)

Step 2. — From the under surface of the forehead flap reflect a narrow flap
of skin to form the septum or philtrum of the new nose (Fig. 337) and through
the wound thus made divide the bone in the flap longitudinally so as to fold
the bone on itself as in Schimmelbusch's operation.

Step 3. — Freshen the edges of the nasal aperture and suture the forehead
flap in proper position as in Schimmelbusch's method.

Fourth Stage. — After several weeks divide the pedicle using its remnants to
help to repair the defect between the eyebrows. It is better to delay this

198

OPERATIONS UPON THE NOSE

Step as long as possible, as when the pedicle is divided the transplanted bone
may atrophy, especially in syphilitics.

The result of the operation so far is to provide the patient with a hideous
excrescence which an Ananias or an enthusiast might call a nose. Lexer next
proceeds to fashion a nose from the excrescence.

Fifth Stage. — This stage is begun a few weeks after the pedicle has been
divided.

I. Formation of a Depression Between the Forehead and the Nose. — At the
level of the eyes divide the scars, in front of the angle of the eye, down to the
bone excising any disfiguring scar tissue. The cuts made for this purpose
are about 2 cm. long. From these cuts on each side separate the soft parts
from the bone and cut away all oedematous and thickened connective tissue
(Fig. 338, b).

b c

Fig. 338. — (Lexer.)

The subcutaneous excision of scar tissue leaves a superfluous amount of
skin and hence it is necessary to convert the lateral linear incisions into ellipses
(Fig. 338, b) by excising a little skin from their anterior margins before closing
them with sutures.

2. Formation of the Point of the Nose. — The tissues about the point of the
nose have sunk down and are too voluminous.

On the under surface of the new nose make a semilunar incision which
reaches near the base of the septum nasi already constructed (Fig. 339, a).
Through this incision pass an elevator and raise the skin of the tip of the
nose from the underlying bone (obtained from the forehead). Obtain a fresh
piece of bone from a rib or tibia of the same patient or from some other person
who has required an amputation or resection. Model this fragment of bone
into an oval with a shallow groove on its «on-periosteal side and with some-
what of a convexity on its periosteal side. Push this fragment into the bed
prepared for it at the tip of the nose, periosteum towards the surface, in such
a manner that it lies, subcutaneously, on the bony support of the new nose
and forms a rounded tip to it. The pushing in of the fragment of bone makes

RHINOPLASTY I 99

the semilunar incision gape somewhat but this open wound will heal by granu-
lation satisfactorily (Figs. 338, c, and 339, b and c). For a few days it may be
necessary to leave a pin in situ perforating the fragment of bone and keeping
it from being misplaced.

3. Formation of the Ala of the Nose. — The curved incision used for the
implantation of bone to form the point of the nose in healing contracts and
leaves a small notch which when seen from the side acts as an anterior margin
to the lower edge of the alae. To make this notching more distinct and to
make the clumsy lower edge of the new nose thinner, subcutaneously excise
through the curved incision, the soft tissues on the inner side of the bony
support of the nose and with fine forceps cut out a notch in the bone on each
side so as to widen the nostrils (Figs. 338, c, and 339, b). Last of all fashion
the outer side of the alae by excising a small amount of skin as in Fig. 338, d,
but in suturing this wound stitch its posterior cutaneous edge not to its anterior
cutaneous edge but to the subcutaneous tissue in front of the wound, thus
obtaining a more or less sightly indentation.

III. The destruction of tissue involves only the osseous and cartilaginous
framework of the nose, the surface being left intact.

a be

Fig. 339. — (Lexer.)

Finney's Operation.- — Step i. — Cut away the nail and its matrix from the
ring finger of the left hand. Remove the skin from the back of the finger
up to its middle joint. Denude the tip of the finger completely, leaving the
tip of the bone bare. Stop bleeding.

Step 2. — Introduce a tenotome into the nose and divide all the cicatricial
connections between the retracted tip of the nose and the frontal and superior
maxillary bones. Pull the soft parts of the nose forwards into the best possible
position. Do not cut the skin. Vivify the inner surface of the dorsum of the
nose in the middle line.

Step 3. — Introduce the prepared ring finger into the nose in such fashion
that the tip of the exposed phalanx lies in contact with the nasal process of
the frontal bone and the raw surface of the dorsum of the finger is in contact
with the raw median surface of the inside of the dorsum of the nose. Hold
the finger in position with stitches uniting the edges of the finger wound to
the free border of the tip of the nose.

Step 4. — Hold the hand in position by means of adhesive strips and plaster
of Paris for too weeks.

Step 5. — (Two weeks later). Disarticulate the finger at the metacarpo-
phalangeal joint. Apply dressings.

Step 6. — (One week later than Step 5). Split the tissues in the middle

200

OPERATIONS UPON THE NOSE

line over the nasal spine of the superior maxilla. Flex the finger at the proximal
phalangeal joint. Insert the free end of the proximal ])halanx into the wound
made over the nasal spine of the superior maxilla and fix it there with sutures.
The proximal phalanx forms the column of the nose; the two other pha-
langes form the dorsal support. Later some minor operations will be neces-
sary to narrow the new column of the nose and to improve appearances.

Konig's Operation. — This operation was originally devised for the cor-
rection of saddle-nose, but it is also of great value in the treatment of cases
where the soft parts are absent as well as the hard. The operation as here
described is that done for saddle-nose; the modifications required when the
soft parts are absent are so self-evident that they will not be mentioned.

Step I. — Make a transverse incision across the seat of the saddle (A, B,
Fig. 340). Pull the tip of the nose down into correct position.

Figs. 340, 341 and 342. — Konig's operation.

Step 2. — From the forehead turn down the vertical flap D CFigs. 341 and
342) and suture its free extremity to the point C at the tip of the nose. This
flap is 3^ inch wide and is made by cutting through the soft parts with a knife,
introducing a chisel through the upper part of the wound, and thus elevating
a long narrow strip consisting of skin, periosteum, and the outer table of the
skull. The bone in the flap gives firmness to the new nose.

Step 3. — After the Indian fashion, reflect from the forehead, a skin-flap
E, F, G (Fig. 341), and turn it down so as to cover the nasal defect A, B, C
(Figs. 341 and 342), as well as flap D.

The results obtained from this operation or some of its modifications have
been very satisfactory.

Author's Method. — This is suitable in cases where the nasal bones and the
surface structures are intact but all the cartilaginous septum has been destroyed.

Step I. — Without injuring the perichondrium excise by sharp dissection
thin strips of cartilage from eighth rib. The strips should be about i^i inches

RHINOPLASTY 20I

long, 3-^ inch wide and } i,' inch thick. Preserve these in warm salt solution.
Close the wound.

Step 2. — With a tenotome introduced either through the skin or, as in Finney's
operation, through the nose, divide the cicatricial connections of the nose to
the pyriform aperture. Pull the nose forwards into as good position as possible.

Step 3. — Introduce a tenotome through the skin in the middle line of the
nose just below the osseous nasal bridge. From the puncture make a tunnel
between the skin and the mucosa on each side down to the junction of the
nasal alae and the upper lip, where the skin is again perforated. With an eyed
probe or a forceps pull a thread and by means of the thread pull a strip of
cartilage through each tunnel. Do not permit the ends of the cartilage to
protrude through the skin punctures. The strips of cartilage act as splints or
braces for the nose. Of course it is easy to introduce a strip of cartilage at any
place where it will do most good.

Israel's Operation. — This is merely a modification of Konig's method,
but gives better cosmetic results. The flap D (Fig. 342) is made narrow,
being only about 3^^ inch wide, and when turned down and its free end sutured
in place, exactly as in Konig's operation, it is left uncovered by any other
flap. After a short time the raw surface of the flap becomes covered by granu-
lation tissue and the epidermis spreads over it. The local condition is now the
following.

The tip of the nose is in normal position. The skin and bone flap D (Fig.
342) bridges over the defect created by the incision A, B (Fig. 340), and also
the undivided skin at the root of the nose. Whenever flap D has become
well healed, draw it slightly to one side; make a vertical median incision through
the skin at the root of the nose above the defect. Elevate this skin on each
side of the median incision, bring the edges up, and suture them to the vivified
edges of the new nasal bridge (flap D, Fig. 342).

Von Mangold's Operation. — Step i. — Make a small transverse incision
across the middle line through the skin at the glabella. With a Kocher sound
or blunt dissector burrow a tunnel under the skin, in the middle line down to
the point of the nose.

Step 2. — Expose by incision the seventh or eighth costal cartilage. Excise
a plate of cartilage, with its perichondrium, about i^^ inches long, % inch wide,
and 3^ inch thick.

Step 3. — Push the excised plate of cartilage into the subcutaneous tunnel
prepared on the nose. The side of the graft which has no perichondrium
ought to be directed towards the skin. Close the little wound with sutures.

Step 4. — Make a small incision through the skin in the grooves to the out-
side of each ala of the nose. Through these incisions implant a thin strip
of costal cartilage in each ala.

Von Mangold was able to form good nares, to correct saddle shape and to
obtain a rectilinear nose, but it was necessary to lengthen and improve the
shape of the organ at a second operation after an interval of five months.

Second Operation. — Through an inverted V-shaped incision (apex of V
in middle line at root of nose, legs of V coming down on each side of the nose)
detach the soft structures of the nose and with them the cartilaginous graft.

202

OPERATIONS UPON THE NOSE

Fig. 343. — (Marshall, Journ. A. M. A.)

FiG._344. — (Marshall, Journ. A. M. A.)

MARSHALL S OPERATION

203

from the subjacent structures. Carefully apply the upper end of the graft

of cartilage into the angle between the glabella and the root of the nose. Suture

the wounds.

External lateral deflections of the nose commonly the result of accidents or

blows are often so disfiguring as to interfere seriously with the bearer's chances

of earning his livelihood.

Marshall's Operation. — ("Journ. A. M. A,," Jan. 18, 1913.)

Step I. — With a tenotome puncture the skin over the nasal process of the

superior maxilla where the elevation which makes the nasal prominence begins.

Introduce a chisel about j^f e inch wide, through the puncture, and divide the

Fig. 345. — {Marshall, Journ. A. M. A.)

process without injuring the nasal mucosa (Fig. 343). The division of bone may
be accomplished as widely as necessary without enlarging the skin incision.
Apply pressure to the wound for purposes of hemostasis.

Step 2. — Do the same on the opposite side.

Step 3. — Introduce one blade of an Ashe septal forceps (better a heavier
forceps with longer blades) into the nares, the other blade being outside, and
complete by fracture the mobility of the nasal process along its entire line, for
the upper part of the nasal process can usually be made mobile at the sutures
along the lacrimal and the nasal bones on the corresponding side.

Step 4. — Do the same on the opposite side.

Step 5. — If there is a nasal obstruction through malposition of the septum,
seize the septum with the same forceps and force it into correct position.

204 TORTICOLLIS. WRY NECK. CAPUT OBSTIPUM

Step 6. — If the nose is not yet straight the defect probably lies at the suture
between the frontal and upper extremities of the two nasal bones and both proc-
esses of the superior ma.\illa. Straighten this faulty angle "by a sharp stroke
with the mallet at this point guarded by a rubber-covered lead plate, the force
being directed downwards from the frontal bone, but towards the obtuse angle
(that is, against the deflected side). Elevation can be assisted sometimes to
advantage with a large urethral sound."

Step 7. — Dress the wounds with collodion. Occasionally Marshall inserts
nasal splints for 24 hours. The nose ought to remain absolutely straight with-
out being held in position. Do not use apparatus to hold the nose in position,
such is uncomfortable and gets out of place to such a degree as to do more
harm than good. Marshall instructs his patients to keep a moderate pressure
on the originally deflected side for several days so as to obviate any tendency to
recurrence of the deformity. Figs. 344 and 345 show a patient before and after
operation.

CHAPTER XIX

TORTICOLLIS. WRY-NECK. CAPUT OBSTIPUM

There are several methods of operating on torticollis.

(a) Subcutaneous tenotomy of the sternal and cla\acular portions of the
sternomastoid. This operation is rarely performed, as its only advantage
lies in the absence of scar, while its disadvantages are danger and incom-
pleteness.

{h) Open section of the same structures, plus division of all bands of fibrous
tissue which obstruct reduction of the deformity.

id) Excision of the degenerated sternomastoid (Mikulicz).

WTien the torticollis is of the spasmodic variety, the follo^\•ing methods
have been ad\-ised:

{e) Division or excision of the spinal accessor}- nersx.

(/) Multiple myotomy (Kocher).

Open Tenotomy of Sternomastoid. — The favorite site for dividing the
muscle is J-^ to ^^ inch above the clavicle. The skin incision may be vertical,
oblique, or transverse; probably the oblique is best. Beginning at the outer
edge of the sternal attachment of the sternomastoid, make an incision i to i)^
inches in length, passing upwards and outwards to the middle of the anterior
margin of the cla\-icular portion of the muscle. Retraction of the woimd ex-
poses both portions, which are easily isolated and divided without danger toother
structures. Rotate the head firmly towards the sound side, keeping the shoulder
of the affected side steady. This manoeuvre puts all other contracted structures
on the stretch. Divide all such, even down to beside the carotid packet of
vessels. Attend carefully to hemostasis. Suture. Dress. Lorenz advises
forcible overcorrection before the patient comes out of the anesthesia. The
corrected or overcorrected position must be retained either by an extension
apparatus or by means of a proper collar. After healing has taken place, massage,

WRY NECK 205

exercise, and, for a time, the use of some orthopedic apparatus, such as Sayre's,
are requisite.

Muscle Lengthening. — Thelwell Thomas ("Lancet," March 9, 1912) has
obtained good results by muscle lengthening. It does away with long and tire-
some after-treatment as he does not use any retentive apparatus. Make a
transverse incision over the lower third of the sternomastoid. Expose the
sternomastoid and isolate a sufficient segment of it. Estimate how much the
affected muscle is shorter than its fellow. Split the affected muscle longitudi-
nally for a distance equal to a little more than half the amount of the shortening.
At the lower end of the vertical incision divide the anterior portion of the
muscle transversely. At the upper end of the vertical incision divide the pos-
terior portion of the muscle. Suture the ends of the muscle with chromicized
catgut. Close the wound. It is often necessary to divide bands of deep fascia
as well so as to obtain correction.

Myomectomy. — Mikulicz's Operation. — In severe cases of torticollis Mikulicz
advises excision of the lower two-thirds of the sternomastoid, the upper one-
third being preserved so as to avoid injury to the spinal accessory nerve.

Expose and divide the sternal and clavicular portions of the muscle as in
open tenotomy. Seize the divided ends in forceps and pull the muscle down-
wards and through the skin-wound; as this is done, separate it from its sur-
roundings by blunt and sharp dissection. Avoid injuring the external jugular
vein. When two-thirds of the muscle is isolated, divide and remove it. At-
tend to hemostasis. Divide all cicatricial bands which can be felt. Close
the wound. Apply dressings and pressure enough to obviate dead spaces.
No subsequent orthopedic treatment is required.

Bruns in doing this operation removes only one-third of the muscle. The
chief disadvantage of the operation is cosmetic, viz., the loss of the shapeli-
ness of the neck. It should be reserved for severe or recurrent cases.

Division of the Spinal Accessory Nerve. — The spinal accessory nerve
escapes from the skull through the jugular foramen. It runs obliquely down-
wards and backwards between the internal jugular vein and the digastric mus-
cle, entering the sternomastoid muscle at a point about two inches below
the mastoid process. The nerve pierces the muscle obliquely and proceeds,
across the posterior triangle of the neck to supply the trapezius.

The Operation. — -Make an incision 23^^ to 3 inches in length from the mastoid!
process downwards along the anterior border of the sternomastoid. Expose-
the anterior border of the muscle and divide the cervical fascia. Retract
the muscle backwards. With the finger recognize the transverse process
of the atlas, which is covered by the digastric muscle. The nerve, after pass-
ing between the bony process and the muscle, emerges at the lower edge of
the latter and passes to the sternomastoid. Expose the nerve and either
divide it or excise about 3^^ inch of it. Close the wound with sutures. Dress..
The results of the operation are usually good; the danger is practically nil.

Nerve Section for Spasmodic Torticollis. — Division of the posterior pri-^
mary divisions of the cervical nerves was first carried out by Gardner of Ade-
laide and Keen of Philadelphia in 1888. The operation is only suitable for
very severe cases in which the disease has rendered life a burden. The object

206 TORTICOLLIS. WRY-NECK. CAPUT OBSTIPUM

of the operation is to paralyze all the muscles involved — e.g., when the spasm
turns the head to the right and extends it one should paralyze the left sterno-
mastoid and trapezius and the right splenius capitis, trachelomastoid, superior
and inferior oblique, rectus capitis, posticus major complexus and trapezius.

Robert Kennedy ("Brit. Med. Journ.," Oct. 3, 1908) has endeavored to
simplify the exposure of the nerves, no easy matter at the best.

Step I. — Make a vertical skin incision from 3^ inch above the superior
curved line downwards for 3 to 3)-^ inches midway between the external ear
and the external occipital protuberance.

Step 2. — Define the posterior edge of the sternomastoid and deepen the
incision behind the sternomastoid until the oblique fibres of the splenius capitis
are exposed. Do not injure the spinal accessory nerve which may lie near
the lower angle of the wound.

Step 3. — Define the upper border of the splenius capitis and divide that
muscle in the line of the original incision. Divide the subjacent connective
tissue exposing, above, the complexus whose fibres run longitudinally, and
below, the trachelomastoid whose fibres run obliquely.

Define the outer edge of the complexus and the upper edge of the trachelo-
mastoid.

The upper part of the wound is crossed by the occipital vessels. Deep
down in a triangle formed by the occipital vessels and the two muscles lies
the superior oblique muscle.

Step 4. — Follow the outer border of the complexus to its highest slip of
origin (third cervical articular process). Detach this slip from the bone.
Repeat this with the slip originating from the fourth articular process. Re-
tract the trachelomastoid outwards. Fold the complexus inwards and so
expose several nerves entering its deep surface. "The largest is the great
occipital or internal branch of the posterior primary division of the second
cervical and this pierces the complexus about the level of the lower edge of the
lobe of the ear. Above the point at which the great occipital enters the com-
plexus a slender branch can be seen entering the muscle and it can be traced
back to the posterior primary division of the first cervical nerve. The latter,
however, is best found by tracing out the slender branch of communication
with the second posterior primary division which as a rule is present, passing
upwards from the second division across the inferior oblique. It is very diffi-
cult to deal satisfactorily with the suboccipital nerve unless this communi-
cating branch is early found and traced upwards at once to the first division
which lies between the vertebral artery and the arch of the atlas, and of course,
the operation is only imperfectly performed unless the first division is ade-
quately dealt with. A short communicating branch leads from the second divi-
sion down to the third division and is a safe way of reaching the latter. The
fourth and fifth divisions can be easily found passing downwards and back-
wards close to the vertebrae. The nerves, from the second downwards, should
be isolated to the point of separation into anterior and posterior primary
divisions, but not further, and undue traction can quite easily pull the anterior
primary division backwards and expose it to the danger of being damaged.
The first nerve is sectioned just proximal to its branches, and the others near

MULTIPLE MYOTOMY 207

their point of separation from the anterior primary division. In the great
majority of cases the nerves once sectioned are excised from the point of section
as far distally as can be reached."

Step 5. — The nerves having been exposed excise a segment of each. Do
not stretch the nerves lest rupture of the roots occur and paralyze the anterior
primary divisions. Resection of the nerves means total and permanent pa-
ralysis of the muscles involved. Kennedy suggests another method of operation
in cases where the spasm, though very violent, has not been of long standing,
and which refuses to yield to any known treatment short of operation. In
such acute cases, i.e., where the affection has lasted only a few months and
there seems hope of cure, Kennedy gives the muscles rest by dividing and
immediately suturing the spinal accessory of one side and the posterior primary
divisions of the opposite side. "The result is that the violent spasm is im-
mediately abolished, the afifected muscles degenerate, and in the course of
some weeks, after the nerves have regenerated, as indicated by the gradually
returning sensation, the muscles begin to get built up again and shortly begin
to resume their functions."

Multiple Myotomy. — Kocher's Operation. — Two incisions are necessary.

1. Make an incision i3<4 to il^ inches in length along the anterior border
of the sternomastoid, commencing opposite the angle of the jaw and passing
upwards. Di\dde the platysma and if possible save the external jugular vein.
Open the sheath of the sternomastoid along its anterior border. Introduce a
blunt dissector under the muscle and divide it layer by layer. Attend to
hemostasis. Close the wound with sutures. If desired, the spinal accessory
nerve may be stretched or divided during this procedure.

2. The patient is turned on to his sound side. Beginning at the mastoid,
make a transverse incision backwards. Through this divide the trapezius
transversely and incise the splenius capitis and complexus muscles. Avoid
injuring the great occipital nerve, which here traverses the complexus and
trapezius. The inferior oblique muscle arises from the spinous process of the axis
and is inserted in the transverse process of the atlas. Look for this muscle
in the space between the atlas and axis and divide it. Attend to hemostasis.
Close the wound.

Monod and Vanverts vnite. as follows: "Section should be made of the muscles which
participate in the spasm. It is necessary, by anatysis, to determine prior to operation the
muscles involved. One may be compelled to practise, according to the case, the following
operations : division of sternomastoid and of the muscles of the nape of the neck on the opposite
side (tj-pical rotary tic); division of the sternomastoid and of the muscles of the nape of the
neck on the same side (rotary tic with predominance of lateral deviation) ; division of sterno-
mastoid and bilateral division of the muscles of the nape of the neck (rotary tic with much
posterior extension)."

Remarks. — In some cases of torticollis no operation seems to be effectual;
such are usually due to affections of the posterior nerve and muscle groups.
Extirpation of the nerves involved has been ad\ased, but this is a very compli-
cated and, for most surgeons, inadvisable operation, and is not a glittering
success.

2o8 EXCISION OF CERVICAL RIBS

In Other cases any operation involving tenotomy is successful. When
the muscle is greatly degenerated and adherent, Mikulicz's procedure is the
best. In spasmodic varieties of torticollis section of the spinal accessory nerve
is the operation of choice.

CHAPTER XX
EXCISION OF CERVICAL RIBS

Excision of Cervical Rib. — Cervical ribs vary much in size and may be
unilateral or bilateral. They articulate with the seventh cervical vertebra and
may end as a longer or shorter process lying among the tissues of the neck or
their anterior end may be united to the first thoracic rib or to the sternum.
Commonly no sjinptoms are produced, but sometimes the rib exercises pressure
on the vessels or on the nerve trunks passing over it or on both. When these
symptoms are severe and do not give way to conservative treatment, operation
becomes necessary-. Occasionally the rib itself is short but is continued forwards
as a strong band of connective tissue and this band exercises pressure and gives
rise to trouble. In such a case excision of the connective-tissue band is of course
the proper treatment.

A. Operation from in front. Step i. — Incision. — Numerous incisions have
been devised: (a) Transverse, a finger's breadth above the clavicle reaching
from the sternomastoid to the trapezius, ib) Oblique, along the anterior
edge of the trapezius or a half inch in front of it. {c) Vertical over the most
prominent part of the swelling caused by the rib. One incision is as good as
another provided that free access is secured; sometimes it is necessary to com-
bine two incisions so as to obtain room.

Step 2. — Divide the platysma and superficial fascia, doubly ligating and
dividing the external jugular vein. Divide the deepT fascia. Penetrate the
underlying loose, vascular fatty tissue so as to expose the great vessels and
the brachial plexus. Cautiously retract the vessels and nerves from over the
cervical rib.

Step 3. — By blunt and sharp dissection separate from the rib the soft parts
attached to it. Great care is necessan,- to avoid injuring the pleura which may
be attached to the rib. The danger of pleural puncture has been much exag-
gerated. Subperiosteal resection of the rib is easier than extra-periosteal but
one or more cases have been reported in which a secondary operation was re-
quired owing to reformation of the rib. At first expose and isolate a small
median portion of the rib. From this as a starting-point follow the rib towards
the spine and divide it with bone forceps, being careful to leave no sharp spicules
protruding from the stump left attached to the spine. Follow the rib to its
anterior attachments and di\-ide them. Remove the rib. If complete. excision
is very difficult or risky it may occasionally be wise to resect merely that portion
of the bone which is exercising injurious pressure on the vessels and nerves.

Step 4. — Attend to hemostasis. Close the wound with deep and superficial
sutures.

CERVICAL TUMORS 209

B. Operation from behind. (Streissler's method.) From a point ^:4 inch
(2 cm.) lateral to the spinous processes of the vertebrae and one hand-breadth
above the vertebra prominens make an incision downwards parallel to the spine
to a point one hand-breadth below the vertebra prominens. Divide the trape-
zius, both the rhomboids, serratus posticus and splenius; separate the fibres of
the complexus and semispinaUs colli. Expose the transverse processes of the
two lower cervical and two upper thoracic vertebrae. The articulation between
the cervical rib and the transverse process of the seventh cervical vertebra with
its strong ligaments is now in view. Remove the transverse process and so
expose the thin neck of the rib. Pass a curved elevator around the neck of the
rib and divide it, being careful not to injure the nerve roots immediately in front
of it. Seize the rib with strong forceps and with sharp and blunt dissection free
it from its connection as far forwards as possible. If the rib is too long or
its anterior connections are too firm to permit complete and easy removal
through the posterior wound, finish the removal through an anterior incision.
The results obtained from excision of cervical ribs have usually been good.
Streissler ("Ergebnisse der Chir. und Orthopedie," v, 280) gives an exhaustive
account of cervical ribs.

CHAPTER XXI
EXCISION OF CERVICAL TUMORS

The various operations for the removal of cervical tumors, if at all exten-
sive, should never be undertaken by a tyro in surgery. These operations are
very dangerous in the hands of one who is not possessed of a good working
knowledge of anatomy, especially of the anatomy of the living, and of wide
surgical experience.

A good type of the operations under discussion is the removal of tubercu-
lous glands. Ideally, when the disease is extensive, one should endeavor to
remove all the cervical glands, and their lymphatic connections in one piece.
This is, of course, impossible; but it is a good plan for the surgeon to try to
approximate the ideal, even although he knows that his endeavors to do so will
fall far short.

Greenwood SutcUffe ("Practitioner," lxxx\dii, 641) gives the following indi-
cations for the treatment of tuberculous cervical glands in children. When the
disease has lasted not more than six months dietetic treatment with rest (in
the open air) gives good results. Rest here means lying down and not running
about. When the disease has lasted longer, there is usually caseation and opera-
tion is demanded. The author has found that suction hyperemia is often of
great benefit in recent disease and that where caseation has taken place or even
where abscess has formed, a small incision followed by suction hyperemia after
the Klapp-Bier method, often renders excision unnecessary. When a reasonable
trial of these simpler remedies fails, operation is proper.

What are the dangers of the operation?

I. Hemorrhage. — If care is taken, bleeding need cause little anxiety. The
precautions taken to avoid air embolism will certainly have the eflfect of pre-
venting much hemorrhage.

2IO EXCISION OF CERVICAL TUMORS

2. Air Embolism. — During inspiration the blood in the cervical veins
is under negative pressure. If under these circumstances the vein is wounded,
air is liable to be sucked into it and thus into the heart — a very fatal accident.
Careful attendance to the principles of technic for cervical operations will
obviate most of the danger.

(a) The wound through the skin and fascia should be large enough to give
free access to every part to be operated upon.

(b) The wound should be kept moist, and if the slightest "hissing" sound
be heard in the wound, the finger should press the tissue at a point nearer the
heart than where the wounded vein is. The "hissing" signifies entrance of
air. The digital pressure is meant to hinder the passage of the air towards
the heart. At the same time as the finger pressure is applied, a spongeful of
water must be squeezed into the wound. This effectually prevents more air
getting in. The wound in the vessel must be caught by pressure forceps. J.
B. Murphy places a small pack of gauze, with a thread attached to it to keep
it from being lost, under the sternal attachment of the sternomastoid muscle.
The pressure of the pack keeps the cervical veins full, prevents the danger of
negative pressure, and makes the veins very visible. This expedient is of great
value; the trifling increase in hemorrhage is of no importance. When "hiss-
ing" in the wound occurs and makes one suspect air embolism, remember
that it may be due to the pleura being accidentally opened. The pleura ex-
tends an inch or more above the first rib.

(d) Never cut in the dark or without full knowledge of the safety of what
is being divided.

(e) Bleeding points are at once caught by pressure forceps. If it is sus-
pected that forcipressure kept up for a few minutes will be insufficient to stop
the bleeding, the vessel should be secured by a fine ligature.

(/) In removing the glands no forcible tearing should be perpetrated.
Veins are often very friable.

(g) Structures about to be cut ought not to be on tension. Tension empties
veins and makes them look like bands of fibrous tissue.

(h) When in the slightest doubt as to the contents of a strand of tissue
which must be severed, apply two forceps or two ligatures and cut between.

When, in spite of all precautions, air has been sucked into a vein, fill the
cervical wound loosely with wet gauze; do not apply forceps to the vein; during
the succeeding expirations forcibly compress the chest; do not lower the head
and shoulders of the patient.

3. When operating down low in the neck on the left side, avoid injuring
the thoracic duct. Such injury is not uncommon. If noticed at the time,
one sees a little clear fluid escaping. Compression sutures in the vicinity of
the injured duct plus gauze packing usually leads to recovery, but fluid escapes,
in spite of treatment, for about two weeks, and there is great emaciation. The
injury generally heals in about three weeks or less. P. Lecene thoroughly
discusses this accident ("Revue de Chir.," Dec, 1904).

INJURIES TO THORACIC DUCT

211

Edward Harrison (Brit. J. of Surj!^., 191 7, IV, 304) rcvicwinjr the treatment
of wounds of the duct comes to the following conclusions:

1. Suture is the best treatment. Suitable in splits and tears. (Five cases
all successful.) When there is com[)letc division of duct, end-to-end suture is
best.

2. Implantation into any convenient vein. In one case the divided duct
was put into the central segment of the external jugular vein which was divided
for the purpose and fixed by sutures.

3. Occlusion of duct by ligature or forcipressure. This gave many good
results, possibly because in 18 out of 40 cases there were two terminal branches
of the duct and perhaps only one of these was occluded. Collateral circulation
may aid in recovery after ligation.

4. Tamponade is a dernier ressort.

4. Injury to Important Nerves. — The danger of injuring important nerves
in the neck is by no means great. The vagus is well protected, lying in the
carotid sheath. If care be taken, the spinal accessory nerve can usually be
recognized and often preserved; its preservation is of much greater impor-
tance in the young than in the mature. Injury to the phrenic and the recurrent
laryngeal nerves is extremely rare. Injury to the cervical sympathetic system
seems to produce no ill results.

The Operation. — In slight cases where the glands are neither" numerous nor
adherent the operation is extremely simple. An incision is made over the
swelling and through this the tumors are easily shelled out. The method of
operating about to be described is for extensive and complicated disease.

Fig. 346.

Fig. 347. — Superficial cervical nerves.

The patient lies on his back with the shoulders supported and the head
turned towards the side. The scalp should be covered by a weU-fitted gauze
or rubber cap, to keep the hair out of the way. An oblique incision is made
along the sternomastoid muscle from the mastoid process to near the sterno-
clavicular articulation. The external jugular vein is exposed and divided be-
tween two ligatures. The skin anterior and posterior to the incision is dissected
from the subjacent tissues and retracted. If necessary, a second cut may be
made parallel to and near the clavicle, from the lower end of the oblique incision
outwards. Another incision, and one which leaves little noticeable scar, follows
the margin of the vertical hair line of the back of the neck; to this cut is joined
one following the clavicle forwards (Fig. 346). Expose the sternomastoid
and free it from its surroundings throughout its whole length. Notice the point

212 EXCISION OF CERVICAL TUMORS

of emergence of the superficial cervical nerves at the posterior edge of the
muscle; the nerves are not small, and here the muscle is more firmly attached
to its surroundings than elsewhere, hence this point constitutes an anatomic
landmark (P'ig. 347). One-half inch above this landmark the spinal accessory
nerve emerges from the sternomastoid muscle and is easily found. The nerve
enters the muscle about two inches below the tip of the mastoid process, after
passing over the prominent transverse process of the atlas. In cases of tuber-
culosis it is commonly easy to trace the nerve in its course to the trapezius and
to separate it from the diseased structures. In the young it is important to
preserve the nerve, because Fenger has shown that its division leads to droop-
ing of the shoulder and to scoliosis.

The packet of fascia which contains the carotid artery, internal jugular
vein, and the vagus must now be exposed. Once exposed, the protection of
these extremely important structures becomes more or less easy. Up to this
time no attempt has been made to remove diseased tissues. The disease is
now attacked. Beginning near the lower end of the wound and by the side of
the carotid packet, the removal of the diseased glands with the gland-bearing
fascia is generally a comparatively easy matter and can be carried out sys-
tematically. If the important anatomical structures are not exposed and pro-
tected at an early stage in the operation, systematic, thorough removal of the
glands is very difficult and dangerous. The diseased structures having been
removed and all hemorrhage stopped, carefully suture the wound in the cervical
fascia, preferably with catgut. Suture of the fascia and platysma most notably
removes tension from the skin-wound. If the fascia is not well united, the skin-
wound is liable to stretch and give rise to a wide, ugly scar. Provide drainage
at the lower angle of the wound. Close the skin-wound neatly, using in-
tradermic sutures or ordinary sutures, preferably of horse-hair. Horse-hair
SI tures, being elastic, leave less scar than sutures of any other material. After
operations on the neck, very extensive dressings are required as small dressings
are difficult to keep in place.

In the course of any operation for the removal of tuberculous glands some
of them may be ruptured and from them there escapes caseous material. Such
extravasated matter must be carefully wiped away, and it is good practice
to scrape the remnants of the caseated material from the ruptured gland,
subsequently mopping the part scraped with liquid carbolic acid, followed
by the application of alcohol to neutralize the carbolic. When glands are so
firmly united to the great vessels of the neck that their removal is very risky,
it is proper to remove as much of the gland as possible and sterilize the re-
mainder with liquid carbolic, afterwards neutralizing with alcohol.

Subcutaneous Removal of Tuberculous Glands in the Neck and Sub-
maxillary Regions (DoUinger's Operation). — The operator sits behind the
head of the patient and wears an electric headUght. An assistant holds the
patient's head free and moves it to suit the convenience of the operator. Be-
ginning near the external auditory meatus, make an incision, 2 3-^ to 3 inches
in length, downwards and backwards, parallel to and about }i inch from the
margin of the hair. Through this incision packets of glands in almost all the
cervical region may be reached and removed by blunt dissection, the surgeon

LYMPH GLANDS OF NECK 213

undermining the skin to a point below the packet to be removed and removing
the glands from below upwards. Nerves and vessels must be pushed aside.
When the glands are seized with forceps, they often tear or collapse, especially
if they are caseated. This accident, according to Dollinger, does no harm,
provided the debris is promptly washed away. Cases in which peri-adenitis
has caused the formation of many firm adhesions are unsuitable for this opera-
tion. After removal of the glands the whole wound must be reviewed, cleaned,
drained, and sutured. The hemorrhage is remarkably slight.

The location of particular groups or packets of glands is as follows: I. The
retroauricular and subauricular glands lie next to the incision and are easily
removed.

II. The preauricular glands lie on the parotid beneath the masseteric fascia
which they penetrate and so reach the subcutaneous tissues. To reach them
pass under the external auditory meatus. The facial nerve is not in danger.

III. The glands under the head of the sternomastoid lie posterior to the
accessory nerve, which must be carefully preserved.

Glands also He in front of and beneath the nerve and must be removed
with great care. One reaches these glands from the wound by dissecting under
the posterior edge of the sternomastoid.

IV. Glands in the vicinity of the lower end of the parotid gland and of the
posterior facial vein are reached by burrowing between the skin and the sterno-
mastoid. When the disease is of long standing, the posterior facial vein is
often obliterated. Preserve the external jugular vein and the great auricular
nerves.

V. Glands about the submaxillary salivary glands. These are usually
three in number and lie between the salivary gland and the lower jaw. One
next burrows between the skin and the sternomastoid to the group of glands
anterior of the muscle, and illuminating the wound with the headlight, opens
their fascial covering and removes them bluntly.

VI. The submental glands, two in number, lie between the anterior bellies
of the digastric. These are best removed through a small incision directly
over them.

VII. Glands in the lateral triangle of the neck number about 50. The
upper ones can be easily reached through the primary incision. The lower
ones lying in loose connective tissue are easily pushed upwards and extirpated.
Look out for and preserve the branch of the spinal accessory going to the trape-
zius, the cervical and the brachial plexus. These structures are separated
from the glands by a layer of cervical fascia. The external jugular vein is
often obliterated.

VIII. The deep cervical glands lie along the great vessels under the sterno-
mastoid, and can be reached by undermining the muscle. If the glands are
firmly united to the vessels, pull them to the surface with a sharp hook and
carefully dissect them free. Remember that the traction empties the internal
jugular vein and makes it look like an innocent band of tissue.

This proceeding seems to the author very hazardous. Bollinger's opera-
tion seems to be excessively difficult, and may easily be very incomplete, but
that surgeon has performed it in very many cases, and with excellent results.

214 EXCISION OF CERVICAL TUMORS

■[ Bollinger's description of his operation appears in the "Proceedings of the
German Surgical Society," 1903.]

When the disease for which operation is required is malignant, almost
everything holds good which has been said regarding the excision of tuber-
culous glands, but the work is more complicated and difficult. That malig-
nant disease should be excised as thoroughly as possible is as true in the neck
as elsewhere, but thoroughness is more difficult to attain in this region. The
incision made must vary according to circumstances. It may be obliquely
vertical, transverse, or a horseshoe-shaped flap with its pedicle upwards or
downwards may be dissected from over the tumor. When the growth is ex-
posed, it must be separated from its surroundings. In doing this it is usually
wise to attend to the most dangerous part first. Thus, when feasible, the
surgeon should begin the enucleation at the point nearest the large vessels,
so that in case of accident or difficulty these may be under control. If the
carotid artery or the internal jugular vein passes into or becomes inseparably
united to the tumor, it is well to know the trouble early in the operation so that
one may inteUigently make up his mind as to the propriety of braving the
dangers of a completed operation or the advisability of closing the wound
before it is too late to recede.

Fig. 348. — Crilc's clamp.

The carotid artery lies deeper than the vein and is rarely involved in the
disease. The vein is often infiltrated or surrounded by the tumor and requires
ligation or removal, which is not particularly dangerous. Ligation of the
common carotid has a mortality of about 26 per cent, (from cerebral softening
principally). See p. 839. In operations for malignant disease Crile applies
his clamp (Fig. 348) to the artery and thus temporarily controls it. Some
surgeons throw a soft temporary ligature around the artery, which serves the
same purpose as Crile's clamp but does not do so in quite as elegant a
fashion. Temporary control of the carotid is of great value in operations for
malignant neoplasms.

If it seems probable that the tumor may be dissected free from the vessels,
it is often proper to lay a ligature loosely in position around the internal jugular
vein (to the cardiac side of the growth) so that, should air embolism be seriously
threatened during the later stages of the operation, an assistant can quickly
tighten the thread and avert danger.

Note. — In connection with severe surgical operations on the neck it should be
distinctly understood that section of the vagus nerve is not necessarily fatal.
Giordano (quoted in "Annals of Surg.," June, 1894) finds that after mal-
treatment of the nerve in surgical cases the mortality is not higher than 45
per cent, while in resection it is 75 per cent. Crile ("Problems Relative to
Surgical Operations," 1901) has made numerous experiments on the vagus and
reports a number of cases in which the vagus of one side was excised without ill

CERVICAL FISTUL.*: 21 5

effect. Before operations in which the vagus may be irritated or divided he
finds it wise to administer J'loo grain of atropin in order to prevent any cardiac
or respiratory inhibition.

Hydrocele of the Neck ; Cystic Lymphangioma.— A hydrocele of the neck
consists of a monolocular or multilocular cyst which may extend into the
anterior mediastinum or deep down among the large vessels of the neck. The
disease is congenital. Of course, the ideal treatment is extirpation, but this
is rarely proper because of its difficulty and danger. If extirpation is decided
on, the operation ought to be delayed until the end of the first year of life
(Arrou). The most common operative treatment consists in evacuation by
trocar and cannula, followed by irrigation with a 2 per cent, solution of carbolic
acid, or by injection of tincture of iodine diluted with water. This simple
treatment often gives excellent results; it is liable to fail when there are many
compartments or loculi in the cyst. When evacuation and injection fail or are
inappropriate, marsupialization affords a means of treatment which is thorough
and is safer than extirpation. Marsupialization consists in incising the cyst;
suturing the edges of the wound in the cyst to the skin; opening the subsidiary
cyst cavities; evacuating all the contents and providing for drainage by means
of a gauze tampon. In the course of the operation part of the cyst-wall may
be removed and the interior of the cavity may be swabbed first with liquid
carbolic acid and then with alcohol to neutralize the carbolic.

Congenital cervical fistulae require radical treatment when they give rise
to much inflammation or to cystic tumors; esthetic considerations may call
for their removal. Occasionally the fistulae are shallow and their extirpa-
tion is then easy. Usually they are complete, reaching from the neighbor-
hood of the tonsil (Rosenmiiller's fossa behind the tonsil), passing under
the digastric muscles to penetrate the cervical fascia and the skin in almost
any location between the sternomastoid muscles. Such fistulas must be com-
pletely excised, otherwise recurrence is liable to take place. The skin-incision
must be extensive and the cord-like fistulous track followed (preferably with-
out being opened), under guidance of the eye, up to its pharyngeal termina-
tion. The dissection is not one for the tyro in surgery to attempt. The re-
moval of the pharyngeal end and closure of the pharyngeal wound are most
difficult, but this difficulty has been evaded in a most ingenious manner by
Fritz Konig. After the fistula has been mobilized to a point above the digas-
tric muscle, Konig separates it still further from its surroundings by blunt
dissection until the pharyngeal mucous membrane is nearly reached; then he
opens the mouth with a Whitehead speculum, passes a stout probe with an eye
on the proximal end through the wound, and makes its point appear elevating
the mucous membrane in front of the lower margin of the tonsil. An incision
made through the mouth over the end of the probe permits the latter to be pulled
through, and with it a thread of sUk. The end of the fistula, after being tied
to the thread, is easily pulled into the mouth, fastened by a couple of stitches
to the wound in the mucosa, and its free end cut away. The external wound
is now closed. Instead of a long fistula leading from the pharynx to the skin,
there is a short, harmless fistula leading from the back to the front of the
tonsil. This simple "dodge" of Konig's is one of great value.

2l6 EXCISIOX OF CERVICAL TUMORS

Median cervical fistulae are different from those alluded to above; they
are the result of non-obliteration of the thyroglossal duct. The thyroglossal
duct leads from the foramen caecum on the tongue through the root of that
organ down to a low point in the neck. On its way down the duct either passes
through or is closely connected with the body of the hyoid bone. Excision
of a patent or inflamed duct below the hyoid is easy; above that bone, it may
be difficult or easy, generally the former. If the duct passes through the
hyoid, the portion enclosed in the bone must be thoroughly removed even if
it is necessary to excise a portion of the bone itself. Occasionally that part
of the duct which traverses the tongue gives rise to a tumor consisting of tissue
very like that of the thyroid gland. Cysts arising from distention of the
duct above the hyoid may give rise to ranula-like tumors. In treatment
of ranula it is well to bear this fact in mind. A stubborn and obscure recurrent
phlegmonous inflammation in the submental region may be due to an unsus-
pected remnant of the thyroglossal duct.

Lingual thyroid may occasionally be easily shelled out of the tongue or
extensive operations may be necessary.

W. G. Spencer (Royal Soc. Med. Surg. Sect., 1914, 163) draws attention
strongly to the fact that a lingual thyroid not infrequently is the only active
thyroid present in the individual and that as a consequence hj^jothyroidism
must result should that tissue be removed. He writes "from the standpoint
of a clinical examination, then, it is of primary importance to recognize the
presence of the isthmus of the thyroid gland or the reverse. When the isthmus
is absent, so that the tracheal rings from the cricoid cartilage downwards can
be felt, it should be assumed that the patient's actively secreting thyroid may
have been developed in the course of the thyreoglossal tract, and although there
may be a fullness on either side of the trachea suggesting the existence of
lateral lobes, yet these may be parathyroids destitute of any true thyroid
function."

Spencer thinks that when the lingual thyroid has caused so much swelling
at the base of the tongue as to impair breathing or has ulcerated and hemor-
rhage has followed, then the removal of a small wedge and suture, or a limited
application of the cautery is the proper treatment. If it is necessary to excise
the lingual thyroid probably Matti's operation will be found suitable (Archiv
f. Klin. Chir., ciii, 248).

Matti's Operation. — Preliminary tracheotomy is advantageous.

Step I. — Make a curved collar incision through the skin and platysma at
the upper margin of the hyoid bone. The length of the incision depends on
the size of the tumor but in any event it ought to be long enough to permit
preliminary ligation of one or both lingual arteries beside the great horn of
the hyoid. Reflect the flap of skin and platysma upwards as far as possible.

Step 2. — Isolate and divide the middle of the body of the hyoid bone.
Split the raphe between the mylohyoid, geniohyoid and genioglossus muscles and
retract these muscles laterally along with the two segments of the hyoid bone.

Step 3. — Remove the tumor after dividing its firm attachments to the
hyoid bone. This may sometimes be accomplished without penetrating
the lingual mucosa. The operation may be much facilitated if an assistant

SYMPATHECTOMY 21 7

presses upon the lingual surface of the tumor with his fingers in the patient's
mouth.

Step 4. — If the mouth has been penetrated, the wounded mucosa must be
sutured. The wound must be packed or drained, the muscles sutured correctly
and the skin closed except where the drain protrudes.

CHAPTER XXII
EXCISION OF THE CERVICAL SYMPATHETIC

Jonnesco describes the total excision of the cervical sympathetic very
nearly as follows:

Step I. — Cutaneous incision: Make a cut from behind the mastoid process
downwards along the posterior border of the sternomastoid to a point a little
below the clavicle. The external jugular vein is divided between two ligatures.

Step 2. — Separation oj the posterior border of the sternomastoid: To avoid
section of the external branch of the spinal accessory nerve and the diffi-
culties often met in freeing the posterior border of the muscle in the upper part
of the wound, make an incision along the muscle parallel and close to the
posterior margin. Separate the fibres of the muscle and operate through this
elongated button-hole.

Step 3. — Search for and isolation of the sympathetic nerve: Retract the
muscle and with it the packet of cervical vessels and nerves (carotid artery,
internal jugular vein, vagus nerv^e) inwards and upwards. Two blunt hooks
or one wide blunt retractor are useful for this purpose. Look for the nerve
in the middle of the wound, either on the posterior surface of the sheath of
the vascular packet with which the nerve may have been retracted inwards
or on the vertebral column, where it lies in a special aponeurotic sheath. The
nerve is easily found. It is impossible to confound it with the vagus, the
descending branch of the hypoglossal (descendens noni), or the phrenic. To
dispel all doubt as to identity follow the nerve upwards and see the superior
gangUon (Fig. 349).

Step 4. — Isolation and resection of the superior ganglion: Follow the nerve-
trunk upwards to the gangUon and isolate the latter from below upwards
by blunt dissection with a director. Divide its afferent and efferent fibres with
blunt-pointed curved scissors. When the upper end of the ganglion is isolated,
divide or tear away the trunk which leads from it towards the skull (Fig. 350).

Step 5. — Liberation of the inferior thyroid artery: This artery is surrounded
by a dense and often adherent nervous plexus consisting of the sympathetic
trunk and its branches. The nerve often is swollen at this point, forming
the middle cervical gangUon. Put tension on the nerve-trunk already isolated
and follow it downwards. Elevate the nerve and the inferior thyroid artery
together and separate them by careful blunt dissection (Fig. 351).

Step 6. — Isolation and resection of the inferior ganglion: This is the most
difiicult step in the operation, as the ganglion lies deeply imbedded in a special
lodge at the base of the neck or even in the thorax, behind the clavicle, against
the neck and head of the first rib, between the scalenus anticus and longus

2l8

EXCISION OF THE CERVICAL SYMPATHETIC

colli muscles and just above the pleura. Using the trunk of the nerve as a
guide, penetrate to the ganglion, which lies sometimes internal to, and some-
times (though rarely) external to, the vertebral artery. The ganglion is

Sup. ganglion

Sp. accessory nerve -j.
Sternomastoid

Carotid packet I ..J'"

Sympath. n.
Inf. thyroid artery

Inf. ganglion
Vertebral artery

Phrenic n.

Fig. 349. — E.xcision of cervical sympathetic. (Jonnesco.)

adherent to the artery and enlaces it in a meshwork of its efferent and afferent
fibres (Fig. 351). With appropriate retractors retract the scalenus anticus,
thyroid axis, and the vertebral artery and vein, downwards and outwards;

Sympath. n.

Inf. thyroid artery-

Middle ganglion-

Scalenus ant.
', Thyroid axis

Vertebral n.
Fig. 350. — (Jonnesco.)

retract inwards and forwards the sternomastoid muscle and the carotid sheath
with its contents. Divide, with a grooved director, the cellular and aponeurotic
tissues covering the vessels and the ganglion. Seize the ganglion with for-

SYMPATHECTOMY

219

ceps and isolate it successively from the vertebral artery externally and from
the rib and spine internally. Isolate and divide the afferent and efferent
fibres, and remove the ganglion.

The dangers which may be encountered are:

1. Injury to the vertebral artery and vein.

2. Injury to the first intercostal artery or its cervical branch.

3. Injury to the subclavian artery, especially on the left side.

4. Injury to the pleura.

5. Friability of the ganglion, rendering morcellement necessary.

6. Intimate union of the inferior cervical and first thoracic ganglia into
one mass, from which a portion must be removed.

7. Injury to the retroclavicular venous plexus. This accident will be
rare if the trunk of the nerve is followed closely.

Inf. thvroid art.

Middle ganglion

Inferior ganglion

Vertebral art. and
vein

Vertebral n.

Fig. 351. — (Jonnesco.)

Step 7. — Suture of the Wound. — Close the wound completely with buried and
superficial catgut sutures. The superficial stitches ought to be introduced
in the intradermic fashion so as to leave little scar. There should be no drainage.
Apply dressings.

Immediately after operation on one side the corresponding pupil dilates,
the face flushes, eye waters, and nose secretes abundantly. These phenomena,
except the pupillary dilatation, are very transitory. The pulse falls below
normal for a few days; after partial resection of the sympathetic it is accelerated.
The operation seems to have no ill effects.

After the patient has recovered from the operation on one side the other
side should be attacked in the same manner.

Jonnesco ("German Surg. Congress," 1906) has performed cervical sym-
pathectomy in 159 cases, in 141 of these the three gangha were removed with
or without the first thoracic ganghon. In all but two cases the operation was
bilateral. There were no deaths and no secondary trophic troubles. The
therapeutic results were:

I. Twenty-five cases of exophthalmic goitre (two subtotal resections;

220 EXCISION OF THE CERVICAL SYMPATHETIC

twelve complete; eleven cervico-thoracic resections). In every case the disease
was primary Basedow's disease, either complete or incomplete, often of serious
degree. All the patients recovered, every symptom disappearing. He recom-
mends strongly the complete operation with or without removal of the first
thoracic ganglion.

2. Glaucoma. — Eighty-eight cases of superior sympathectomy have been
collected showing sixty-one cured or improved, twenty-two unimproved,
five aggravated.

3. Epilepsy. — One hundred and seventeen cases with but twelve definite
cures.

4. Trigeminal Neuralgia. — In one case resection of the superior ganglion
resulted in recovery which has lasted four years, in another case for six months.

De Souza has had similar experiences in Basedow's disease and in facial
neuralgia.

Farquhar Curtis finds that the mortality after sympathectomy for Basedow's
disease is very high and the ultimate results in the survivors fair. (''Annals
Surg.," March, 1906.) Alexander of Liverpool at one time performed sym-
pathectomy frequently for epilepsy but gave it up. The operation is still sub
judice. *

Periarterial Sympathectomy. — R. Leriche (La Pr. Med., Sept. 10, 191 7 and
May 15, 1920) recommends periarterial sympathectomy in causalgia and cer-
tain trophic troubles. He believes that most if not all rebellious causalgias
are due to disturbances of the sympathetic system, that the burning pains
following certain nerve wounds is not due to the injury to the nerve itself, but
to lesions of the neighboring perivascular sympathetic or of the intra-nervous
sympathetics, e.g., of the sympathetic fibres brought into the median nerve
by its special artery. This explains the fact noted by Marie, Meige and Mme.
Benisty, that the pain after nerve wounds is a reaction proper to nerves
provided with a special artery or which are near a large artery.

The sympathetic plays a very great part in the production of the true
Babinski — Froment reflex contractures in which vaso-motor and thermic
phenomena are associated with motor disturbances of the muscles. In cases
of this kind Leriche has seen motor troubles disappear almost completely
after sympathectomy. The day after operation mobiUty has returned notably
in hands up till then so contracted that the fingers were flexed into the palm or
stiflfly extended dorsally. Sympathectomy on the brachial artery has ap-
parently cured ulnar claw hand (griffe cubital).

The results of Leriche's observations are: — (i) In causalgia periarterial
sympathectomy sometimes cures, almost always improves (2) trophic ulcer-
ations. Five patients submitted to operation. All cured. (3) Blue oedema
of the extremities. Three submitted to operation. Cured; much improved i;
some improvement i. (4) Reflex disturbances 18 operations. Practically
cured 3, (disappearance of vaso-motor disturbances and of contractures).
More or less improved (some almost cured) 10; improved but with later incom-
plete recurrence 2 ; failures 2.

*Leriche [Bui. Soc. Chir. Paris 21, Dec, 1920] has relieved or cured (i) progressive
facial hematroph}-, (2) post-herpetic hemicrania, and (3) permanent lagophthalmos in
facial palsy bj- means of excision of the superior cer\-ical sympathetic ganglion.

PERIARTERIAL SYMPATHECTOMY 221

In the i6 cases with true improvement there was diminution of contracture
with more or less reappearance of voluntary motion. After some weeks as
the vaso-dilatation caused by the sympathectomy lessens, retrogression takes
place but the operation is of value, according to Heitz, as a step in treatment.
The treatment by sympathectomy followed by hot paraffin baths, massage and
reeducation gave the best results in Babinski's service.

(5) In one case of diffuse parenchymatous goitre Leriche performed unilateral
periarterial sympathectomy of the superior thyroid and noted that there was a
''veritable melting away of the corresponding lobe." If this observation is
verified it will help to explain the good results from ligation of the thyroid
vessels.

The Operation. — Expose the artery as usual for a distance of 8 to 10 cm.
(3-4 ins.). Incise the tunica adventitia and separate this sheath from the
artery by sharp or blunt dissection. If the integrity of the vessel is accidentally
injured too much, doubly ligate it and excise a segment. The whole procedure
is more or less like subserous decortication of an inflamed appendix. When the
decortication of the artery is completed close the wound.

The reactions following operation are primary and secondary. Primarily
the artery gradually contracts to }/^ or even 34 its normal size throughout the
denuded segment, while the segments above and below remain normal. The
pulse usually disappears, but the circulation is not abolished. For some
hours the pulse is imperceptible or very weak and the limb is colder than it's
fellow.

Secondary Reactions. — After 3-6 or more frequently 12 or 15 hours the local
temperature rises 2° or even 3° (centigrad). Arterial pressure sometimes
becomes 4c. higher than on the opposite limb. These reactions slowly diminish
after two weeks, lasting longer when the artery is resected than when its outer
tunic alone is removed. The value of periarterial sympathectomy is entirely
sub judice. It's preponents are apparently fairly conservative in their claims.

In hyperthyroidism with extreme exophthalmos and nervous symptoms out
of proportion to the size of the thyroid C. H. Mayo removes the superior
sympathetic ganglion (sometimes the middle one also) and through the same
incision ligates the superior thyroid vessels. It is best to operate with both
general and local anesthesia. An incision is made opposite the bifurcation of
the carotid, the sternomastoid is retracted outwards, the carotid packet is
drawn inwards and opened posteriorly so as to demonstrate the vagus as this
nerve may be mistaken for the sympathetic. Under normal conditions the
sympathetic ganglion is 3^ to 34 inch wide and has many branches. After
division of the connecting branches the upper part of the ganglion is torn off
or cut and the lower portions of the nerve cut or torn off at the middle ganglion
unless that also is removed. The superior thyroid vessels are secured by
ligating the upper poles of the thyroid. Sympathectomy causes relaxation of
the eyeballs, slight ptosis of the upper lid with general improvement of symp-
toms. In Mayo's cases when the vessels of both upper poles were ligated in
addition to the sympathectomy the primary results were good but time enough
has not passed to permit conclusions being drawn regarding permanency.

Pleth (see p. 75) recommends this method of sympathectomy as a cure for
trifacial neuralgia.

222 RETROPHARYNGEAL ABSCESS AND TUMORS

CHAPTER XXIII

RETROPHARYNGEAL ABSCESS AND TUMORS

There are two methods of opening retropharyngeal abscess, viz., through
the mouth and through the neck.

1. Opening the Abscess through the Mouth. — No anesthetic, not even
cocaine, is permissible. If the pharyn.x and larynx were anesthetized, there
would be increased danger from inspiration of discharges. A knife, the edge
of which is protected with cotton or adhesive plaster to within one inch of the
point, is guided on the finger of the left hand through the mouth to the posterior
wall of the pharynx. An incision is made into the abscess at its most promi-
nent point. The knife is at once withdrawn. If the patient is a child, the
operation should be performed in the Rose's position — i.e., with hanging head,
and in any case as soon as pus begins to flow the head should be lowered and
the body elevated. The after-treatment consists in the use of antiseptic gar-
gles and sprays and in keeping the wound open by daily probing, if this is
necessary.

2. Drainage through the Neck, — Chienes Operation. — Make an incision
two inches in length along the posterior margin of the sternomastoid, beginning
at the apex of the mastoid process and running downwards. After division
of the deep fascia one can by blunt dissection reach the anterior surface of
the bodies of the cervical vertebrae where the abscess is situated. The skin
and fascia having been incised as above, the pus may be reached and evacuated
by Hilton's method. This is a very safe and easy procedure.

Remarks. — Retropharyngeal abscess may be acute or chronic. It is only
for the former that operation through the mouth is suitable. On purely
theoretical grounds the operation through the mouth must be condemned for
the following reasons: (a) When the pus begins to flow there is danger of asphyxi-
ation, {h) No dressings can be applied to soak up discharges and keep out
dirt, (c) There is grave danger of septic pneumonia and of infection to the
gastrointestinal canal, {d) If the case is one of tuberculous abscess, secondary
infection is certain. Practically it has been found that by using Rose's position
or by inverting the patient during the first flow of pus the danger of asphyxia-
tion is averted, and that in acute cases rapid recover^' does ensue. An advan-
tage is claimed for this operation, viz., that an anesthetic is not necessary, but
certainly in case of need the external operation can be done under a local
anesthetic.

The advantages of the external route are: (c) The possibility of careful
removal of diseased foci, e.g., diseased bone, etc.; {b) the possibility of treat-
ing the abscess antiseptically and providing for permanent draining; (c) the
possibility of avoiding secondary infection; {d) the avoidance of the danger
of drowning the patient in his own pus.

The principal disadvantage is the scar which must be left, but as a rule it
is not very noticeable.

RETROPHARYNGEAL TUMORS 223

Retropharyngeal Tumors. — I. The tumor is not adherent to the spinal
column, but is movable. Perform tracheotomy. Tampon the larynx or tra-
chea. Place the patient in Rose's position. Introduce a mouth-gag and open
the mouth. Pierce the tongue with a needle and pull through a stout thread
which serves as a handle to manipulate the tongue. Make an incision through
the mucous membrane of the posterior pharyngeal wall and expose the tumor
freely. Busch has shown that the tumor lies loosely imbedded in the retro-
pharyngeal tissues and can be shelled out. Generally blunt dissection with
closed curved scissors will result in easy removal of the growth. Clean the
pharyngeal cavity and the wound with a non-poisonous antiseptic.

If necessary to obtain more room, the soft palate may be divided longitu-
dinally. This wound must be closed by suture as soon as the tumor is removed.

II. The tumor is so extensive that removal through
the mouth is impossible. The pharynx must be opened ^^ , r ^$^

from the neck.

Step I. — Make a U-shaped incision beginning in
front of the masseter and ending at the tip of the mas-
toid process. The lowest part of the U reaches below

the level of the hyoid bone. Doubly ligate and divide , ^^'?- 352 —Exposure
1 • 1 • -r. n 1 1 1 • n '^^ pharynx from the

the external jugular vem. Reflect upwards the skm-nap neck.

outlined by the incision (Fig. 352).

Step 2. — Divide the cervical fascia along the anterior margin of the sterno-
mastoid. Expose the external carotid artery. This artery, partly covered
by the internal jugular vein, should be sought on the line of the anterior margin
of the sternomastoid between a point on a level with the hyoid and one on a
level with the upper edge of the thyroid cartilage. Before tying the vessel
expose at least one of its branches. This precaution is recommended because
the internal has occasionally been mistaken for the external carotid.

Step 3. — Doubly ligate the artery and divide it between the ligatures.
Expose as thoroughly as possible such part of the tumor as may present between
the inferior maxilla and the mastoid. If it is feasible to remove the tumor
through this space, do so; otherwise proceed to the next step.

Step 4. — Cut through the soft structures covering the inferior edge of the
horizontal ramus of the lower jaw at a point just in front of the masseter muscle.
Through this incision with an elevator separate the periosteum from the bone
sufficiently to allow of subperiosteal section of the bone. With finger-saw,
forceps, Gigli's wire or the chain saw divide the bone. Dislocate the temporo-
maxillary joint and turn the ascending ramus of the jaw upwards together
with the soft parts covering it. This gives very free access to the pharyngeal
wall.

Step 5. — Isolate the tumor by blunt dissection if possible. Do not open
the pharyngeal cavity before it is absolutely necessary to do so. Remove the
growth.

Step 6. — Pack the cavity with iodoform gauze. Replace the dislocated
portion of the lower jaw and wire it in position. Close most of the wound
in the soft parts by interrupted silkworm-gut sutures, leaving an opening
through which the gauze pack protrudes. Dress.

224 CESOPHAGUS

In one case the writer was surprised to find that he was able to shell out
in the above manner a large tumor affecting the right side and roof of the
pharynx, without tearing or dividing the pharyngeal mucous membrane.

As a preUminary to the operation tracheotomy may or may not be per-
formed. If the growth, either from size or location, does not interfere with
respiration; if the surgeon ligates the external carotid artery near its origin
and does not open the pharynx until the tumor is almost entirely separated
and hemostasis has been secured, then a preliminary tracheotomy appears
superfluous.

CHAPTER XXIV
CESOPHAGUS

(Esophagotomy. — The oesophagus may be opened either in the neck or in
the posterior mediastinum. The latter operation is discussed elsewhere.

Cervical oesophagotomy is performed for the removal of foreign bodies,
the treatment of stricture, the excision of small, sharply defined tumors, or as a
step in the operation of oesophagostomy. Place the patient on the table with
shoulders slightly elevated and the face turned towards the right. Beginning
at the level of the thyroid cartilage, make an incision downwards for about
three inches along the anterior margin of the left sternomastoid muscle. Divide
the platysma, superficial and deep fasciae. The omohyoid may be divided
or retracted according to convenience. Retract the thyroid gland and trachea
towards the right. Notice, in the wound, the common sheath containing the
carotid, internal jugular, and vagus. Retract these structures to the left.
The oesophagus will now be exposed. If a foreign body is present, fix the
oesophagus with small volsellum forceps and make a longitudinal cut into it
over the foreign body. If necessary, enlarge the wound with a probe-pointed
bistoury or with scissors. Gently extract the foreign body. This frequently
requires much patience. The incision through the oesophagus should be made
on the side, as the recurrent laryngeal lies in the groove between it and the
trachea.

When no foreign body is present distending the oesophagus, pass an oesoph-
ageal bougie through the mouth and cut down upon it when incising the gullet
wall.

V. Haecker (Muenchener med. Woch., Oct. 15, 1907) reports the case of a
pregnant woman who swallowed her plate with artificial teeth. This irregular
body became impacted where the oesophagus crosses the left bronchus. At-
tempts at removal by the oesophagoscope having failed, Friedrich opened the
oesophagus just above the upper thoracic aperture and removed the plate after
dividing it with cutting forceps. The wound was packed around an oesophageal
catheter through which food was administered. Soon an cesophageal-bronchial
fistula formed and gangrene developed. Gastrostomy was now performed
and for three months the patient was nourished through the gastric fistula.
After this time the broncho- oesophageal fistula closed and the patient recovered
perfectly.

(ESOPHAGEAL DIVERTICULA 225

Bodies impacted low down in the oesophagus have been extracted through
a gastrotomy wound in twenty out of twenty-four cases (v. Haecker). A
bougie passed through the mouth gives great assistance in the work.

Foreign bodies may be removed from the lower oesophagus through the
stomach. M. H. Richardson successfully performed gastrotomy, explored the
lower oesophagus and removed a plate containing four teeth which had been
lodged there for eleven months. A peach stone was arrested 6 or 7 inches above
the cardiac orifice; the usual measures failed to dislodge it; W. T. Bull per-
formed gastrotomy, passed a small bougie, with a loop at its point, from the
stomach to the mouth, pulled a stout thread through the oesophagus with the
bougie; tied a sponge to the lower end of the thread and pulled the sponge
through the oesophagus and out of the mouth. The sponge swept away the
foreign body.

Through the oesophageal wound one may divide or forcibly dilate a stricture
or even remove a small tumor. For such purposes, however, the operation will
be but little used, as strictures are generally more suitably treated by other
means, and tumors eradicable by the above operation must be of great rarity.

Closure of the Wound. — Close the oesophageal wound by a row of sutures of
fine catgut not involving the mucosa. Lessen the size of the external wound
by a few stitches at its upper and lower extremities. Loosely pack the remainder
of the wound with iodoform gauze. Apply plentiful dressings. Treves advises
the use of some orthopaedic apparatus to secure rest for the parts.

For the first day or two after the operation the patient should be nourished
by means of enemata; subsequently food should be administered through a
small soft-rubber stomach-tube passed through the mouth. This method of
feeding must be kept up until it is evident that the oesophageal wound has
healed. The cervical wound requires frequent dressing and the mouth must
be washed at short intervals with some antiseptic lotion. The great danger
to be apprehended is sepsis, especially septic mediastinitis.

(Esophageal Diverticula. — Diverticula occasionally are present in the neck
and communicate with the oesophagus or pharynx. When these are large,
food passes into them and serious symptoms, even death, may result. The
condition is often unrecognized by the physician. In serious cases operation
is demanded. Sometimes good results are obtained by having the patient
swallow a whip cord and using this as a guide, passing bougies in a manner
analogous to the passage of Gouley's tunnelled sounds over a whalebone fili-
form in urethral stricture (Mixter).

The Operation. — Proceed as in oesophagotomy. Retract the trachea to-
wards the right, the sternomastoid and the sheath containing the carotid,
internal jugular, and vagus to the left. Pass an oesophageal bougie through
the mouth into the diverticulum, if this is possible. Recognize the divertic-
ulum and its relations to surrounding structures. Remove the bougie. Sepa-
rate the diverticulum from its surroundings. This can generally be accom-
plished by blunt dissection. Where the diverticulum joins the oesophagus its
neck may be as thick as a man's thumb. Divide the neck of the diverticulum
layer by layer close to the oesophagus. With catgut, suture the wound of the
mucous membrane. The wound of the outer tunics of the neck of the diver tic-

2 26 OESOPHAGUS

ulum is closed by an invaginating suture like Lembert's intestinal stitch.
Partially close the external wound. Provide very free drainage by means of
iodoform gauze. The after-treatment is the same as that for cesophagotomy.
When the diverticulum is comparatively small the skin-incision need not be
longer than that for cesophagotomy; but when it is large, then the incision must
be longer. It is better to make an incision longer than is absolutely necessary
than be cramped, while operating, through lack of room.

Girard and A. E. Halstead in cases of small diverticula avoided opening the
sac. .After exposing and isolating the sac, they surround it near its base by
a catgut purse-string suture, invaginate the diverticulum into the oesophagus,
pull the purse string tight and tie it. This method avoids the necessity of
drainage. The pouch is said to become atrophied.

Gehles Method. — To avoid dangers of mediastinitis, etc., especially in de-
bilitated individuals, Gehle ("Muenchener med. Woch.") operates as follows:

Expose and isolate the diverticulum. Make a small opening into the
distal end of the sac. Remove the mucous membrane as well as possible with
a sharp spoon. Through the sac pass a small oesophageal tube into the stomach.
Rotate the sac (and tube) on its long axis, to the extent of i8o°. FLx the
sac in its position of torsion by means of three catgut purse-string sutures after
freshening the surfaces to be brought in contact. These sutures tie the sac
firmly to the tube. Suture the opening in the sac, where the tube protrudes,
to the superficial fascia. Close the wound around the sac. Gehle was able to
feed his patient through the tube on the day of operation. The tube was
removed on the sixth day. On the sixteenth day both solid and fluid food could
be swallowed.

To the author it appears that Gehle is wrong in calling the operation "radi-
cal," but in suitable cases it seems to be the least dangerous method and at
the same time the alteration in position and shape of the diverticulum promises
good practical results. It is difficult to believe that curettement will suflS-
ciently remove the mucosa to permit of obliteration of the lumen.

CESOPHAGE.AL STRICTURE

Non-malignant strictures of the oesophagus should be treated by the passage
of bougies through the mouth. It is said that dilatation may sometimes be
aided by the hypodermic administration of suitable doses of thiosinamin (thio-
sinamin, 15; antipyrin, 7.50; water, 100. Dose, 0.5 c.c. Ten injections usually
suffice) or some of its equivalents. This drug acts by softening scar tissue
to such an extent that mechanical treatment is greatly facilitated. The oesoph-
agus commonly becomes greatly distended above the site of a stricture hence
it is often difficult to pass a sound into the stricture. Under these circum-
stances retrograde catheterization becomes proper.

Abbe's Operation. — The oesophageal pouch which forms above a stricture
is a great hindrance to the passage of bougies. Abbe overcomes this difficulty
by retrograde dilatation which he carries out in characteristically ingenious
fashion. Perform gastrotomy. Pass a fine whale-bone bougie from below
upwards until it protrudes from the mouth. To the end of the bougie tie

CESOPHAGECTOMY 227

two long and stout threads of braided silk (whip cord will do). Pull the bougie
out through the stomach wound and leave the two threads protruding from
the mouth and the stomach wound. Tie the lower end of one thread to an
eye at the point of a conical oesophageal bougie (Billroth). By pulling on the
upper end of this thread it is easy to bring the conical tip of the bougie into
the stricture and render that stricture tense. Keep up gentle traction to
dilate the stricture with the bougie and at the same time pull the second cord up-
wards and downwards vigorously with a see-saw motion. The friction of the
cord divides the stricture without damaging other strictures. The conical bougie
rapidly passes upwards as the friction wears away the strictures, and the
largest bougie suitable to the oesophagus is rapidly forced upwards to the mouth
by a few moments' stretching and "string-sawing." The gastrotomy wound
may now be closed by inversion and double suturing. Subsequent passage
of a full-size bougie once a week will complete the cure, but must be continued
at longer intervals for one year or more. Instead of dividing the stricture
by friction and bougies, Ochsner draws a rubber tube, under tension, through
the stricture. When the tension is taken off the tubing it expands and so
dilates the stricture. In the course of some days, during which larger or double
tubes are introduced, Ochsner obtains good results.

The author was much prejudiced against the Abbe operation, thinking it
harsh and dangerous, but since seeing it performed by Abbe he has changed
his views.

In any method of treatment where a gastrostomy is performed, do not
administer thiosinamine. If this drug has any marked softening effect on the
scar tissue forming the stricture it ought to have a similar and disastrous effect
on the union between the stomach and the belly wall.

In one case operated on by Maurice Richardson a friable stricture existed
in the oesophagus immediately below the opening of a diverticulum. Richard-
son split or ruptured the stricture longitudinally and repaired the defect by
means of a flap provided by the diverticulum. The excess of tissue in the
diverticulum was excised

CEsophagostomy may be performed below a stricture or neoplasm as a means
of feeding, but gastrostomy is infinitely easier and safer to perform and is
much less disagreeable to the patient subsequently. It may be performed
above the stricture to permit the passage of a funnel-shaped tube from the
pharynx over the chest wall to a gastric fistula (Gliick), The operation is
practically the same as oesophagotomy but the oesophageal wound is kept patent
either by suturing or by the introduction of a rubber tube.

Cervical (Esophagectomy for malignant neoplasms is not very promising,
according to deQuervain's statistics, but if performed early and thoroughly,
results ought to be improved.

1. Expose the oesophagus as in oesophagotomy, the incision must be more
extensive as a rule. If the thyroid adheres to the neoplasm, remove that portion
of the thyroid. Carefully separate the oesophagus from the back of the trachea
and larynx, paying special attention to the preservation of the recurrent
laryngeal nerve. Completely isolate the affected segment of the gullet.

2. Choose the line of section at least }/2 i^ich above and below the neoplasm.

2 28 CESOPHAGUS

Introduce an anchor suture of silk or hemp into the wall of the gullet above and
below the part to be removed. Divide the oesophagus at the selected points.
Attend to hemostasis.

3. A. A very limited portion of gullet has been removed (4 cm., 1^ inches,
Czerny), restore the continuity by sutures. B. If a longer portion has been
excised and approximation is impossible, anchor the upper and lower oesopha-
geal stumps to the skin by means of sutures. Pack the wound carefully, paying
special attention to protecting the mediastinum. When the wound has become
sufficiently covered with granulation tissue a secondary oesophagoplasty may be
attempted or a tube may be passed from the pharynx to the stomach as men-
tioned in oesophagostomy.

C. Primary oesophagoplasty (Arbuthnot Lane, "Brit. Med. Journ.," Jan.
7, 1911). Cut a flap of skin about 5 inches long and 2 or more inches wide (ac-
cording to the amount of disease to be removed) extending horizontally from a
vertical line to the left of the larynx over the anterior and right sides of the neck.
Reflect the flap up to its base. Expose and excise the affected segment of
gullet. Fold the skin flap in the form of a tube of appropriate diameter and
suture it carefully to the oesophageal stumps. Pass a tube through the pharynx
and oesophagus and leave it in situ for feeding purposes. (Gastrostomy is com-
monly performed as a preliminary operation so that nourishment can be
given.) Pack the wound with gauze and partially close it with sutures.

D. Secondary oesophagoplasty has been performed byHascker and others but
it is so similar to the primary operation that a special description is unnecessary.

Antethoracic CEsophagoplasty. — Roux ("Semaine medicale," Jan., 1907)
reported an operation for impermeable oesophageal stricture. The operation
consists in performing an oesophago-jejuno-gastrostomy.

1. Open the abdomen. Choose a very mobile loop of jejunum. Doubly
ligate and divide four or five of the vessels passing to the loop of jejunum pre-
serving the peripheral vascular arcades intact. Be sure that sufficient blood
passes through the vascular arcades of the selected portion of gut from unligated
vessels near its anal end. Apply intestinal clamps to and divide the gut at both
ends of the selected segment.

2. Anastomose the open anal end of the segregated segment to the stomach
near its lesser curvature.

3. With forceps make a subcutaneous tunnel from the abdominal wound to
the notch of the sternum. Protect with gauze the oral end of the segregated
segment of jejunum and pull it up through the tunnel. With sutures fix the
upper end of the gut to the upper end of the tunnel. Pass a stomach tube
through the segment of gut buried in the chest wall, into the stomach and fix
it to the opening at the sternal notch.

4. With suture or Murphy's button restore the continuity of the intestine.
If the patient survives the above rather strenuous procedure the cervical

oesophagus may be exposed, incised and anastomosed to the upper end of the
subcutaneous tube by means of flaps of skin.

Th. Gliick in cases of malignant oesophageal stricture exposes the cervical
oesophagus, makes an opening in it, and unites the opening to the skin. A
gastrostomy has also been performed. When the wounds are healed Gliick

CESOrHAGOPLASTY 229

introduces a rubber tube through the mouth to emerge from the oesophageal
fistula and pass over the chest to enter the stomach via the gastrostomy opening.
The upper end of the tube is funnel shaped so as to remain in the oesophagus.
Prof. Gluck informed the author that his patients could swallow their food
satisfactorily, the bolus passing through the rubber gullet as well as if there
was peristalsis.

In one case of oesophageal cancer Kelling ("Zent. fiir Chir.," No. 36, 191 1)
found the mesentery of the small intestine too short to permit of Roux's opera-
tion being performed so he operated as follows : Laparotomy. The transverse
colon was found long and mobile. At each end of the most mobile and con-
venient segment of colon two intestinal clamps were applied and the gut divided.
After restoring the continuity of the remainder of the colon, the right end of the
segregated segment was closed with sutures and the left end was anastomosed to
the stomach. The meso-colon was divided below the vascular arcade, only the
left portion being retained intact. A Stamm-Kader gastrostomy was performed.
An incision was made through the skin from the level of the mamma on the left
of the sternum down to the abdominal wound and a subcutaneous gutter formed
in which the mobilized colon was planted, the skin wound being sutured over
the gut. The abdominal wound was closed. After seven days the buried blind
end of the colon was opened and its mucosa sutured to the skin. After 25 days
cervical oesophagostomy was performed. To unite the upper end of the trans-
planted colon to the cervical stoma by means of a tube of skin, two parallel
incisions about four finger-breadths apart were made through the skin just
above the cervical opening to below the fistula on the chest. By undermining
it was easy to form a tube of the skin between the incisions and so to complete
the new oesophagus. The raw surfaces occasioned by the formation of the
epidermal tube were covered by pedunculated flaps of skin taken from else-
where on the chest.

Instead of using intestine in antethoracic cesophagoplasty, Bircher and Wull-
stein have constructed a tube entirely composed of skin just as Kelling did for
part of the oesophagus in his case.

Frangenheim (German Surg. Congr., 191 2) reported one case of antethoracic
cesophagoplasty in which both skin and jejunum were used; the patient after
the lapse of a year was still swallowing all sorts of food without trouble.

Jianu's CEsophagoplasty. — Open the abdomen. Pull the stomach forwards.
Divide the great omentum transversely below the gastro-epiploic vessels. Li-
gate and divide the right gastro-epiploic vessels. The greater curvature of the
stomach is now free from the omentum and well nourished by the left gastro-
epiploic vessels.

Put a row of mattress sutures through both the anterior and posterior
walls of the stomach along the line A B, Fig. 353. (With a complex machine
devised by Hiiltl, Willy Meyer in one movement inserts a double line of wire
stitches along A B and cuts between, thus saving time and soiling.)

Incise the stomach (both walls) along the line CD. Close the flap of
stomach between the cut CD and the greater curvature by a double line of
sutures (CD') so as to form it into a tube open at its distal end (C) and con-
tinuous with the cardia at D.D'. This tube is well nourished by the left

230

PHARYNGOTOMY AND LAKYXGOTOMY

gastro-epiploic vessels. Bury the line of mattress sutures by a row of Lembert
sutures. The result is seen in Fig. 354. Make a subcutaneous tunnel from
the abdominal wound upwards on the chest to about the level of the third
costal cartilage. Incise the skin here. Pull the tube of stomach up through
this tunnel and suture the mucous membrane at its distal extremity to the
skin. The rest of the operation is the same as in some of the procedures
alreadv described.

"'mm^^'^'^

Fig. 353.

Fig. 354.

Willy Meyer (Trans. Surg. Section A. ]M. A., 1913) thinks it feasible to
complete the Jianu operation by opening the chest in the seventh left inter-
space, e.xcising the diseased oesophagus, closing the distal oesophageal stump
and making an end to end anastomosis between the proximal stump of the
oesophagus and the open end of the "Jianu tube." This would of course be
much preferable to the antethoracic cesophagoplasty, is entirely possible
technicallv but must ever remain extremelv dangerous.

CHAPTER XXV

PHARYNGOTOMY, LARYNGOTOMY, PARTIAL
LARYNGECTOMY, AND LARYNGECTOMY

SUBHYOID PHARYNGOTOMY

Place the patient on his back, the shoulders supported on a cushion and
the head extended. Palpate the hyoid bone and thyroid cartilage.

Step I. — Make a transverse cutaneous incision immediately below and
parallel to the hyoid bone. If the operation is for the purpose of exposing
the entrance to the larynx, an incision two inches in length is sufficient; if for
the removal of a tumor of the pharynx or upper larynx, the incision must be
much longer.

Step 2. — Divide the platysma myoides, and omohyoid, sternohyoid, and
thyrohyoid muscles close to the hyoid bone, but leaving sufficient of their
substance attached to the bone to permit of their union by suture.

PHARYNGOTOMY 231

Step 3.— Divide the thyrohyoid membrane along the posterior surface of the
hyoid, the knife being directed backwards and upwards. Leave enough
membrane attached to the bone to permit the use of sutures when closing the
wound. Attend to hemostasis.

Step 4. — The mucosa now pouts into the wound during expiration; seize it
with forceps and divide it. Be careful not to injure the epiglottis. Insert
two catgut sutures into the upper edge of the wound in the mucosa to act as
guides or tractors when closure is begun. Pull the epiglottis out of the wound
and insert into it a suture to be used as a tractor. The upper part of the
larynx and the lower pharynx now lie exposed, and one may proceed to re-
move any foreign body or accessible tumor. If the operation is done for
malignant disease of the upper zone of the larynx (extrinsic disease — Semon),
or if any hemorrhage is anticipated, it is wxU to perform a preliminary
tracheotomy.

Step 5. — Close the wound in the mucosa with fine catgut sutures. Unite
the thyrohyoid membrane, the divided muscles, and the skin each by a separate
layer of sutures. Insert a small drain of gauze or oiled silk down to the line
of suture, closing the wound in the mucosa. If a large part of the pharynx
has been excised, it is wase to pack the cavity with gauze and only partially
close the wound with sutures; under these circumstances a tracheotomy will
have been performed.

TRANSHYOID PHARYNGOTOMY

Vallas obtains access to the pharynx by a median incision.

Step I. — Make a median cutaneous incision from a point one finger-breadth
above the hyoid to the thyroid notch. Divide the skin, subcutaneous tissue,
etc., and separate the mylohyoid muscles.

Step 2. — Denude a small portion of the hyoid bone in the middle line and
divide the bone with scissors or forceps. Retract the two halves of the hyoid
and the attached soft structures. This gives a space about i^-^ inches in
width, and exposes the mucous membrane of the pharynx above and the
thyrohyoid membrane below the bone.

Step 3. — Guided by a finger passed into the pharynx through the mouth
open the pharynx, cutting from above downwards.

Step 4. — Having attended to the disease which necessitated operation,
close the w'ound with several layers of sutures, after providing for drainage.
It is unnecessary to suture the hyoid bone.

SUPRAHYOID PHARYNGOTOMY

Eremitsch, Griinwald, Fedoroff and others recommend suprahyoid pharyn-
gotomy as a means of access to tumors, especially to those at the base of the
tongue or on the epiglottis. Preliminary tracheotomy is unnecessary. Place
the patient on his back. Support the shoulders, letting the head fall backwards.

Step I. — Make a tranverse incision, concave upwards about 3^^ inch above
the hyoid. Divide the skin and platysma.

232 PHARYNGOTOMY AND LARYNGOTOMY

Step 2. — Retract the submaxillary gland which presents. Find the inser-
tions of the digastric muscles and preserve them. Divide transversely the
mylohyoids, geniohyoids and hyoglossi. Open the pharynx, being careful
not to injure the epiglottis. The pharynx, soft palate, tonsils, epiglottis and
the base of the tongue are well exposed. In order to operate on the base of
the tongue the posterior half of the tongue must be pulled into the wound
by means of a sharp retractor.

INTERCRICOTHYROTOMY. LARYNGOTOMY

This operation is commonly employed as a safe substitute for tracheotomy
as' a preliminary to operations upon the tongue. Butlin is an enthusiastic
advocate of the operation which he uses in all such procedures as excision
of the tongue, of the upper jaw, etc. It only consumes about one minute of
time and renders easy work which would otherwise be troublesome.

Place the patient on his back with head thrown back and the neck sup-
ported on a firm pillow. Identify the thyroid and cricoid cartilages by touch.

Step I.— With finger and thumb hold the larynx steady. Make an inci-
sion 1 3^ inches long in the middle line over the lower part of the thyroid,
the cricothyroid interval, and the cricoid. Retract the edges of the wound.
Expose the cricothyroid membrane. Attend to hemostasis.

Fig. 355. — Butlin's laryngotomy cannula.
X. Silver tube inserted into cannula. On this it is easy to fix a rubber tube through which the anesthetic

can be administered.

Step 2. — Divide the cricothyroid membrane transversely just above the
cricoid cartilage and so avoid injury to the vocal cords and the cricothyroid
vessels. Penetrate the mucous membrane. Pass a closed forceps through
the wound in the mucosa and open the blades so as to dilate the wound.

Step 3. — Pass a Butlin's laryngotomy cannula into the cavity of the larynx.
The error has been made of passing the cannula (Fig. 355) into the cellular
tissue with nasty results. Fix the cannula in place by tapes passed around
the neck.

It is easy to administer an anesthetic through the cannula. After the
operation on the tongue or mouth is completed the cannula may be removed

LARYNGOTOMY 233

as soon as the patient is put to bed. No stitches are required to close the
wound.

LARYNGOTOMY AND PARTIAL LARYNGECTOMY

Laryngotomy is an operation in which the larynx is split open, its interior
exposed, and any foreign body or disease removed. The operation is frequently
accompanied by partial laryngectomy.

The Operation. — Step i.— Perform a low tracheotomy. Insert a Tren-
delenburg or a Hahn cannula.

Step 2. — Make a median incision from a point immediately below the
hyoid bone to one just below the cricoid cartilage. Divide the cervical fascia
to the full extent of the wound. Separate the sternohyoid muscles by blunt
dissection.

Step 3. — Incise the cricothyroid membrane after fixing the cricoid carti-
lage with a sharp hook or small volsella forceps. With a probe-pointed
strong knife, with strong scissors, or with thin-bladed bone forceps divide
the thyroid cartilage accurately in the middle line. When the cartilage is
very hard, Treves advises the use of a fine saw instead of the bone forceps. In
such cases probably it might be easier and less damaging to pass a Gigli wire
saw through the wound in the cricothyroid membrane, behind the thyroid
cartilage and out through a cut in the thyrohyoid membrane, and saw through
the cartilage in the middle line from within outwards.

Step 4. — Retract the lateral halves of the thyroid cartilage with sharp hooks.

Step 5. — Remove the foreign body or tumor or excise the laryngeal contents
completely.

Step 6. — Either completely or partially close the larynx with sutures.
Partial closure, a gauze wick being left for twenty-four hours to drain the lower
angle of the wound in the larynx, is preferable to complete closure.

Step 7. — Replace the Trendelenburg by an ordinary tracheotomy cannula.

In Step 5 various degrees of interference may be requisite. Even in cases
of rather extensive malignant disease below the vocal cords (intrinsic disease)
thorough removal of the growth and surrounding soft parts plus energetic
scraping of the cartilage often gives good results. If the growth invades the
cartilage, then portions of that structure must be removed. Sir F. Semon
("Brit. Med. Journ.," Oct. 31, 1903) limits the term partial laryngectomy to
cases where not less than one wing of the thyroid cartilage, with, possibly, a
part of the cricoid and one arytenoid, is removed. Removal of small fragments
of these cartilages he includes under the name "thyrotomy."

The lymphatics of the larynx may be considered as being in two groups,
one above the other, below the true vocal cords. The cords have very scanty
and thin lymphatics which drain into the supraglottic zone for the most part.
The network of lymphatics above the vocal cords (supraglottic zone) is very
dense, easily injected, covers the epiglottis, the aryteno-epiglottic folds, the
superior or false vocal cords, and the ventricles of the larynx. The subglottic
zone of lymphatics is not so dense as that above. "Though the two lymphatic
territories of the larynx largely communicate with each other in the posterior
walls of the larynx, it is rare to obtain a complete injection of the endolaryngeal

234 PHARVNGOTOMY AND LARYNGOTOMY

network by puncturing only one of these territories. It may be added that
injections easily cross the middle line; but though the mass injected into one-half
of the larynx easily passes into the mucous membrane of the other side, it
is, on the other hand, exceptional for it to pass as far as the corresponding
glands of that side." ("The Lymphatics," Poirier, Cuneo, Delamere. Leaf's
translation.)

The great importance of the above anatomical facts is very evident and
they show very clearly the reasonableness of Semon's dicta regarding the
conditions required for successful thyrotomy for malignant disease. Semen
gives the name "extrinsic malignant disease" to that situated in the supra-
glottic lymphatic zone, and "intrinsic" to that in the subglottic zone.

Conditions Essential to the Success of Th3nrotomy for Malignant Disease. —

1. Operation must be restricted to early stages of intrinsic malignant disease.

2. Early diagnosis is indispensable.

3. Operation must be thorough. No sentimental considerations as to
the amount of vocal power to be retained must interfere with the removal of
sufficient healthy tissue from around the neoplasm in all directions.

4. Laryngoscopic examination rarely gives correct information as to the
extent of the disease. If, on opening the larynx, the disease is found to invade
the cartilages, partial laryngectomy must be performed, "or indeed any other
operation, the necessity of which may become apparent when the extent and
depth of infiltration of the new growth have been definitely ascertained."

Intralaryngeal operations are useless in the face of malignancy: they
merely take away portions of the growth and may stimulate it to more rapid
development. Even in cases where there is doubt, but malignancy is strongly
suspected, th}Totomy is the proper operation. When the disease is situated
on the posterior laryngeal wall or when it is too advanced for thjTOtomy or
partial laryngectomy to be successful, then total laryngectomy becomes a
necessity. In cases of extrinsic malignant disease of the larynx subhyoid
pharyngotomy gives the best access for its removal.

LARYNGECTOMY

Complete Laryngectomy. — The operation of laryngectomy is called for
in cases of malignant disease of the larynx. Usually cases in which the disease
has broken through the bounds of the larynx and invaded neighboring tissues
are considered inoperable, but, as will be seen in succeeding pages, such cases
have been successfully attacked. The greatest danger of laryngectomy is
not the immediate risk of operation, but the subsequent aspiration of wound
secretions into the lungs, causing pneumonia. This danger is combated by
careful asepsis, or, better, antisepsis, and by using the resources of plastic surgery.
After operation it is wise to encourage the patient to leave his bed as early as
possible.

The Operation. — Step i. — Perform a low tracheotomy and insert a Tren-
delenburg cannula to prevent the entrance of blood into the lungs.

Step 2. — Make an incision in the middle line from the hyoid bone to below
the cricoid cartilage. This divides all the soft parts down to, but not through,

AFTER-TREATMENT 235

the cartilages and their connecting membranes. If necessary, convert the
vertical into a T-shaped incision by means of a transverse cut near the hyoid
bone.

Step 3. — (A) Separate the soft parts which are connected with the laryngeal
cartilages, on each side, from the larynx. Do this as much as possible by
blunt dissection; an occasional cut with knife or scissors will be necessary.
In making this separation keep close to the cartilaginous walls of the larynx.
The larynx is now exposed anteriorly and laterally; it is still united to the
hyoid bone above, to the trachea below, and to the oesophagus behind.

(B) If the disease has infiltrated surrounding structures, then, of course,
this step of the operation must be carried out by means of dissection beyond
the disease. The operation becomes, in fact, one for the excision of a tumor in
which the larynx happens to be located.

Step 4. — Stop all bleeding. Divide the thyrohyoid membrane transversely
close to the upper edge of the thyroid cartilage. Injure the oesophagus as
little as possible. Examine the epiglottis carefully. If it is diseased or if its
appearance is doubtful, remove it. Carefully separate the posterior wall
of the larynx from the oesophagus, but always bear in mind the necessity of
getting beyond the disease. The larynx is now attached to the body by the
trachea alone. If possible, cut through the cricoid cartilage transversely
and remove the larynx. If the cricoid is diseased or in a suspicious condition,
make the section through the trachea at as low a point as may be necessary.

Step 5. — Suture the divided trachea to the skin. The trachea is liable to be
retracted downwards. Stop all bleeding. Introduce an oesophageal tube into
the gullet to permit feeding. Pack the wound with iodoform gauze. Apply
dressings. Replace the Trendelenburg cannula by an ordinary tracheotomy
tube.

After-treatment. — Give the patient fluid food through the oesophageal
tube, which is left in situ. It is probably better to omit the introduction
of the oesophageal tube at the time of operation, but to pass the tube each
time the patient requires nourishment. The wound should be frequently
dressed and the mouth should be kept clean.

In order to avoid confusion the author has described the operation of
laryngectomy as if the removal of the diseased larynx constituted the whole of
the procedure. It would be almost as logical to amputate the cancerous breast
without removing the fatty and lymphatic contents of the axilla as to remove
the larynx without attacking the cervical lymphatics at the same time. When
the larynx has been removed and provision has been made to retain control
of the divided trachea (Step 5), it is easy to gain access to the cervical lymphatics
and to remove them in the manner described for excision of cervical tumors
or by some slight modification of that method.

Perier's Operation. — In extirpating the larynx Perier discards the aid of a
preliminary tracheotomy.

Step I. — Make a vertical m.edian incision from the hyoid bone down to a
point well below the cricoid cartilage. Make two horizontal incisions, one at
each end of the vertical cut. The wound is now I-shaped.

Step 2. — Separate the soft parts from the larynx and upper part of the

236

PHARYNGOTOMY AND LARYNGOTOMY

trachea, as has been already described. With a curved blunt instrument
introduced laterally separate the larynx and upper portion of the trachea
from the oesophagus (Fig. 356).

Step 3. — Stop all bleeding. Introduce a stout thread on each side of the
trachea below the line where it is to be divided. These threads are for pur-

FiGS. 356 AND 357. — Excision of larynx. {Monod and Vanverts.)

poses of traction. Rapidly divide the trachea immediately below the cricoid
cartilage and pull the stump upwards and forwards by means of the traction
threads (Fig. 357). Introduce into the trachea a large curved cannula provided
with lugs through which the traction threads may be passed and fastened. The
ends of the threads are left long. The threads prevent the cannula changing
its position and can still be used for traction purposes.
The anesthesia is continued through the cannula.

Step 4. — Complete the extirpation of the larynx.
Close the wound with sutures after providing for
drainage.

Step 5. — Suture the tracheal opening to the lowest
angle of the wound (Fig. 358).

Th. Gliick brings the tracheal stump out through

a special buttonhole in the skin near the sternal

notch, thus isolating it from the laryngectomy wound.

Keen's Method. — In 1898 Keen described a

method of operating, the details of which lead

towards safety. ■ For several days prior to operation

brush the teeth thoroughly and spray the nose and

fauces with a mild antiseptic every two hours, when

the patient is awake.

Step I. — Give chloroform. Median incision from above the hyoid bone

nearly to the sternum. Expose the thyrohyoid membrane, larynx, and two

or more tracheal rings. Divide the isthmus of the thyroid.

Step 2. — Separate the structures to be removed from their lateral con-
nections. Attend to hemostasis.

Step 3. — Put patient in Trendelenburg's position. Divide the trachea
transversely well below the disease and below the area of the beard in men

FtG. 358. — Excision of
larynx. {Monod and
Vanverts.)

LARYNGECTOMY 237

(lest hair grow into the trachea). With three sutures fix the upper end of
the trachea to the skin. Introduce an ordinary tracheotomy tube Yi inch
in diameter. Secure the tube with sterile tapes passed around the neck.
Continue the anesthetic through a sterile rubber tube passed into the cannula
and provided with a funnel.

Step 4. — Pull the upper end of the trachea forwards, and by blunt or
sharp dissection separate it from the oesophagus. Close any accidental
wounds of the oesophagus at once with Lembert sutures. Remove the
disease and the larynx.

Step 5. — Pull the epiglottis into the wound and remove it.

Step 6. — Suture the anterior wall of the oesophagus to the tissues just below
the hyoid bone. This must be done thoroughly to prevent leakage from the
mouth into the wound.

Step 7. — Remove the tracheotomy cannula and close the external wound.
Provide drainage for twenty-four hours. Apply dressings above and below
the tracheal opening, which is protected by any framework — e.g., a pill-box
without top or bottom — covered with gauze to filter the air.

After -treatment. — Put to bed without bolster or pillow. Raise the foot of the
bed on a chair. Get the patient up as soon as possible (about the third day).
For one or two days feed by enemata. By the third day the patient can swallow.

F5derl has paid great attention to means of avoiding postoperative pneu-
monia due to the aspiration into the lungs of secretions from the open wound
generally left after laryngectomy. The method of operating adopted by him is
based on experience gained in a case of tracheal stenosis. In this case he re-
sected the affected portion of the trachea and restored continuity by means
of a circular suture of the windpipe. The result was perfect. After the trachea
has been divided, and provided it is not abnormally adherent to its surround-
ings, it is very easily pulled up. On the cadaver it has been shown that the
larynx may be completely excised, the hyoid bone united by sutures to the
first ring of the trachea the head thrown into a position of overextension, and
that the sutures will still hold.

FoderVs Operation. — A preliminary tracheotomy is performed. The larynx
is removed, but the epiglottis and the ary-epiglottidean folds are preserved if
possible. Hemostasis is carefully secured by means of ligatures, pressure, or
torsion. Unite the ends of the ary-epiglottidean folds to the posterior mem-
branous portion of the trachea, and complete the continuity of the posterior
part of the tube. The lateral and anterior portions of the windpipe are united
by catgut sutures. The sutures are not tied until all of them are in place. Two
or more of the anterior sutures surround the hyoid bone (submucously), catch
the base of the epiglottis, and surround the first tracheal ring. After these deep
sutures are tied, silk sutures are inserted through the soft parts, and help to
relieve tension on the buried stitches. The external wound is closed.

Foderl remarks ("Archiv f. klin. Chir.," Iviii, 803) that after his operation
scarcely any more wound secretion enters the respiratory tract than does so
subsequent to any of the endolaryngeal operations. A nearly linear circular
wound is left, the windpipe is cut off from the rest of the wound, and there
is little danger of the aspiration of wound secretions.

238 PHARYNGOTOMY AND LARYNGOTOMY

Foderl has operated on one case in the above manner. The patient was
out of bed on the second day, able to feed himself with the oesophageal tube
on the third day, and went home after two weeks. Eight months after opera-
tion there was no recurrence. Deglutition was good. Speech could be heard
at thirty feet. The patient still wore a fenestrated tracheotomy tube, but
he was expected to give up that before long.

The operation of laryngectomy is not absolutely limited to cases in which
the disease is confined to the larynx itself. Portions of the oesophagus, etc.,
may be removed along with the larynx. Narath ("Archiv f. klin. Chir.," Iv,
840) has published some instructive experiences on this subject. The follow-
ing description is based on Narath's work :

Combined Laryngectomy and (Esophagectomy. ^^/f/? i. — Perform a low
tracheotomy.

Step 2. — Extend the tracheotomy wound upwards in the middle line to near
the chin. Reflect the skin on either side of the neck so as to expose the larynx
and surrounding structures. Isolate the diseased organs.

Step 3. — Divide the trachea below the disease. The inferior portion of
trachea (i.e., the portion leading to the lungs) is separated from its surroundings
for a short distance and its open end brought into the tracheotomy wound in
the soft parts; and is there sutured after the tracheotomy tube is removed.
In the manoeuvre the open end of the trachea is so bent that its opening faces
directly forwards. There is little danger of blood being aspirated into the
tracheal opening in its new position.

Step 4. — Remove the larynx and such portions of the oesophagus as may
be diseased, remembering to cut away too much rather than too little.

Step 5. — If comparatively little of the oesophagus has been removed, it may
be possible to secure closure of its lumen by means of suture. If a large portion
of the anterior oesophageal wall has been removed and a small portion to the
posterior, it has been possible to loosen the remnants of the posterior wall
from their surroundings sufl5ciently to permit of the upper and lower fragments
being brought together and so to obtain a continuous posterior oesophageal
wall.

Step 6. — Pack the whole wound with iodoform gauze. Change the dressings
whenever it is desired to nourish the patient. Nutriment is given through a
stomach-tube.

As the wound heals the cutaneous edges become inverted and the granu-
lations covered with epithelium until at last the whole space between the pos-
terior oesophageal wall and skin is covered by epithelium. Thus a gutter
is formed leading from the pharynx to the intact oesophagus below. At the
lower end of the gutter the tracheal opening is seen facing forwards. The
gutter must now be converted into a tube by a plastic operation very similar
to the operation for hypospadias.

On each side of the gutter A, B (Fig. 359) make the skin-flaps abed and
a' b' c' d'. The hinge of the flap a b c d is along the line a b; that of flap
a' b' c' d' is along the line a' b'. Having separated the above flaps from the sub-
jacent tissues, turn them inwards so that the edge d c of the one flap meets and
is sutured to the edge d' c' of the other flap. The oesophageal gutter has now

TRACHEOTOMY

239

been converted into a tube the anterior half of which is lined by epidermis.
The external or raw surfaces of the two flaps (abed and a' b' c' d') now call
for treatment. Continue the horizontal incision a, d outwards to the point e;
the incision b c to f; a' d' to e'; b' c' to f. Separate the flap e d c f from the
subjacent tissues, the base of the flap being the line e f. Do the same with
the flap e' d' c' f. Slide the two flaps towards each other so that the edge d c
meets the edge d' c' in the middle line. Suture. The sliding of these flaps

Figs. 359 and 360. — (Esophagoplasty.

is rendered possible because the skin of the neck is so loosely attached to sub-
jacent structures. After healing has taken place, if it is desired to make use
of an artificial larynx, it will be necessary to make an opening into the pharynx
at the point A (Fig. .360). A cannula is placed in the trachea. By means of
a T-joint on the exposed part of the cannula a tube is led upwards over the
skin through the opening at A into the pharynx. In the cannula is placed a
reed. As the patient expires air the reed gives a musical note; the vibrating
air is carried into the pharynx through the system of tubing described and is
modified by the tongue, lips, etc., into speech. The speech is, of course, in
one tone, viz., that of the reed.

CHAPTER XXVI

TRACHEOTOMY

Tracheotomy is an exceedingly simple operation under some circumstances,
but when, as is often the case, one has to dispense with the use of an anesthetic
and operate on a struggling, choking child, on an inconvenient table, in a
badly lighted room, without proper assistance, the task of the surgeon is no
light one.

There are two classical sites at which the trachea may be opened — one
above, the other below, the isthmus of the thyroid gland. At the former site
the trachea is much more superficial than the latter.

The High Operation. — Place the patient on his back with the shoulders
raised on a pillow, the head extended, and in a good light. If possible, ad-
minister a general or local anesthetic. With the finger locate the thyroid and
cricoid cartilages.

Step I. — From a point a little below the middle of the thyroid cartilage
make an incision, exactly in the middle line, downwards for a distance of about
i3>-^ inches. Expose the deep fascia, which is attached to the thyroid car-

240 TRACHEOTOMY

tilage above and the isthmus below. Divide the fascia in the middle line.
By blunt dissection expose the trachea, the rings of which are easily felt with
the finger. If there is not enough space between the cricoid cartilage and the
isthmus of the thyroid (which lies across the third and fourth tracheal rings),
make short transverse incisions, through the deep fascia where it is attached
to the thyroid cartilage; this permits one to drag the isthmus downwards. In
children preservation of the isthmus is of little value. Thomas Bryant stated
long ago that its division did no harm, and the author, following his advice,
has, when operating on children, paid no attention to preserving the thyroid
isthmus, but has divided it whenever it seemed convenient to do so. St. Clair
Thomson (Brit. Med. J., Oct. ii and 25, 1919) recommends that about 20 drops
of 2^^ per cent, cocaine solution (in children 5 drops of i per cent, solution) ibe
injected by means of a hv'podermic syringe directly into the trachea as early in
the operation as possible before completion of tracheal exposure. If the trachea
is not opened until 10 minutes have elapsed after the injection, there will be
none of that spasmodic coughing which is a real danger. Crosby Green advised
this procedure in Thyrotomy for cancer of the lar>'nx when the injection should
be made through the crico-thyroid membrane.

An evident objection to injection of cocaine is that the prevention of cough-
ing may mean serious pulmonary trouble due to retention of mucus, blood, etc.,
in the trachea. Therefore its use should be avoided in bronchitic or emphy-
sematous conditions or if there is any "water-logging."

Step 2. — The trachea is now bare to the extent of three or four rings. Fasten
the trachea with a sharp hook a Uttle to one side of the middle line. Let an
assistant hold the hook. Guided by the finger, introduce a knife slowly but
steadily into the trachea at the lower end of the exposed area. Be careful
not to push the knife in so far as to injure the posterior wall of the trachea.
Cut upwards in the middle line until three tracheal rings are divided. Hold the
knife in position in the trachea until, guided by the knife, one can insert into
the trachea a closed hemostat or blunt-pointed narrow-bladed scissors. With-
draw the knife. Open the blades of the hemostat or scissors so as to distend
the tracheal wound, and slip a tracheotomy tube into position. There are
many manoeuvres or dodges to facilitate the introduction of the cannula;
the one described has suited the author. A few surgeons discard the cannula
but suture the edges of the tracheal wound to the corresponding edges of the
skin. One suture on each side suffices to keep the tracheal opening patent.

Transverse Tracheotomy. — Otto Franck ("Munch, med. Woch.," 1910,
No. 6) recommends the following method:

1. Transverse incision over the cricoid. The wound gapes spontaneously,
giving excellent exposure.

2. Division of the linea mediana albicans and retraction of the muscles
down to the isthmus.

3. Transverse incision into the trachea immediately below the cricoid.
When the head is extended the tracheal wound remains wide open.

4. Introduction of tracheotomy tube and suture of the excess of skin wound.
When the cannula is removed the tracheal wound closes of itself.

TRACHEOTOMY 24I

The Low Operation. — The steps in the operation are very similar to those
of the high operation. The incision begins near the cricoid cartilage and runs
downwards for two inches. After the cervical fascia is divided blunt dissec-
tion will serve to expose the trachea. All veins which appear during the dis-
section must be drawn aside or divided between ligatures or forceps. The
index finger of the left hand should be frequently put into the wound to feel
the position of the trachea and to discover if any abnormal artery is in the way.
The author well remembers the glee with which the late Sir John Struthers
used to exhibit a specimen showing an enormous abnormal artery crossing the
territory involved in a low tracheotomy. If the isthmus of the thyroid appears,
it should be pulled upwards. The trachea is opened in exactly the same man-
ner as is done in the high operation.

The low operation is not suitable in children, as in them the trachea is
very deeply situated, their necks are short, and the thymus gland gets in the
way. For adults and adolescents the low operation is suitable.

Fig. 361. — Konig's cannula. Fig. 362. — Trendelenburg's cannula.

Figs. 361 and 362. — (Esmarck and Kowalzig.)

When the operation is performed in cases of obstruction from external
pressure, e.g., in cases of goitre, and some obstruction exists below the trache-
otomy opening, a tube should be passed down the trachea beyond the obstruc-
tion. In emergency, one may use a gum-elastic catheter for this purpose,
passing it through the tracheotomy cannula. Konig has devised a special
metal cannula with a long pliable tube which is occasionally of service (Fig.
361). When a tracheotomy tube has to be worn for a long time, one made of
hard rubber is less irritating and more durable than the usual metal instru-
ment. Fenestrated tubes permit the patient to breathe through the natural
passages, and are useful to test whether it is safe to discard the cannula or not.

Trendelenburg's cannula (Figs. 362 and 363) has rubber so arranged round
the intratracheal part of the tube that it can be inflated and fill up the space
between the trachea and the tube, thus preventing the entrance of blood,
etc., into the limgs. This cannula is of great service during certain operations
on the upper air passages, as through it anesthetics may be administered.

242 TRACHEOTOMY

Instead of surrounding the tube with an inflatable rubber bag, some sur-
geons prefer to cover the tube with compressed sponge, which when moistened
swells in situ and serves the same purpose. (Hahn's cannula, Fig. 364.)
When a tracheotomy cannula is in position, it must be retained by means of a
tape passed round the neck and secured to the eye-holes provided in the instru-
ment. The inner tube should be frequently removed and cleaned. During
the first few days after operation the outer tube should never be removed
except by the surgeon. Patient or nurse should never be permitted to remove
the outer tube until the surgeon has satisfied himself by observation that they
are capable of replacing it.

Fig. 363. — Trendelenburg's cannula in situ. Fig. 364.— Hahn's cannula.
Figs. 363 and 364. — {Esmarch and Kowahig.)

Tracheotomy is occasionally performed as a preliminary to such opera-
tions as excision of the larynx, Kocher's excision of the tongue, etc. Pre-
liminary tracheotomy is either mediate or immediate. When the "mediate"
operation is chosen, it should be performed two or three weeks before the major
operation to which it is preliminary.

The advantages claimed for mediate tracheotomy are: (i) The patient
has free respiration for a period of weeks and so may gain strength. (2) The
patient becomes accustomed to respiring air which has not passed through
the nose and mouth. (3) The tracheal wound becomes fixed to the soft parts,
thus anchoring the windpipe and preventing retraction after the larynx, for
example, has been excised. (4) The tracheotomy having been done before-
hand, the duration of the major operation is shortened thereby.

Advocates of the immediate operation claim: (i) That the time con-
sumed in performing tracheotomy is not sufficient seriously to influence the
success of the major operation; (2) that it is unnecessary to accustom the
patient beforehand to breathing through a cannula: (3) that while the patient
is breathing through the cannula discharges from the cancerous tongue or
larynx are liable to gravitate down the trachea, past the cannula into the lungs,
and cause pneumonia, while the resisting power of the lungs is lowered from
receiving air directly through the tracheotomy tube; (4) that if any attempt is
to be made to restore the continuity of the windpipe after laryngectomy, the
adhesions formed around the tracheotomy wound will prevent the necessary
elevation or pulling up of the lower trachea.

In the opinion of the author the disadvantages of mediate tracheotomy are
greater than the advantages, and the immediate operation is preferable, except
when it is preliminary to excision of the tongue.

CHAPTER XXVII
FOREIGN BODIES IN TRACHEA OR BRONCHUS

Sometimes foreign bodies may be expelled from the trachea by inverting
the patient, but, as a rule, the body impinging against the larynx will set up
such spasm as to render its expulsion impossible. Lejars is most vigorous in
his denunciation of the method. Tracheoscopy or tracheo-bronchoscopy
(Killian), whether the tube be introduced through the mouth or through a
tracheotomy wound, has frequently permitted the extraction of foreign bodies.
This is a most valuable procedure and in most cities there are men who possess
the necessary apparatus and skill to ^carry it out. [See Chevalier Jackson's
article in Binnie's Regional Surgury, Vol I.] If tracheoscopy is not available
recourse must be had to high tracheotomy. A general anesthetic is desirable.
Do not place the patient in the dependent position until the trachea is opened.
After opening the trachea and retracting the edges of the tracheal wound with
retractors or stitches, the foreign body will often pop out, or may be lifted out
with forceps or a scoop. If the foreign body does not promptly appear opposite
the wound, investigate the lower surface of the glottis; if the body happens to be
there, remove it. Lowering the patient's head and shoulders, after opening the
trachea, is often helpful. Touching the mucosa of the trachea excites coughing
and so may force the foreign body into view Coughing and inversion of the
patient may bring a non-impacted body from the bronchus into the wound.

If the above measures are successful the author inserts a linen or silk suture
in the trachea on each side of the wound and leaves these long to serve as
tractors by means of which the nurse may easily open the trachea should
oedema glottidis or such like accident develop. These threads may be re-
moved after twenty-four or forty-eight hours. Cover the wound loosely with
warm, moist, non-fluffy gauze. Instead of the thread tractors a tracheotomy
cannula may be used. It is not a safe practice to close the wound entirely.

If the above means fail to give relief it is best either to suture the edges of
the tracheal wound to the skin or to insert a large cannula and let the patient
rest. After some hours, or next day, reopen the wound; if the body is not
now coughed out, introduce a small laryngeal mirror and by the aid of a strong
light investigate the trachea. If the body is seen caught in the mucosa, spray
with cocaine and endeavor to extract it with laryngeal forceps or a wire loop.
This may require several sittings before success is attained.

When a foreign body is impacted in a bronchus and the above measures
fail to give relief, one may either attempt its extraction by means of posterior
bronchotomy or await the formation of a pulmonary abscess which may be
opened and drained. Unfortunately, posterior bronchotomy is a formidable
operation and if the Fabian policy is adopted the patient may die before or after
solidification of the lung, and pneumotomy under the most favorable circum-
stances is no triviality.

The bronchoscope has made a great difference in the treatment of foreign
bodies in the trachea and ought to be employed but only by an expert.

243

2 44

FOREIGN BODIES IN TRACHEA OR BRONCHUS

POSTERIOR BRONCHOTOMY (SCHWARTZ'S OPERATION)

Anatomy. — The bronchi may be reached through the posterior medias-
tinum, and as this region is full of vitally important structures it is necessary
to review its anatomy in a practical manner. If one excises the third to the
ninth dorsal vertebrae inclusive, the posterior mediastinum will be sufficiently
exposed for study. The most superficial (posterior) structures which pre-
sent are vascular, viz., to the left the aorta, to the right the azygos vein. At
the lower part of the exposed area these vessels lie alongside each other and
hide all subjacent structures. As these vessels ascend they separate, the

Thyroid

Com. car A

Sup. lar. n.

Vagus

Int. jug. V.
Trachea

Inf. thyroid a.
Recurrent lar. n.
Subclav. art.

■-ubclav. V.

Fig. 365. — (Poirier and C harpy.)

aorta going to the left where at the level of the fourth dorsal vertebra it passes
forwards (as the aortic arch) into the anterior mediastinum; the azygos vein
ascends towards the right until it bends forwards at the level of the fourth dorsal
vertebra to enter the anterior mediastinum. The aorta and azygos thus form a
triangle with base above, and the floor of which is formed by the oesophagus.
The apex (lower end) of the triangle is about two inches below the bifurcation
of the trachea. The thoracic duct follows the inner side of the aorta and later
the subclavian artery. The right and left pleurae approach each other between
the aorta and azygos behind, and the oesophagus in front. The right pleura
passes behind the oesophagus in front of the azygos so as to form a sort of
cul-de-sac (Quenu). The two pleurae are loosely connected by areolar tissue.
The position of the pneumogastric nerves is well seen in Fig. 365. To expose

BRONCHOTOMY

245

the oesophagus it is necessary to retract the pleurae and with them the pneu-
mogastric nerves. Retraction of the pleurae and of the oesophagus exposes
the trachea and primary bronchi.

I. RIGHT BRONCHOTOMY

The Operation. — Place the patient in the latero-ventral position on the
edge of the table with the right arm hanging over the table (Fig. 366).

Step I. — From a point (A) at the junction of the spine and median border
of the scapula make an incision to a point (B) about i^^ inches to the right
of the spines of the vertebrae. From the point B, cut downwards parallel to
the spinous processes for a distance of about five inches (C). Make the in-
cision C, D which passes just below the angle of the scapula. The result

Figs. 366 and 367. — Bronchotomy. (Schwartz.)

is the flap A, B, C, D. Reflect the flap A, B, C, D outwards so as to expose
the fifth, sixth, seventh and eight ribs; the flap consists of all the soft parts
down to the ribs. J. D. Bryant^ makes the flap with its pedicle towards the
spine.

Step 2. — Subperiosteally divide the spinal ends of the exposed ribs just
external to the transverse process (about ij^ inches from the mid-line of
the back). In the same way divide the ribs as far outwards as possible. Care-
fully raise the lower and inner angle of the flap, consisting of ribs and inter-
costal muscles, and separate it from the subjacent structures. Divide the
intercostal muscles along the posterior or spinal line on which the ribs were
divided, carefully exposing and tying the intercostal vessels. Divide the inter-
costal muscles parallel to and below the lowest rib to be mobilized. Care-
fully separate the parietal pleura from the flap of ribs and intercostal muscles;
in doing this, gauze dissection, i.e., brushing away the pleura with gauze, will
be useful. Turn the flap outwards; this is possible because the ribs have been
divided far out and the periosteum and intercostal structures act as a hinge
(Fig. 367).

Step 3. — Carefully separate the pleura from the remnants of the ribs at-
tached to the spine and from the side of the vertebrae. Push the pleura and the

246

FOREIGN BODIES IX TRACHEA OR BRONCHUS

lung outwards, away from the mediastinum (Fig. 368). As soon as the side
of the vertebra is passed, the azygos vein may be seen running vertically through
the wound and at the upper end, arching forwards to reach the anterior medias-
tinum (Fig. 369^. Continue the separation of the pleura under the arch of
the azygos until the oesophagus, lying on the bodies of the vertebrae, is reached.
External to the oesophagus lies the pneumogastric nerve. Retract the pleura
outwards.

Figs. 368 and 369. — Bronchotomy. (Scli'dartz.)

Step 4. — Introduce the finger deeply into the wound directly in the concavity
of the arch of the azygos and feel the hard, prominent, posterior border of the
cartilaginous rings of the bronchus. Pick up the membranous posterior wall
of the bronchus with sharp hooks or forceps, and incise it. Remove the foreign
body. The exposed bronchus is situated about 2^<4 inches from the surface
of the ribs (Gliick).

Step 5. — Introduce a soft dressed drain to the wounded bronchus, possibly
fixing it to the bronchial wound by means of a fine stitch of catgut. • Be sure
there is no loose "fluff" about the gauze at the end of the tube. The drain
must be soft to prevent dangerous pressure necrosis. Replace the flap and
sutures, leaving or making space for the exit for the drain. If the foreign body
has given rise to a peribronchial phlegmon, a more liberal drainage by means
of loose packing of gauze may be advisable.

II. LEFT BRONCHOTOMY

Place the patient in the left latero- ventral position with the left arm hanging
over the edge of the table.

Steps I and 2.- — Same as in right bronchotomy except that the work is done
on the left side.

Step 3. — Separate the parietal pleura from the remnants of ribs attached to
the spine. When the side of the vertebrae is reached, the huge aorta is found
lying against the side of the spine. At the upper end of the wound the aorta
passes towards (arch of aorta) the anterior mediastinum. Continue the
separation of the pleura under the arch of the aorta to a height of about 2
inches. The left pneumogastric soon presents. Stop the dissection and

THE THYROID 247

pull the lung (covered by the intact pleura) outwards with a good retractor.
With the linger in the depth of the wound feel the posterior prominent edges
of the bronchial cartilages. The rest of the operation is the same as in right
bronchotomy.

In cases of tracheal stenosis threatening life and comfort, whether the
stenosis is from contraction or compression, the ideal treatment is to remove the
cause. [Thyroidectomy, tracheal plastic, etc.]. Where this is impossible
one may perform tracheotomy and introduce through the aflfected area a long
cannula (Konig's cannula; lobster tail cannula) but the cannula irritates the
air passages and gives rise to so much trouble that the cannula may require
to be removed. Under these grave circumstances, the patient being "between
the devil and the deep sea," Th. Gliick suggests posterior bronchotomy. In
one of Gllick's cases of pneumectomy the patient, while convalescent from the
operation and original disease, was able to breathe easily and comfortably
through the thoracic wound while the nose and mouth were completely closed.
This suggestion seems entirely reasonable and should be borne in mind. Pos-
terior bronchotomy is, of course, no operation for the tyro, but in a few cases
the e.xperienced surgeon may find it of value.

CHAPTER XXVHI
GOITRE; BRONCHO CELE ; STRUMA

It may not be out of place to remind the reader that there are several
varieties of goitre; viz., parenchymatous, where there is uniform enlargement
of the thyroid tissues; adenomatous, where the glandular tissue is in excess and
forms single or multiple tumors; cystic, where from degeneration a cavity is
formed filled with colloid or other fluid and often containing adenomatous
masses. There is also that form known as "exophthalmic goitre," where the
tumor is associated with notable general symptoms. In any of the above
varieties operation may be required.

THYROID

Experiments and clinical observations have so enriched our knowledge,
still woefully scant, of the function of the thyroid and the parathyroid glands
that it is imperative to preface any description of the operations performed
for goitre by a very few practical remarks on the thyroid and parathyroids, on
hj-perthyroidism, hypothyroidism and hypoparathyroidism. The thyroid is
surrounded by a thin, firm membrane of fibro-elastic tissue which sends
processes between the glandular units for their support and which act as
pathways for the blood-vessels and lymphatics of the gland. This covering
must not be considered as a capsule in a surgical sense; it is, surgically, part
and parcel of the gland itself. Bands of dense connective tissue unite the
covering of the thyroid with the trachea (ligaments of the thyroid). Fig. 370

248

goitre; bronchocele; struma

shows how the pretracheal portion of the deep cervical fascia forms a fibrous
or surgical capsule to the thyroid; it is the structure referred to as the fibrous
capsule when the operation of thyroidectomy is described. Any space which
may exist between the fibrous capsule and the thyroid gland is filled with
loose connective tissue. The loose connective tissue is apt to be most abundant
behind the lateral lobes of the gland. This connective tissue under the pres-
sure of a goitrous enlargement becomes condensed and is what Mayo speaks
of in his subcapsular operation.

The parathyroids are two or more glandular bodies which exist on each side of
the neck behind the lateral lobes of the thyroid. The bodies are elliptical,

"are 6 or 7 mm. long, 3 or 4 mm. broad and i-
may be as much as 15 mm." (Piersoll.)

or 2 mm. thick. The length

S.h.S.t.

370.

C. Fibrous or surgical capsule. P. Parathyroids. MC. Connective tissue packing, or Mayo's capsule.
X. Carotid packet of vessels and nerves. Tr. Trachea. Oes. CEsophagus. S. h. Stemo-liyoid. S. t.
Stemo-thyroid. S. m. Sterno-mastoid.

The parathyroids lie between the fibrous capsule and the thyroid, in the
loose areolar tissue there present; they may be in contact with the thyroid or
with the capsule or with both. Halsted writes, "One is likely, therefore, to
encounter these little bodies, usually two on each side, at any level from the
superior to the inferior pole on the postero-internal surface of the gland, but
most commonly just internal to the rounded postero-external border and quite
regularly near the site of the distribution of the terminal branches of the inferior
thyroid artery. If the thyroid is lobulated in this situation, as is quite com-
monly the case, a parathyroid may be concealed in the cleft between the
lobules." The parathyroids "are little ovoid, spheroid, lenticular or very flat
bodies, exhibiting much variety in form and size and even in color. Externally
they often resemble fat very closely in consistence as well as in color" (Halsted).
The blood-supply of the parathyroids has been carefully studied by Evans
(Halsted and Evans, "Annals of Surg.," xlvi. No. 4) Fig. 371. The glands
are always supplied by definite parathyroid arteries which usually arise from
the inferior thyroid, but frequently come from an anastomosing channel ex-
isting between the inferior and superior thyroid arteries.

Few, if any, direct vascular connections exist between the parathyroids and
the connective-tissue envelope of the thyroid.

THE THYROID

249

Complete excision of the thyroid glands has been followed by myxoedema
and by tetany. These operations were performed before the importance of
the parathyroids was known. Later, when the thyroid has been completely
removed, experimentally, but the parathyroids preserved, myxoedema has
developed, but not tetany. Hypothyroidism due to degeneration of the thyroid
leads to cretinism or to myxoedema. Overactivity of the thyroid (hyper-

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Fig. 371. — Thyroids and parathyroids seen from behind. {Halsted and Evans.)

thyroidism) gives rise to a complex of symptoms described by Graves in 1835
and by Basedow in 1840, and known by the names exophthalmic goitre, Graves'
disease, Basedow's disease. Usually the thyroid is evidently enlarged in hyper-
thyroidism, but sometimes it is apparently normal in size. The normal ap-
pearance is, however, only apparent; closer examination shows that the secret-
ing epithelium, instead of merely lining the acini, pushes in folds into the
acini, thus greatly increasing the secreting surfaces without notably increasing

250 goitre; bronchocele; struma

the size of the gland. This is important to remember. When the parathyroid
glands are excised tetany results (hypoparathyroidism). Halsted observed the
early symptoms of tetany in one patient and was able to keep the disease in
check by the administration of the parathyroids of beeves and later by Beebe's
parathyroid-nucleoproteid. In the published statistics of partial strumectomy
the death rate from tetany is 3.5%; in Kocher's clinic only }-2% (.\rnd). Of
course there are many cases of non-fatal tetany following partial strumectomy.
The reason why many cases of tetany recover is probably due to the fact that
the parathyroids have not teen removed, but that their circulation has been
interfered with and has, in time, become reestablished. One must remember
that a lingual thyroid may constitute the whole active thyroid; that its re-
moval may lead to disaster (see p. 216).

Indications for Strumectomy. — Very many goitres are removed for cosmetic
reasons. The position, size, and character of the goitre may each constitute
a positive indication for operation. Position and size may give rise to re-
spiratory and circulatory troubles, as well as to interference with nerves. The
character of the disease indicates whether ot not internal treatment may be of
value. Soft colloid nodules usually decrease and occasionally disappear during
internal treatment. Diffuse strumata are those most suitable to medication
with iodine administered externally and internally. Medical treatment must
be stopped as soon as it is shown to be ineffective, or the slightest evidence of
iodism or of Basedow's disease appears (De Quervain).

The local use of iodine is liable to cause adhesions around the goitre and
thus render operation more difficult. Injections of iodine or such like drugs
are always improper.

Almost all forms of goitre are suitable for operation if causing symptoms or
deformity or increasing in size rapidly. In exophthalmic goitre (Basedow's,
Graves' disease) the use of iodine is more dangerous than in other forms.
Remember that Graves' disease often remains stationary or improves under
any or no treatment, hence operation is by no means always called for, but
remember also that, as the disease progresses, the powers of resistance decrease,
hence operation must not be too long delayed.

The chief local characteristic of exophthalmic goitre is the great vascularity
of the gland. The principle of treatment is to remove degenerated segments
and decrease the blood-supply. Kocher, since 1890, has done this by multiple
ligation of the thyroid arteries and partial excision. This work he accomplishes
in several sittings. Most surgeons operate in these cases exactly as in ordinary
goitre.

Kummel operates either by enucleation or resection of a portion of the goitre
or partial ligation of the afferent vessels. His statistics show 70 per cent,
recoveries with 5 per cent, mortality.

Kocher (''Brit. Med. Journ.," June 2, 1906), out of one hundred and forty-
nine cases, had nine deaths; one hundred and forty cases were kept under
observation long enough after operation to permit of a definite statement as
to results: of these one hundred and thirty-one were cured and nine notably
ameliorated. He writes:

"If we ligature one artery we get some, but only a slight, amelioration of the

HYPERTHYROIDISM 2$!

symptoms. If we ligature two arteries the effect will be exactly so much greater
as more of the function is inhibited. If we take away one lobe of the gland the
efifect is still greater. If we put a ligature on three of the four arteries, we may
have a very good result, and still better if we excise one lobe and put a ligature
on the superior thyroid artery of the other side: it will be even more complete
when we combine unilateral excision with the resection of the upper and lower
half of the other lateral lobe. If we have begun with one or two ligations,
and have had an unsatisfactory result, we are sure to complete it by adding a
third ligature or by excision of one-half of the gland. In short, we may say that
by operation it is in our hands to guarantee a more or less complete result."
These are Kocher's words, and the surgeon of Berne was not given to
exaggeration.

In July, 1910, Kocher reported that he had operated four hundred and
sixty-nine times for Basedow's disease with a mortality of 3.4 per cent. In the
last seventy-two cases there was no death. Glycosuria and hypertrophy of the
thymus positively contraindicate operation. To refuse operation during the
initial period of the disease is to lose the best chance of success.

Mayo's statistics in cases of exophthalmic goitre are as follows: Prior
to January i, 1906, there were fifty primary thyroidectomies with five deaths
(10 per cent, operative mortality).

From January i, 1906, to July i, 1910, there were 459 primary thy-
roidectomies with sixteen deaths (3.4 per cent, operative mortality).

During this latter period there were 267 primary ligations with eleven deaths
(4.1 per cent, operative mortality).

The reason for the death rate being higher after ligation than after thyroid-
ectomy is of course that the lesser operation was chosen in the more dangerous
cases, in fact in patients for whom any severe operation was entirely unjustifiable.

C. H. Mayo suggests that some of the good results following ligation of the
thyroid arteries or after sympathectomy may be due to destruction of many
of the lymphatics coming from the thyroid; this destruction of lymphatics is
well calculated to diminish absorption of the thyroidal secretions and thus to
prevent hyperthyroidism.

The fact that alarming symptoms of hyperthyroidism very commonly fol-
low operations for Graves' disease have led to many endeavors to obviate these
symptoms and dangers. None of the endeavors have been proven effectual
though some of them may be so. A good rule to adopt is one based on common
sense, viz., handle the goitre gently as so to avoid expressing thyroid juices
which may be absorbed and cause trouble. Observance of this rule may do good
and cannot do harm. It probably does no good, as Crile has gently massaged
goitres in Graves' disease and has seen no evil follow. C. H. Mayo after re-
moval of goitres swabbed the wound with Harrington's solution so as to close the
lymphatics and prevent absorption. He has come to the conclusion, and other
surgeons agree with him, that this procedure while it may be harmless, is of no
particular value. Crile came to the conclusion that fear or psychic shock was a
great factor of danger in the highly strung subjects of exophthalmic goitre, and
to avoid this he adopted the plan of "stealing" the goitres according to his wells
known principles of anoci-association. He carries out the following measure-

252 goitre; bronchocele; struma

two to four days before the operation: (i) Operating room clothes are worn by
the patient continually. (2) Hypodermic injection of sterile water daily at 8
A. M. (3) Inhalations of Nitrous Oxide and Oxygen at 9 a. m. daily, the pa-
tient being informed that this is 'for the heart.' (4) On the day of operation
morphine gr. ^^ with atropine gr. K50 is administered at 8 a. m. in place of
sterile water. (5) At q a. m. Nitrous Oxide and Oxygen having been admin-
istered the operation is performed. If the symptoms are severe and the opera-
tive risk great, operation is performed with the patient in bed. Complete local
anesthesia is obtained by novacaine. After the goiter has been removed and
hemostatis effected the wound is dressed with gauze wrung out of a i to 5000
watery solution of Flavine. After 24 hours the divided muscles are sutured
with catgut and the wound closed.

The following are Crile's rules for after treatment: Place the patient in a
comfortable position and keep him quiet with morphine in gr. ^q doses repeated
as may be necessary. Give plenty water by the mouth. Enemata of water
with bicarbonate of soda and 5 per cent, glucose if required. Hypodermoclysis
(under complete local anesthesia) if indicated. Ice bag to heart continuously.
House inhalations (Tr. Benzoini Co.5j to a pint of hot water) twice daily. If
the temperature reaches ioi°F. apply 4 ice bags to the body; if 102°, 8 to 12
ice bags. If the temperature is 104° apply a complete ice pack as follows:
Put large rubber sheets both over and under the patient to keep him dry.
Entirely cover the patient (except head and neck) with about 150-200 lbs. of
cracked ice. By means of an electric fan direct a current of air over the patient
from the foot of the bed. As a rule under the ice pack treatment the tempera-
ture falls about 2° each hour. Discontinue the pack as soon as the temperature
falls to ioo°F. If there is decompensating myocarditis give Digitalin gr. 3^5
hypodermatically (into muscle) every two hours until the patient is able to take
digitalis by mouth, when MM. xxx of tincture of digitalis is given every three
hours until the maximum effect is secured or nausea presents itself. If there is
acute dilatation of the heart slowly inject intramuscularly strophanthin m.g. ^-^
in 10 cc. salt solution. Klose and others think that failure to cure exophthalmic
goitre by operations on the thyroid as well as the severe symptoms following
thyroidectomy are due to toxic material coming from the thymus (see p. 268).
Riedel performs thyroidectomy under local anesthesia using an extremely weak
solution of cocaine or eucaine plus some adrenalin. The injections are massive —
first under the skin and then under the deep fascia and fibrous capsule of the gland.
A pint or more of the solution is used. This of course obscures to some extent
anatomic relationships but it so distends the spaces in the areolar tissue between
the fibrous capsule and the true capsule of the gland that it practically separates
the gland from its surroundings so that it is easy to find and ligate the vessels
and remove the gland. If Crile's ideas are correct regarding reflex nerve im-
pulses causing ejaculation of thyroid juice, then Riedcl's massive injections are
well calculated to cut off these impulses and at the same time facilitate the opera-
tion. Mayo's rules for operation in Graves' disease are: If the condition is fair,
operate; if the pulse is 130 to 160, or if it suddenly fluctuates in tension and
rapidity, if there is anaemia with swelling of the feet, the patients are placed upon
belladonna treatment for some days. The more severe types are also given

ANATOMY

253

X-ray exposures in addition, a treatment which is continued from two to six
weeks.

Whenever the symptoms are severe Mayo contents himself with ligating the
superior pole of the thyroid on one or both sides: later, if necessary, he removes

Fig. 372. — Posterior view of
trachea, etc., showing course of re-
current laryngeal nerve. (Esmarch
and Kowalzig.)

Fig. 373. — Superficial veins over a
goitre. {Esmarch and Kowalzig.)

part of the gland when the patient is in better condition. In very grave cases
he treats the goitre by injections of boiling water after the manner of Porter.

Besides the two lateral lobes and isthmus which compose the thyroid gland,
the remnant of the thyroglossal duct running up from the isthmus often forms
an extra lobe, the pyramidal lobe, and along its
course there may be developed irregular masses
of glandular tissue — accessory thyroids. The
frequent presence of these extra masses of
thyroid is not surprising, the thyroid itself being
developed from the thyroglossal duct; surgically
they are of importance, as their presence is cal-
culated to confuse the operator, ignorant of their
existence.

The thyroid is surrounded by a strong
covering of fascia — fibrous capsule. When a
goitre is present in the gland (adenoma or cyst),

it is, of course, surrounded by more or less altered Fig. 2,1 a— De Quervain, Deutsche
glandular tissue — glandular capsule. The word
capsule, being applied both to the outer fibrous

covering and to the glandular tissue inside which (chTef liTd 'acces^soo^'^°'^^* '™* ^""^^
the tumor lies, leads to confusion when methods

of operating are described. In the succeeding pages the outer or surgical
capsule will be called the fibrous; the inner, the glandular capsule.

The arteries of the thyroid are : (a) The superior thyroid, entering the upper
pole of the lateral lobe; (b) the inferior thyroid, entering the posterior surface of

Leitschf. chir., cxvi, 574.
I. Superior thyroid artery and vein.
2. Superior thyroid vein. 3. Acces-
sory inferior thyroid vein. 4. Inferior

254

goitre; bronchocele; struma

the lower pole and in close and, surgically, dangerous relation to the recurrent
laryngeal nerve (Fig. 372); (c) the thyroidea ima, entering the isthmus from
below.

The veins of the thyroid are of very great importance; a study of Kocher's
schemata (Figs. 373 and 374) will give a fair idea of their location and im-
portance.

Operations for the cure of goitre may be divided into three groups: I.
Excision; II. Intraglandular enucleation; III. Incision and evacuation.

I. EXCISION

Complete excision of the thyroid gland is an unjustifiable operation, as it
is followed by fatal consequences. As in the case of other organs, nature has
been lavish in her provision of functional material in the thyroid, and it is safe
to say that one-fourth of the gland is sufficient for the maintenance of health.

De Quervahi's methods of operating upon the thyroid are worthy of serious
study.

I. Ligation of the Inferior Thyroid Artery External to the Fibrous Capsule of the
Gland. — Through Kocher's collar incision divide the platysma and expose the

Stenfotkj/md

Mrous carjusa/e -^^v^-s.'^

True capsule

Route toJnf.Thyr.Att.

Stfrno ^/mstoid

>^ Omo //^oi'd

/Vatf/swa

Trachea

Recvrre//t /ar.?/
Oesopha^u^s ^.^^^^
Parat/ii^roid

Carofu/parht

Inf.//ij//vida^^^m

Fig. 375-

inner margin of the sternomastoid muscle. Retract the muscle gently out-
wards (Fig. 375). IMake a vertical incision about i inch in length through
the external fascia of the sternohyoid; separate this fascia from the muscle and
retract it outwards with the sternomastoid. It is now easy to penetrate the
loose connective tissue until the carotid packet of vessels and nerve is reached.
Note the carotid tubercle of the transverse process of the 6th cervical vertebra;
about % inch (i cm.) below this the convex curve of the inferior thyroid artery
can be felt immediately to the inner -side of the carotid packet. The artery
may be found slightly higher or lower in individual cases. The advantage of
this route is that when the sternohyoid and sternothyroid muscles are to the in-

DE QUERVAIN S METHODS

255

ner side of the line of dissection one is in little danger of opening the fibrous
capsule of the thyroid and thus one avoids interfering with the numerous veins
which lie between the gland and its fibrous capsule.

With suitable retractors gently retract the sternohyoid and thyroid muscles
and the thyroid gland towards the median line, the sternomastoid and the

(fe?l

hu.. 370. — dc Quervain. Deutsche Zeilsch. f. Fig. 377. — dc {Jucrvaui. Deutsche Zeitsch. f.
Chir., cxvi, 574. Chir., cxvi, 574.

outer portion of the sheath of the sternohyoid being at the same time retracted
outwards.

With dissecting forceps clear the inferior thyroid artery from the loose
connective tissue around it and ligate it. The only vein which interferes in the
dissection is the median thyroid and it, as a rule, is at a higher level.

Fig. 378. — dc Quervain. Deutsche Zeitsch. J.
Chir., cxvi, 574.

Fig. 379.-

-de Quervain. Deutsche Zeitsch. f.
Chir., cxvi, 574.

2. The inferior thyroid artery has been ligated, the skin and platysma have
been reflected from the whole thyroid region. Make a longitudinal median
incision between the two sternohyoid and sternothyroid muscles and penetrate
the fibrous capsule of the gland. In the usual manner dislocate the affected

Fig. 380. — de Quervain. Deutsche Zeitsch. f.
Chir., cxvi, 574.

Fig. 381. — de Quervain. Deutsche Zeitsch. f.
Chir., cxvi, 574.

lobe of the thyroid inwards. There will be much less venous bleeding than in
the usual operation because of the Hgation of the inferior artery. From this
point onwards De Quervain follows no "hard and fast" method of operating.
According to the needs of the individual case he performs resection, enucleation

256

goitre; bronchocele; struma

or a combination of these methods, and like most surgeons he always leaves a
substantial portion of the posterior surface of the gland in order to avoid in-
juring the recurrent laryngeal nerve and the parathyroids.

In performing resection the following may be taken as a type: Ligate
the upper pole of the lobe of the gland to be removed. Note and clamp the
vessels running over the gland at the chosen site for section (Fig. 384),

Fig. 382. — de Queniain. Deutsche Zeilsch. f. Fig. 383. — de Queroain. Deutsche Zeilsch. f.
Chir., c.xvi, 574. Chir., cxvi, 574.

Incise the true capsule along the anterior part of the outer surface of the
gland. Make a similar incision through the true capsule to the inner side of
the lobe. Excise all the gland lying between these two incisions, leaving the
posterior portion of the true capsule with a moderate amount of glandular
tissue attached to it.

Fig. 384. — de Quervain. Deutsche Zeitsch. f. Chir., cxvi, 574.

Attend to hemostasis. Suture the remnant of the gland close to the wound
after providing for drainage. Figures 376 to 381 show types of resection.
When enucleation is preferable to resection one or several of the thyroid arteries
may require preliminary ligation. Figures 382 and 383 show various types of
enucleation.

Partial Excision — ^Excision of One Lobe

Method A. — Kocher's Transverse Incision. — Step i. — Over the most promi-
nent part of the tumor make a slightly curved transverse incision (concavity
upwards) from the outer surface of one sternomastoid muscle to the corre-
sponding point on the other. Make the incision too long rather than too short,
as thorough exposure is the key to safety. Divide the skin and platysma.
Reflect the divided tissues upwards and downwards; the sternohyoid, stemo-

kocher's operation

257

thyroid, omohyoid, and inner margin of the sternomastoid muscles lie more or
less exposed. Find the anatomic middle line of the neck. Remember that
a unilateral goitre pushes this line towards the opposite side (Figs. 385
In the median line divide the fascia uniting the right and left muscle
groups. Do this extensively both upwards and downwards under guidance
of the finger passed under the fascia. Pass the finger under the muscles of

Fig. 385. — {Kocher.)

the diseased side immediately below the larynx and, if necessary, divide them
transversely to the extent necessary for thorough exposure of the tumor. It
is well to divide the muscles between clamps so as to prevent staining of the
wound with blood. Demonstrate the fibrous capsule of the thyroid and split
it without injuring the gland beneath. Division of the fibrous capsule is
absolutely essential.

{Kocher.)

Step 2. — With the finger separate the fibrous capsule from the anterior sur-
face of the gland, at the same time pulling the muscles and fibrous capsule
outwards with blunt retractors. The goitrous thyroid now presents, covered
by a peritoneal-like membrane (Fig. 394). Any veins (accessory veins) passing
from the fibrous capsule to the gland must be doubly ligated and divided. Do
the same for the outer and posterior surfaces (Figs. 386, 387, and 388). Now
dislocate the goitre and pull it out of the wound. This removes pressure from

^5^

goitre; bronchocele; struma

trachea. If a general anesthetic is being used, warn the anesthetist before
dislocating the gland.

Step 3. — Systematic ligation of vessels.

(a) With Kocher's director push the fibrous capsule inwards and outwards
from the upper pole of the thyroid until the superior thyroid artery and vein
are isolated like a pedicle. Divide these between ligatures applied tightly
(Fig. 389).

Fig. 387. — (Kocher.)

(b) Vigorously retract the muscles (sternomastoid, etc.) of the afifected side.
Firmly pull the goitre over towards the sound side (Fig. 388). The inferior
thyroid artery lies on the deep muscles of the neck and may be felt as a trans-
verse or oblique pulsating cord running from the outer side, under the carotid
to the thyroid gland, where that structure is attached to the trachea. Isolate
the artery with great care and precision, because close to it is the recurrent
laryngeal nerve. Only apply one ligature to the vessel. Many surgeons ligate
each branch of the inferior thyroid close to the gland and so avoid the nerve.

-^x

388.— (Kocher.)

Fig. 389. — {Kocher.)

(c) At the lower pole of the tumor on its median side look for, doubly
ligate, and divide the thyroidea ima artery and the accompanying veins (Fig.

391)-

Step 4. — Isolate the thyroid isthmus. Doubly ligate and divide all vessels
visible on it. Catch the isthmus in strong forceps (Fig. 392) and crush it
forcibly. Remove the crushing forceps. Doubly ligate the gutter crushed in
the isthmus with single or chain ligatures and divide it.

Step 5. — The gland now remains attached to the trachea and cricoid by its
inner margin. If this portion of the gland is healthy, cut away the gland in

MAYO S OPERATION

259

such a manner as to leave a thin layer in situ, protecting the recurrent laryngeal
nerve. Ligate any bleeding vessels.

Step 6. — Wash the wound with hot solution. Examine for any bleeding
points. Return any divided muscles to their normal place and unite them
by sutures. Provide for drainage^ especially in exophthalmic cases. Close

Fig. 390. — {Kocher.)

Fig. 391. — {Kocher.)

the wound. Apply dressings. The drainage must be removed in twenty-
four hours if no fluid blood is escaping.

Method B. — Mayors Operation. — Step i. — As in method A.

Step 2. — With the fingers separate the fibrous capsule from the anterior
surface of the gland, at the same time pulling the muscles and fibrous capsule
outwards with blunt retractors or forceps. Doubly ligate and divide any

Fig. 392. — {Kocher.)

accessory veins. Expose and elevate the upper pole of the th3'roid; doubly
ligate and divide the superior thyroid vessels.

Step 3. — Elevate the lower pole of the th}T:oid and bring it into the wound.
If necessary make an incision along the outer posterior border of the thyroid
so as to divide any condensed areolar tissue which may be adherent to the
peritoneal-like investment of the gland. This incision is not always necessary.

26o

goitre; bronchocele; struma

With a piece of gauze wipe or brush all areolar tissue adherent to the posterior
surface of the gland from the gland so that that surface of the gland has no
moss of areolar tissue left adherent to it, but presents a smooth peritoneal-
like appearance. If this is done carefully and every bit of areolar tissue, which
may have penetrated into sulci on the gland surface, has been brushed off and
left adherent to the fibrous capsule, then the parathyroids must also have been
brushed off and preserved. Continue this gauze dissection or brushing to the

i''i*- sgo'—O^^y^-)

middle line. Ligate the inferior thyroid artery close to the tumor as the gauze
dissection is being carried out. This leaves the recurrent laryngeal nerve
behind and usually out of sight.

Steps 4, 5 and 6. — As in method A.

Method C. — Halsted's operation is the same as Kocher's or Mayo's up to
a certain point. The following quotation from Halsted gives the main points
of his method. " Contrary to the universal custom, I do not, as a rule, complete
at this moment the full delivery of the entire gland, for fear of soiling, but
grasp very firmly between the thumb and finger the superior pole and pull it
forwards and towards the mid-line far enough to make the ultraligation of the
superior thyroid vessels perfectly easy. Attempts to completely dislocate the

HALSTED S OPERATION

261

entire gland of the inferior pole in this manner at this stage of the operation
may cause the rupture of some delicate blood-vessels and consequent staining
of the field containing the parathyroid glandules. But, if judiciously done
in the manner described, the superior pole may be fearlessly grasped, because
at this horizontal level there are no vessels behind the superior pole to be torn.
When the superior thyroid vessels have been safely passed by the thumb or
finger, one may proceed with considerable roughness and without fear of hemor-
rhage to dislocate even the highest and deepest superior pole. This grasp of

Fig. 394. — {Mayo.)

the upper portion of the lobe, putting on stretch the superior thyroid vessels,
must not be relinquished until released by the ultradivision of the finest branches
distributed to the thyroid gland in the vicinity of the superior pole. The upper
end being thus liberated the delivery of the entire lobe is continued, and without
the tearing of the blood-vessels. From this step on, throughout the operation,
until the last vessel has been divided, the thyroid lobe must be firmly drawn
towards the opposite side, alternate relaxation and compression and undue
pressure on the trachea being carefully avoided. From above downwards and
from before backwards the vessels as they bind or as they present must be
clamped and divided at their point of entrance into the gland, as far peripherally
as possible. Except in the case of the larger branches it is usually unnecessary
to clamp the distal end of the cut vessel, hemorrhage from the gland side being

262

goitre; bronchocele; struma

prevented by the pressure exerted on the thyroid lobe by the unremitting
traction towards the opposite side of the neck. By this method the recurrent
laryngeal nerve, usually seen, is little endangered. In the course of the libera-
tion of the lobe the nerve may be dragged well to the front of the trachea; of
the right nerve this is particularly true. When in the immediate neighborhood

Fig. 395. — {Balfour, Annals of Surgery.)

of this nerve, at what might erroneously be termed the hilus of the th>Toid lobe,
one plunges the sharp-pointed clamps into the thyroid gland, seizing the binding
vessels after they have disappeared from view in its substance. WTien the habit
is well acquired, little if any time is lost by practising the clean, bloodless method
of operating for goitre. The operation can be carefully performed in about the
time required for its detailed description."

RESECTION' 263

Method D. — Angular Incision (Kocher). — Beginning on the sternomastoid
muscle at the level of the thyroid cartilage, make an incision through the skin
and platysma, reaching the median line and following the direction of the natu-
ral folds or creases of the skin. Continue the incision downwards in the middle
line to the notch of the sternum. Reflect the angular skin-flap and expose the
sternomastoid, which must be retracted outwards. The rest of the operation
is the same as in ^Method A. This method of exposure is of much value in cases
where the goitre extends far upwards or downwards.

Method E. — v. Mikulicz's Method of Resection. — The following description
is from v. Mikulicz's article, quoted by Berry (" Diseases of the Thyroid Gland") :
" I began the operation, intending to perform the ordinary one of removal of the
left lobe, and hoping to be able to leave the right intact. In the course of the
operation, however, it became evident that the right lobe lay partly behind the
sternum, and would, if left, prove a source of danger to the patient. So instead
of doing the usual extirpation, I resected this lobe in the following manner:
First of all it was isolated as far as possible in the usual way with blunt instru-
ments. The smaller blood-vessels were tied with double catgut sutures. I
then tied the superior thyroid artery and vein in the ordinary manner at the
summit of the lobe; also the superficial vessels passing to the lower part of the
gland. I now, by means of short snips of the scissors, freed that portion of the
tumor which was adherent to the front and side of the trachea, but took care
not to go too far back, so as not to come into collision with the recurrent laryn-
geal nerve. Eventually the whole tumor was attached only to the angle be-
tween the trachea and oesophagus, where it covered the recurrent nerve and
inferior thyroid artery. This attached portion, the hilus of the gland, I treated
like the short, thick pedicle of an ovarian tumor. . . . While my assistant
with his fingers compressed the vessels entering the hilus, I split the pedicle
lengthwise with blunt scissors into several portions, seized each of these in a
strong pair of pressure forceps, and placed catgut ligatures in each of the clefts
so formed. Then the goitrous mass was cut off with scissors, leaving a pedicle
of 5 to ID mm. {yir'/o inch) in length. The forceps squeezed out nearly all the
glandular tissue, leaving in their grasp little but connective tissue. The result
was that the catgut ligatures could easily and safely be placed around the sepa-
rated portions of the pedicle. Not a drop of blood came away from the cut
surfaces; only here and there in the intervals was a little oozing; this slight
hemorrhage was easily stopped by the application of a few ligatures. The
remainder of the gland had now shrunk to a lump about as large as a chestnut
which lay in the angle between the trachea and oesophagus. Neither recurrent
nerve nor inferior thyroid artery came into view on this side."

The above operation has been frequently repeated and has proved very
successful. The advantages of the procedure are: (a) avoidance of the recur-
rent nerve; {h) avoidance of injury to the parathyroids; (c) retention of portions
of the lobes attacked, and hence the possibility of removing parts of both lobes.

Donald Balfour (Annals Surg., May, 1914) describes a method almost the
same as that of Mikulicz. It is particularly suitable for non-toxic goitres where
the operation is for the relief of pressure symptoms and the removal of deformity.

Expose the thyroid through the usual collar incision. If both lobes are en-

264 goitre; bronchocele; struma

larged, dislocate them both. Determine how much glandular tissue must be
removed from each side to ensure symmetry and cure. Divide the isthmus, if
possible, between clamps. Free the isthmus and lobe on one side from their
tracheal attachments anteriorly and laterally sufficiently to relieve all pressure
and to permit of proper suturing after resection. Do the same to the other half
of the gland.

Apply a series of Ochsner forceps around the area to be resected: one forceps
about I inch from the upper pole, one near the lower pole, three or four laterally
on the larger vessels in the capsule, and two or three on the tracheal side. These
forceps mark the limits of the resection and enable one to control bleeding by
traction on them along with support of the lobe from behind with the finger.
Make an incision through the capsule around the lobe just within the circle of

ligature.
around Isihmus

Trachea

Thuroidea ima
Vein.

Fig. 396. — Resection-enucleation.

forceps (Fig. 395). " Wedge" out the interior of the gland. Multiple adenomas
and masses of colloid are easily enucleated by the finger. The superior and in-
ferior poles and a layer of gland tissue covering the posterior capsule are left
intact. Bring the walls of the wounded gland into contact and fix them to-
gether by a continuous mattress suture of catgut introduced behind the row of
Ochsner forceps. Remove the forceps. Introduce sufficient stitches to com-
plete the closure of the glandular wound and to assure hemostasis.

Method F. — Resection-enucleation (Kocher). — This method is very like that
of V. Mikulicz, but avoids leaving large ligated masses near the location of
the recurrent nerve. Kocher has noticed that when many large pedicles are
ligated near the nerve the necessary contraction of the tissues by the ligature
often causes injury to it.

The Operation. — Step i. — Expose the anterior surface of the diseased half
of the thyroid as in Method A. Crush (with forceps), ligate, and divide the
isthmus close to the disease.

Step 2. — Through the cut surface of the isthmus the goitrous nodule will
present (Fig. 396). Beginning at the isthmus wound, with the finger or Kocher 's
director penetrate the glandular capsule down to the disease and separate the

ENUCLEATION 265

former from the nodule along the lines A B and C D. Note that the separation
of glandular capsule from goitrous nodule is only along these two lines. With
strong forceps crush the glandular capsule along the lines of separation, remove
the forceps, apply ligatures to the crushed tissue, and divide the glandular
capsule.

Step 3. — Grasp the goitrous nodule and overlying glandular capsule and
separate this mass from the posterior portion of the glandular capsule until all
that connects the goitrous mass to the body is the outer portion of the glandular
capsule (B D, Fig. 396) well external to the line of the recurrent nerve. Crush
this portion of the capsule; ligate and divide it.

By the above procedure the diseased tissues are removed, and with them the
anterior portion of the gland. All the posterior surface of the gland is left,
which is advantageous because danger to the recurrent nerve, and the para-
thyroids, is avoided and much useful glandular tissue is retained. Hemorrhage
is less than in enucleation. Kocher says that this operation, while very valu-
able, is of more limited application than excision. It is inapplicable in cases of
diffuse follicular colloid degeneration.

Method G. — Freeman's Method (Surg. Gyn. and Obst., July, 1914). — Dis-
locate the gland through the usual collar incision. Separate ligation of the
superior thyroids may be practised if desired. Pull the lobe forwards so as to
put its attachments on the stretch and form more or less of a pedicle next to the
trachea.

Thread both ends of a 12-inch loop of strong silk or fishing line through the
eye of a probe and pass it from behind forwards through the substance of the
gland near its attachments.

Introduce several such loops of thread through the gland, one near each end
and one or more near the centre. Place a segment of strong wire (No. 17
German silver, "orthodontia wire") through the loops behind the gland and a
similar wire between the ends of the thread in front of the gland. Tie the threads
over the anterior wire firmly enough to control the circulation without injuri-
ously crushing the glandular tissue. About 3^^ inch distal to the wires cut away
the lobe in a more or less wedge-shaped fashion. Suture the wound with a con-
tinuous catgut stitch to cover the raw surface and prevent subsequent bleeding.
Pull the wires out of the loops and remove the latter. Close the wound as usual.
Freeman has used this method successfully in about twenty goitres of moderate
size and excessive vascularity — as in Graves' disease.

II. INTRAGLANDULAR ENUCLEATION

Step I. — Expose the anterior surface of the diseased lobe by Method A or
D. (See "Excision.")

Step 2. — Note the most prominent part of the tumor, and at this point
freely incise the glandular capsule. Before incising, clamp or doubly ligate
any prominent vessels. Be sure to penetrate to, but not into, the tumor.
It is not always necessary to incise the glandular capsule as the tumor may
have so grown as to push aside all the gland tissue which originally covered it.
In such a case it is easy to enucleate the growth by brushing aside with gauze
all tissue adherent to it.

266 goitre; bronchocele; struma

Step 3.— With blunt dissection, using the finger, Kocher's director, or closed
blunt scissors, shell the tumor out of its glandular capsule. Sometimes this is
more easily accomplished if the fluid contents are drawn off, as in the case of a
large ovarian cyst. The shelling-out must be done rapidly, as bleeding is often
abundant. The surgeon must always keep his instrument close against the
tumor-wall, otherwise the vascular glandular capsule will be injured and more
bleeding provoked.

Step 4. — Immediately on the removal of the tumor temporarily pack the
cavity with gauze and pull the whole cavity forwards. Gradually remove the
gauze, and with forceps, ligatures, and catgut stitches stop hemorrhage. The
hand placed behind the thyroid can press the floor of the wound cavity forwards
within reach and control. Hemostasis must be absolute, as primary union is of
great importance.

Step 5. — Provide for drainage for twenty-four hours. A tubular drain is
best. Close the wound with sutures. For this purpose Berry uses three layers
of fine sutures. One layer obliterates the cavity in the gland, another unites
the muscles, and a third, the skin-wound.

Where large multilocular cysts are present F. J. Shepherd ties and divides
the superior thyroid vessels, delivers the gland and enucleates the tumor.
This leaves a thin layer of gland tissue behind, and there is no danger of injur-
ing the recurrent nerve. Occasionally Shepherd ties the inferior thyroid as well
as the superior. In the light of Evans' researches into the blood supply of
the parathyroids, ligation of the inferior thyroid artery becames a matter of
much greater gravity than it was formerly thought to be.

III. INCISION AND EVACUATION: MARSUPI.ALIZATION

In certain cases of cystic goitre where repeated attacks of inflammation have
caused the formation of many adhesions none of the preceding methods are
applicable, and a simpler operation must be done.

Step I. — Make an incision over the most prominent portion of the tumor
and expose a few inches of its surface.

Step 2. — Doubly ligate the vessels of the tumor capsule (both fibrous and
glandular capsule) and incise the tumor. Stitch the edges of the wound in the
cyst-wall to the skin.

Step 3. — Explore the cyst with the finger and shell out all degenerated col-
loid masses. Stop bleeding by means of forceps, ligatures, hemostatic sutures,
hot water, and packing. Drain the cavity.

The great objection to this procedure is the open wound which is left, the
dangers of subsequent infection, and the possible persistence of a fistula; its
advantages are ease of accomplishment and immediate safety. The operation
has a distinct though limited field of usefulness.

IV. TRANSPLANTATION OF THYROID OR PARATHYROID
GLANDULAR TISSUE

Payr ("German Surg. Congress," 1906) has made some remarkable ex-
periments on animals and has endeavored to prevent the tetany and cachexia
strumipriva which follow complete thyroidectomy. In animals he implanted

INJECTIONS IN GOITRE 267

fragments of thyroid gland into a pouch made in the spleen. Hemorrhage
ceased as soon as the ''living tampon" was sutured in place. Omentum was
stitched over the splenic wound. After some days the rest of the thyroid gland
was removed without ill resulting. As a control Payr in some cases subse-
quently removed the spleen and caused death from tetany.

Encouraged by the above Payr operated on a girl of six years, a complete
idiot who had been treated for three years with thyroid tablets unsuccessfully.
He removed a part of the healthy thyroid from the patient's mother and im-
mediately implanted it in the child's spleen. Both patients recovered from the
operation. The psychic improvement in the child was "incontestable." Payr
has noticed that grafts from ductless glands generally do well in the spleen
while those from excretory glands do not do so well.

Following Payr's lead, Halstead has endeavored to transplant parathyroid
glands which have been accidentally deprived of their vascular supply during
strumectomy.

In a case of tetany following thyroidectomy a cure resulted from the implan-
tation of two parathyroid bodies under the skin of the abdomen. The im-
plants were obtained from two men operated on for goitre. (W. Davidson,
"Beitr. z. klin. Chir.," Ixvi, Hft. i.)

V. INJECTIONS OF BOILING WATER. (Miles Porter, "Journ.
A. M. A." July 12, 1913)

Any fairly large all-glass graduated syringe may be used. The glass barrel
prevents one from injecting air; the more water the syringe holds the less rapidly
will the water cool; the plunger and barrel being both of glass prevents binding
or breaking due to unequal expansion. The needle ought to be long and rather
fine.

Boil the syringe and needle in the water to be used for injection and keep
the water boiling until the time of injection. When more than one injection is
given at a treatment, reboil the syringe immediately before the next injection to
insure having the water used as near the boiling point as possible.

Handle the syringe with long forceps (the points of which have been heated)
and with sterile gauze or muslin. After cleaning the skin anesthetize it at the
site of injection, with Schleich's solution. Avoiding any large superficial veins
pass the long needle deeply into one lobe and inject the boiling water. Porter
has used from 40 to 230 minims at one injection. Partly withdraw the needle
and make another injection. With the long needle it may be possible to make
two injections into each lobe and one into the isthmus through the same punc-
ture. The discomfort produced by the treatment is usually slight and consists
of a feeling of distension and of pain running up to the occiput. In some cases
the pain has been severe. The goitre usually becomes larger and harder follow-
ing the injection but later on decreases much. The improvement in symptoms
is usually prompt and progressive for one or two weeks. The injections should
be repeated at intervals of one or two weeks. The greatest number of injections
given any one patient was eleven. Porter has used the treatment chiefly in
three classes of cases; i. Patient too sick to make a safe surgical risk. Cases

268 THYMUS GLAND

also of substernal goitre, the removal of which would be extra hazardous. 2.
Patients with very mild symptoms. 3. When major surgical procedures have
been refused.

The author has had no personal experience in the " boiling water" treatment
of exophthalmic goitre, but Porter who 'devised it is a most reliable surgeon and
his findings have been amply corroborated by others.

CHAPTER XXIX
THYMUS GLAND

An enlarged thymus gland may so press upon the trachea as to necessitate
operation. Operation may be either exopexy with or without partial excision
or it may be one of complete excision.

The thymus and thyroid glands being both branchiogenous organs may be
simultaneously affected by the same influences. Thus the cause of Graves' dis-
ease may act on both these glands and the biochemical activity of each may have
its effect on the production of the symptoms. Klose thinks that the fact that
thyroidectomy only gives 70-80 per cent, of cures in Graves' disease, indicates
that there is another source of toxin than the thyroid, viz., the thymus. (See
H. Klose, "Chir. der Thymus-driise. Ergeb. d. Chir.," viii, 1914.)

The work of Garre ("Zent. f. Chir.," Dec. 6, 1913) has demonstrated that the
thymus may be responsible for the symptoms of Graves' disease. He reported
the following case: Woman twenty-seven suffered for three months from
marked Basedow's disease with severe diarrhoea. The trouble followed a gyne-
cologic operation. The thyroid gland was scarcely enlarged; there was dulness
over the manubrium sterni; lymphocytosis 46 per cent.; functionally increased
vagotonus; negative adrenalin test; fall of leucocytosis to normal and marked
increased elimination of nitrogen under a milk diet; increase of the symptoms
after intramuscular injections of thymus extract. All these led Garre to re-
move the thymus. The results were excellent. The diarrhoea stopped at once.
In six weeks the pulse rate dropped to below 100. The weight increased 19
pounds. The exophthalmos, sweating and tremor lessened. The blood pic-
ture remained unaltered.

v Haberer (German Surg. Congr., 1913) reported the case of a man suffering
from exophthalmos, enlarged thyroid, violent and increasing tachycardia.
Hemithyroidectomy did not benefit — neither did ligation of the vessels on the
opposite side which was done two years later. When v. Haberer saw him his
condition was precarious from dyspnoea and tachycardia. Immediate improve-
ment followed thymectomy under local anesthesia, although the thymus itself
proved to be very small. Four months after operation the patient was able to
return to work and was free from dyspnoea, tachycardia and nervousness.

Since it is very difficult, even if possible, to define in which cases the thymus
is the principal offender Klose recommends combined excision as the operation
of choice in Basedow's disease especially in those cases in which fear of a "thy-
mus death" formerly contraindicated operation. He claims (and is supported

EXCISION OF THYMUS 269

by Enderlen and v. Haberer) that removal of part of the thymus makes the
operation of strumectomy for exophthalmic goitre much less dangerous and
distressing as well as giving better ultimate results.

Regarding the technique of the operation Klose writes, "It is possible in
every case under local anesthesia to pull forwards the thymus bluntly after
splitting the deep fascia and then to incise the capsule and enucleate the gland
completely or in part. Experience has shown that complete removal is
harmless in adults. The enucleation must of course be intracapsular. . . .
v. Haberer urges that the posterior surface of the sternum be used as a guide in
order to avoid trouble."

A. Exopexy. — Expose the upper part of the thymus gland by a median
incision above the sternal notch. Pull the gland upwards and forwards. An-
chor it with a few stitches to the fascia over the sternum. In the hands of
Rehn, exopexy gave a good result. In a similar case Fritz Konig resected a
portion of the gland, anchoring the remainder to the sternum, and obtained a
cure of the dyspnoea.

B. Excision of the Enlarged Thymus. (Ehrhardt, "Archiv fiir klin. Chir.
Ixxviii, 602.)

Step I. — Make a median incision from a point just below the larynx to a
point about ^ inch below the upper edge of the sternum. Layer by layer
divide the tissues, including the isthmus of the thyroid, until the trachea is
fully exposed. At each expiration a large part of the thymus rolls forwards in
the root of the neck.

Step 2. — Seize the thymus with forceps and pull it forwards. Enucleate the
gland by blunt and sharp dissection attending to hemostasis at the same time.
Partially tampon and close the wound.

Ehrhardt operated with success as above in one case.

Veau and Oliver ("Arch, de med. des enfants," 1910, Nov.) operated in
three cases in much the same manner using chloroform narcosis. After exposing
the gland and fixing it with forceps they penetrated the capsule first on the left
side and enucleated the gland, then they did the same on the right side, and
closed the cavity with catgut sutures. Veau and Olivier performed total extir-
pation as above described without ill effect, but if one fears removal of the whole
gland one may content oneself with the removal of one half. ("La Presse Med.,"
ix, 1910.)

The surgeon must remember that the thymus gland may cause death from
pressure without the presence of any visible or palpable tumor in the neck.

Chevalier Jackson (" Journ. Amer. Med. Assoc," May 25, 1907) has demon-
strated an enlarged thymus by means of the X-rays, and with the bronchoscope
showed that pressure from the thymus produced scabbard deformity of the
trachea. After tracheotomy Jackson measured the distance from the trache-
otomy wound to a point i cm. from the bifurcation of the trachea and procured
a tracheotomy cannula of this length. The use of a cannula passing through
the constricted trachea notably facilitated the removal of the thymus.

PART II.— THE THORAX

CHAPTER XXX
OPERATIONS ON THE BREAST

Evacuation of Abscess by Incision. — The classical method of incising the
breast to empty an abscess is exceedingly simple. Make an incision through
the skin, beginning peripheral to the areola, along a line radiating from the nipple
and situated over the inflammatory swelling. By combined sharp and blunt
dissection penetrate the abscess, clean the cavity, and provide drainage. The
object of radial incision is to avoid transverse and unnecessary division of
glandular structures.

An abscess forming in the breast itself may break through to the subcu-
taneous or to the submammary areolar tissues. The communication between
the primary focus and the secondary abscess may be narrow. Several foci of
pus may be present and only communicate with each other through narrow
passages. To effect drainage and avoid all deformity Morestin operates as
follows:

From the base of the nipple to the edge of the areola (fortunately the areola
is usually widespread in lactating women) make an incision through the skin.
From this incision pass the knife subcutaneously into the superficial collection
of pus. In withdrawing the knife enlarge the opening but do not cut through
the skin beyond the areola. With a probe, forceps, or even the finger, explore
the abscess and find the communication between it and the intramammary
focus. With the knife enlarge this communication so that drainage will be
free. If any other foci of pus are present penetrate them in similar fashion.
Cleanse and antisepticize the abscess. Introduce drains and apply dressings.

No matter the site of the abscess, above, below, internal or external, the
operation is the same. Bleeding is trivial and ceases spontaneously in a few
minutes. Usually the drain may be removed in from three to five days and
recovery ensues in ten to twelve days. The scar is hardly noticeable.

To avoid deformity from scars it has been suggested to use the principle of
Thomas' operation for adenomata of the breast. Make a curved incision along
the line of junction of the lower edge of the breast and the chest-wall. Pene-
trate to, but not through, the pectoral fascia. Separate the breast from the
chest-wall until it is possible to gain access to the abscess from the deep surface
of the gland. Evacuate the pus. Introduce one or two drainage-tubes into
the cavity and bring their ends out through the wound. Replace the mamma
on the thoracic wall. Partially close the skin-wound by sutures.

271

2 72 OPERATIONS ON THE BREAST

In this operation the incision is larger and the dissection is much
greater than is required in simple incision, but the drainage is excellent
and the resulting scar is below the breast and hidden by the natural fold
existing there.

Mastopexy. — Mastoptosis or pendulous breast is common, may be due to
one or several of many causes, may be harmless except as a disfigurement, but
it may give rise to chronic, painful engorgement and to various inflammations.
Ch. Girard ("Archiv fur klin. Chir.," xcii, 829) describes the various methods
of treatment adopted for mastoptosis and suggests an operation which he has
successfully used.

Step I. — Reflect the breast upwards, as in the Thomas' operation for be-
nign neoplasms, until the second costal cartilage is reached.

Step 2. — Expose the second costal cartilage by incising the pectoral fascia
and bluntly splitting the pectoralis major muscle parallel to its fibres.

Step 3. — With a slightly curved, strong needle pass a very strong catgut
suture from below upwards through the second costal cartilage. Pass this
suture through the fibrous tissue of the upper pole of the mamma. Tie the
suture after tightening it sufficiently to bring the breast up into the desired
position but still leaving the loop of the suture somewhat open like a sling.
Through the loop of the first suture pass about four catgut threads and stitch
each of these to different parts of the under surface of the breast. The result
of the above procedures is that a number of radiating threads pass from the
primary suture in such a manner that all parts of the breast are attached to the
second costal cartilage by a series of slings, but the breast can still be lifted up
from the chest-wall.

Step 4. — From above downwards suture the under surface of the mamma
to the pectoral fascia.

Step 5. — Close the skin wound.

Excision of Non-malignant Neoplasms of the Breast. — I. When the breast
is the seat of very large or multiple non-malignant neoplasms, the whole organ
must be excised, but it is not necessary to remove the pectoral fascia or axillary
contents. Make an oblique elHptical incision over the breast and including
the nipple. This incision runs from above and outwards, downwards, and
inwards; it begins and ends just beyond the confines of the gland. Through
the incision dissect the skin free from the breast; by blunt and sharp dissec-
tion separate the breast from the pectoral fascia and remove it. Attend to
hemostasis. Close the wound.

The operation is perhaps the easiest in surgery. When there is doubt as
to the malignancy or non-malignancy of the disease present, and histological
examination is, for any proper reason, not convenient, then the above operation
should not be performed; the patient ought to be given the benefit of the doubt
and radical measures adopted.

11. WTien the breast is the seat of one or perhaps of two or three small non-
malignant neoplasms, such may be excised, leaving the gland practically intact.

Method A. — Fix the neoplasm by grasping it between the finger and thumb.
Make an incision over the tumor, peripheral to the nipple areola, along a line
radiating from the nipple. Expose the tumor by this incision and either shell

EXCISION BREAST 273

or dissect it out of its bed. Attend to hemostasis. Close the wound, with or
without drainage.

Method B. — Thomas' operation has the great advantage of avoiding visible
scars. It has been sufficiently described on page 271.

Excision of the Breast for Cancer. — A few years ago typical excision of
the breast could be completed in a few minutes. The operation consisted in
making an elliptical incision over the breast, including the nipple, in rapidly
reflecting the skin from the gland, and in tearing and cutting the gland from
the pectoral fascia. Through the wound the finger was pushed up into the
corresponding axilla, and if any lymphatic glands were found enlarged, such
were removed. The operation was primarily safe. The ultimate results were
such that many experienced surgeons claimed recurrence always took place.
Disgusted with the want of success attained, thoughtful operators became
more radical and more successful. The typical operation no longer consisted
in removal of the mamma and the axillary glands if they were palpably diseased,
but the mamma, the pectoral fascia, the axillary glands, and fat were removed
in one piece. The primary mortality of the operation did not increase per-
ceptibly; the ultimate results were infinitely bettered.

The Operation. — The incision A, B, C (Fig. 397) is made through the skin.
The ellipse between B and C includes the nipple and any portions of skin which
may be adherent to the tumor. The skin-flap ABC
E is reflected downwards well below the limits of the
breast and to the posterior border of the axilla {i.e.,
to the edge of the latissimus dorsi). The skin-flap
A B C D is reflected upwards well above the limits
of the breast and so as to expose the anterior bound-
ary of the axilla. Beginning below the breast, one
dissects from the pectoralis major, the fat of the
chest-wall, the pectoral fascia, and with them the

diseased mamma. This is continued to a point well „

^ riG. 397.

above the breast, to the base of the skin-flap A B C D.

There is now a mass of fat, gland, and pectoral fascia unconnected with the
chest-wall, but continuous with the fatty and lymphatic axillary contents. The
chest wound is to be protected by an aseptic pad or towel and the surgeon
attacks the axilla. Beginning on the outer or arm side of the axilla, its fatty
contents are dissected from the vessels and nerve-trunks there situated. The
first effort should be to dissect the axillary vein free from its fatty surround-
ings. Any axillary branches of the vein should be divided between two fine
ligatures whenever found. When this dissection is being made, the arm should
be kept as close to the body as is consistent with free access to the axilla; the
object attained by doing so is that otherwise branches of the axillary vein
would be put on the stretch and rendered unrecognizable, and further that in
this position it is possible to retract the pectoralis major upwards, thus giving
access to the apex of the axilla.

The contents of the axilla are easily separated from the posterior and internal
walls of the space. If it is convenient to save the small nerves crossing the
axilla, they may be preserved; but if, as is usually the case, time would be lost

2 74 ' OPERATIONS OX THE BREAST

in so doing, they should be sacrificed. The only connection left between the
mass to be removed and the body is at the apex of the axilla. If the lymphatics
higher up are believed to be healthy, this connection is divided and the excision
is complete. If, on the other hand, it is suspected that the disease extends
further, then the pectoralis major is divided and access is gained to the chain
of lymphatics running up under the clavicle. These are removed in one piece
with the tumor mass. The wound in the muscle is sutured. The whole wound
is closed, axillary drainage being provided.

When the pectoral fascia is being removed from the pectoralis major,
should any disease be found or suspected to exist in that muscle the whole
muscle must be excised in one piece with the mamma.

Halsted has still further elaborated the operation, making it tremendously
extensive and most remarkably successful. His success is so great that the

author considers the Halsted operation or some
modification thereof to be the preferable treatment
for operable mammary cancer.

Halsted Operation. — (The following description
is compiled from Halsted's articles in the
"Annals of Surgery," vol. xx, No. 5, and xx\'iii.
No. 5.)

Principles of Operation. — The pectoralis major
muscle, entire or all except its clavicular portion,
should be excised in every case of cancer of the
breast, because the operator is enabled thereby to
Fig. 398. — Halsted's incision, remove in one piece all the suspected tissues. The

suspected tissues should be removed in one piece.
Step I. — The skin-incision is carried at once and ever}^where through the
fat (Fig. 398).

Step 2. — The triangular flap of skin A B C is reflected back to its base line,
C A. There is nothing but skin in this flap. The fat which Uned it is dissected
back to the lower edge of the pectoralis major muscle, where it is continuous
with the fat of the axilla.

Step 3. — The costal insertions of the pectoralis major are severed and the
splitting of the muscle, usually between its clavicular and costal portions, is
begun, and continued to a point about opposite the scalenus tubercle on the
first rib.

Step 4. — At this point the clavicular portion of the pectoralis major and
the skin overlying it are cut through hard up to the clavicle. This cut exposes
the apex of the axilla.

Step 5. — The loose tissue under the clavicular portion of the pectoralis
major is carefully dissected from this muscle as the latter is drawn upwards
by a broad sharp retractor. This tissue is rich in lymphatics and is sometimes
injected with cancer.

Step 6. — The splitting of the muscle is continued out to the humerus, and
the part of the muscle to be removed is now cut through close to its humeral
attachment.

Step 7. — The whole mass, skin, breast, areolar tissue, and fat, circumscribed

EXCISION BREAST 275

by the original skin incision, is raised up with some force, to put the submuscular
fascia on the stretch as it is stripped from the thorax close to the ribs and pec-
toralis minor muscle. It is well to include the delicate sheath of the minor
muscle when this is practicable. This step has been modified by Halsted in that
he now ("Annals of Surgery," Nov., 1898) removes the pectoralis minor and
exposes the subclavian vein at its inner part.

Step 8. — The axilla is now stripped of its contents and its anterior wall at one
time, from within outwards and from above downwards. The axillary con-
tents are dissected away with scrupulous care and with the sharpest possible
knife. The axillary vein should be stripped absolutely clean. Not a particle
of extraneous tissue should be included in the ligatures which are applied to
the branches, sometimes very minute, of the axillary vessels. In liberating
the vein from the tissue to be removed it is better to push the vein away from
the tissues rather than, holding the vein, to push the tissue away from it. It
may not be necessary, but it is well to expose the artery and remove the possibly
infected tissue above it. It is best to err on the safe side and remove in all
cases the loose tissue above the vessels and about the axillary plexus of nerves.

Step 9. — Having cleaned the vessels, we may proceed more rapidly to strip
the axillary contents from the inner wall of the axilla — ^the lateral wall of the
thorax.

Step 10. — When we have reached the junction of the posterior and lateral
walls of the axilla, or a little sooner, an assistant takes hold of the triangular
flap of skin and draws it outwards, to assist in spreading out the tissues which
lie on the subscapularis, teres major, and latissimus dorsi muscles. The
operator cleans the posterior wall of the axilla from within outwards. The
subscapular vessels are exposed and caught before being divided. The sub-
scapular nerves may or may not be removed.

Step 1 1 . — Having passed these nerves, the operator has only to turn the mass
back into its normal position and to sever its connection with the body of the
patient by a stroke of the knife from B to C, repeating the first cut through the
skin.

Step 12. — This step did not belong to Halsted's original operation, but has
been added by him subsequently. Make a vertical incision parallel to and near
the posterior margin of the sternomastoid muscle, dividing a few of the posterior
fibres of the muscle. Expose the junction of the internal jugular and sub-
clavian veins. Divide the omohyoid muscle at its tendinous part and draw its
two bellies out of the way. Remove the supraclavicular fat by dissecting
downwards and outwards from the venous junction, and the infraclavicular
fat by dissecting from below. By elevating the shoulder the clavicle can be
raised an inch or more away from the first rib when the operation is so far
completed as to make this desirable. The web of fibrous tissue which binds
the subclavian vein loosely to the clavicle is thus spread out and can be easily
removed. The fingers can be passed from the supraclavicular to the infra-
clavicular and to the subscapular regions under the clavicle, and any fat in
the latter region, near the internal or the posterior border of the scapula be-
tween the serratus magnus and subscapular muscles, which could not be well
reached from the axilla can be drawn out through the neck.

276

OPERATIONS ON THE BREAST

Step 13. — Review the whole wound. Unite the divided omohyoid by a cat-
gut suture. Close the wound in the neck. The edges of the chest wound are
approximated by a buried purse-string suture of strong silk. Of the triangular
flap of skin (A B C, Fig. 398) only the base is included in this suture. The
rest of the flap is used as a lining for the fornix of the axilla. The axilla is never
drained. The open wound remaining on the chest is immediately covered with
Thiersch's skin-grafts.

■Many surgeons, the author included, have devised almost identical opera-
tions for removal of the breast and have found such satisfactory.

Kocher's description of the operation is so excellent that it will be used as the
basis of the following paragraphs. To Willy Meyer, however, belongs the credit

Fig. 399. — Kocher's incision.

Fig. 400. — (Kocher.)

of the radical breast operation in which the dissection of the lymphatics precedes
the removal of the mamma. Meyer's operation was devised totally independ-
ently of Halsted's and was published during the same month as Halsted's.

Step I. — With the knife make a few superficial scratches on the skin to mark
out the line of incision which is shown in Fig. 399. From the clavicle to the
edge of the anterior axillary fold near the insertion of the pectoralis major,
complete the incision through the skin, subcutaneous tissue, and fascia. Expose
the cephalic vein in the groove between the pectoralis major and deltoid, thus
recognizing the upper edge of the pectoralis. Pass the finger around the pecto-
ralis major one to two finger-breadths from the humerus. Guided by the finger,
divide the pectoralis major.

Step 2. — The pectoralis minor now lies exposed to view. Divide this muscle
near the coracoid process, and expose the great vessels and nerves of the axilla.

Step 3. — Beginning above, near the clavicle and coracoid process, dissect

RADICAL OPERATION

277

the fat from the axillary vessels and nerves, and then dissect it free towards the
thoracic wall. By this means the most difficult step of the operation is com-
pleted while the surgeon is fresh, without the annoyance of the loose mass of
mamma, etc., getting in the way, as in the Halsted operation, and while the
chest is still protected against chill by its fatty coverings, which will be removed
later.

Step 4. — Complete the incision around the breast (Fig. 399). Excise the
mamma, surrounding fat, and both pectoral muscles. The wound left is
large (Fig. 400).

Fig. 401. — Skin incision. {Meyer.}

Step 5. — After attending to hemostasis, close the wound, as much as possible,
by sliding the flaps together. Where the wound cannot be closed, cover it with
Thiersch's skin-grafts. Provide for the axillary drainage by a tube introduced
posteriorly.

After such extensive removal of important muscles one would naturally
expect very serious loss of function, but such is not the case; the author has been
assured by various patients that they are able to attend to their own housework
and to dress their own hair satisfactorily.

In the "Jour. Am. Med. Assoc," July 29, 1905, Willy Meyer published an
excellent series of drawings illustrating his operation; these are so helpful that
they are reproduced here without comment (Figs. 401 to 406).

278

OPERATIONS ON Till'; liREAST

Fig.

402. — Insertion of pectoralis major muscle exposed.
Operator's left index finger encircling its tendon.

{Meyer.)

Fig. 403. — Finger under tendon of pectoralis minor muscle. (Meyer.)
\b)vo, cut surface of clavicular portion of pectoralis major parallel to clavicle is visible. (In the living,
the 'lelly of the pectoralis major is not so thoroughly detached from that of the pectoralis minor. It is
done here to show the latter's tendon.)

WILLY MEYER S OPERATION

279

Fig. 404. — Subclavian and axillary veins fully exposed. (Meyer.)
So far, glands and fat tissue not removed; smaller vessels still in connection with main trunks,
under fat towards sulcus bicipitalis, its nail resting on axillary vein.

Finger

Fig.

405-

-Operative field, after removal of the mass.
Stump of pectoralis minor muscle is visible.

{Meyer.)

28o

OPERATIONS ON THE BREAST

Fig. 406. — Showing reformation ui axilla. {Meyer.)

Fig. 407. — Jackson's incision. No. i.

STEWART S OPERATION

281

J. N. Jackson (Fig. 407), J. C. Warren and others have devised ingenious in-
cisions for breast excision the only fault of some of these is that perhaps they
may tempt the surgeon to sacrifice thoroughness of extirpation on the altar of
aestheticism. In cases of cancer in the upper-outer quadrant where the skin
between the breast and the axilla is under suspicion, Jackson's incision N°-2
("Annals of Surg.," Aug., 1920) is valual)le and permits of easy closure (Figs.
408 and 409).

Fig. 408. — Jackson's Incision No. 2.

Fig. 409. — Jackson's Incision No. 2.

In about 16 per cent, of cases of breast cancer, diffusion of the disease and
perilymphangitis cause obstruction of the lymphatics about the shoulder and
lead to oedema of the arm. The consequent suffering is often atrocious and
amputation has often been performed to give relief. Handley's operation of
lymphangioplasty is of value in treating such a condition.

Francis Stewart's Operation (Trans. Arm. Surg. Soc, XXXIII, 1915).

Step I. — From a point on the edge of the sternum remote from the growth
and on a line with the nipple make a curved transverse incision skirting the
upper margin of the breast and ending on the posterior axillary line ABC (Fig.
410). Undermine the skin upwards to the clavicle and the head of the humerus
and from the sternum to the posterior axillary fold. This gives good access
to the axilla.

Step 2. — Separate the clavicular from the costal portion of the pectoralis
major and divide the tendon of the latter close to the humerus. Divide the
insertion of the Pectoralis minor and clear the axilla of its contents in the usual
fashion.

Step 3. — Join the ends of the original incision by a cut which skirts the lower

282

OPERATIONS OX THE BREAST

margin of the breast ADC, Fig. 410J. Undermine the skin downwards to the
edge of the costal arch or lower.

Step 5. — Remo\e the breast, pectoralis major and minor, etc. Attend to
hemostasis.

The advantages claimed for the operation are free exposure of the subscapu-
lar space, avoidance of any scar running on to the arm, convenience of closure
and of dressing.

Tansini's Operation.— (D'Este, "Rev. de Chir.," Feb., 1912.) Stiles has
shown that the breast is a much larger organ than is apparent on ordinary
inspection and palpation (see Fig. 411). There is constant prolongation of the
breast upwards and outwards along the lower border of the pectoralis major
which often reaches as far as the more anterior of the axillary lymphatic nodes
Rieffel, Poirier and Charpy, v, 680).

iWv^-

Fig. 410. — Stewart's Incision.

Fig.

411.

Every modern operation for cancer of the breast aims at the excision of the
skin over the breast along with the breast, the tissues around it which might be
involved and the lymphatic contents of the axilla. In none of the operations
already described (Halsted's, Meyer's, Kocher's, Jackson's) except Jackson's
No. 2, does the incision compel the removal of the skin overlying the
axillary prolongation of the breast.

Tansini's method provides for very unusual and complete removal of the
skin and for such convenient plastic repair of the wound that there is no tempta-
tion to skimp the extensive excision. The operation: Step i. — Make the ovoid
incision A B C D (Fig. 412) through the skin alone. This surrounds not merely
the prominent mamma but the whole mammary region reaching medially (D)
near or even onto the sternum, laterally (B) to the mid-axillary Une, inferiorly
(C) to the upper margin of the seventh rib and superiorly (A) to the summit of
the axilla. Note that the skin between the breast and the axilla as well as
most of the skin of the axilla itself is enclosed in the ovoid.

Step 2. — (a) Beginning at the lower external part of the ovoid (near B)

TANSINI S OPERATION

283

dissect the skin from the subcutaneous fat until the whole infra-axillary region is
exposed and the axillary border of the lalissimus dorsi is reached. At this point
penetrate more deeply so as to expose the serratus magntis above and the upper
digitations of the external oblique below. (If necessary remove the fascia cover-
ing these muscles and some of their superficial fibres along with the mam-
mary mass.) Passing upwards and inwards separate the inferior and lateral
attachments of the pectoralis major from the thoracic wall. Attend to
hemostasis.

(b) In similar fashion dissect the skin downwards and inwards from the
ovoid incision until the desired limits from excision are reached. What are these
desired limits? From a very thorough study Sampson, Handley (Cancer of the
Breast and Its Operative Treatment, p. 183) has come to very definite and rea-

-(Rev. de Chir.

Fig. 413. — {Rev. de Chir.)

sonable conclusions. He writes, "The removal of a maximal circular area of
deep fascia centered upon the primary growth, is a step absolutely essential to
the completeness of the operation, except in very early cases. There is no tech-
nical difficulty involved, if only the skin-flaps are sufficiently undermined, a
step whose importance has been long emphasized by Mr. Stiles and by my friend
and teacher, Mr. Jacobson, and one which is very thoroughly carried out in the
surgical practice of the Middlesex Hospital. It is a significant fact that the
operator, who has the best pubhshed operative results, lays stress on the removal
of a wide area of deep fascia, following the lines laid down by Stiles. Prof.
Cheyne says: " * * * the skin incisions when made should not go straight down
to the muscle. After the skin incisions have been mapped out, the skin and
just sufl&cient fat to enable it to retain its vitaUty should be dissected up, and
the muscular fibres should not be exposed till just below the clavicle above, be-
yond the middle fine in front, over the origin of the abdominal muscles below,

284 OPERATIONS ON THE BREAST

and over the edge of the latissimus behind." It will be found that, judged by
the standard I have set up — i.e., the removal of a maximal area concentric with
the growth — the area of deep fascia defined by Prof. Cheyne is very deficient
in a downward direction, for the abdominal muscles arise well above the costal
margin. The following measurements show the distance from the nipple to
various points on the thorax in two patients with non-pendulous mammae:

Patient Patient j Average

No. I No. 2 "vciOKC

Nipple to tip of ensiform cartilage ' 4 in. 5 in. 4^ in.

Nipple to nearest point of clavicle S in. 6 1^2 in. 5/-iin.

Nipple to nearest point of middle line 3/^ in- 4/'2in- 4 i°-

Nipple to nearest point of edge of latissimus dorsi 5 in. % in.

The distance from the nipple to the clavicle may be taken as the radius of
the circle of deep fascia round the growth, which can, in practice, be removed
without difficulty by undermining the skin flaps sufficiently and prolonging the
incision somewhat in a downward direction.

If the growth starts under the nipple the deep fascia should accordingly be
removed:

Above, up to the clavicle.

Internally, i to 2 inches beyond the middle line.

ExternaJl}', just be3'ond the anterior edge of the latissimus dorsi.

Below, to a horizontal line running 2 inches below the tip of the ensiform cartilage.

Coming now to growths situated near the margin of the breast, it is probable
that the want of coincidence between the area of the present operation and the
circle of infected fascia in these eccentric growths largely accounts for the bad
prognosis associated with them.

The area of tissue removed should be concentric with the nipple only when
the primary growth is situated just beneath that structure. If a cancer is situ-
ated at the sternal margin of the breast it may be necessary to excise the deep
fascia beneath the inner half of the opposite breast. If the growth is situated at
the lower margin of the breast it may be requisite to excise the abdominal deep
fascia far down towards the umbilicus. If the growth is situated in the axillary
tail of the mamma, the deep fascia will require excision in the deltoid region,
and far backwards over the surface of the latissimus dorsi. Unless these con-
siderations are borne in mind the growing edge of fascial permeation will be left
behind at one point or another.

(c) Dissect upwards and towards the axilla the whole mass of breast fascia,
fat and muscle which must be removed. Both pectoralis major and minor must
be removed though sometimes the clavicular fibres of the former may be spared.

(d) While the mobilized mass containing the breast, etc., is supported by an
assistant, clear the axilla of its fat and lymphatic tissue in the usual fashion.
In doing this ligate and divide the external mammary (long thoracic) and
acromio-thoracic vessels, but save the subscapular vessels as they are essential
to the nutrition of the flaps to be used in the plastic repair of the enormous

TANSINI S OPERATION

28s

denuded area of chest. Clear the fat from the infra-clavicular fossa. Along
with the axillary fat remove the fat and cellular tissue lying between the
scapula and the thoracic wall. Remember that all these tissues from the
interscapulo-thoracic space, the axilla, the infra-clavicular fossa and the chest-
wall must be removed in one piece. Attend to hemostasia. Cover the whole
wound with warm dressings.

Step 3. — (a) Place the patient in the lateral posture or midway between the
lateral and ventral postures. Have the arm held somewhat elevated and
abducted. Recognize the spine, the axillary border and the inferior angle of

Fig. 414. — {Rev. de Chir)

Fig. 415. — {Rev. de Chir.)

the scapula. Outline the flap A X Y (Figs, 412 and 413). The pedicle of
the flap should be 7-8 cm. (2^-33^ in.) in diameter. The incision pene-
trates the skin, the subcutaneous tissue and the latissmus dorsi (as soon as that
muscle is encountered). Reflect the flap of skin, latissimus dorsi, teres major
and a portion of the infra-spinatus. In separating these last two muscles from
the scapula be careful to hug the bone, otherwise their nutrient arteries will be
divided and disaster invited.

286 OPERATIONS ON THE CHEST

(b) Mobilize lo some extent the tongue-shaped flap of skin lying between the
dorsal and the thoracic wound. Bring the dorsal flap forward to cover the
thoracic wound and suture it in position (Fig. 415). With the tongue-shaped
flap fill up the dorsal wound. If any raw surfaces are left cover them with
Thiersch's grafts.

J. N. Jackson in about 50 cases has had no skin recurrence. Handley points
out that Halsted, who lays special stress on wide skin excision, has 16 per cent,
of recurrence in the skin, while Cheyne, who removes more fascia than Halsted
but less skin, has only 6.5 per cent, of such recurrence.

At the International Surgical Congress, 1908, Depage reported the following
statistics collected from many sources:

Primary mortality I Apparently well three
•' ' years after operation

1865 to 1875 17.3 per cent. 9.4 per cent.

1875 to 1885 7.0 per cent. 10. o per cent.

1885 to 1895 3.0 per cent. 34.8 per cent.

1895 to 1905 2.8 per cent. 46 . 5 per cent.

While in the decennium 1865 to 1875 among the recurrences 76 percent, were
local and 7.5 per cent, metastatic, in the period from 1895 to 1905 only 29 per
cent, of the recurrences were local and 23 per cent, metastatic. The apparent
increase in the number of metastatic recurrences is of course due to the absence
of prompt local recurrence permitting the victims to live long enough to exhibit
metastases.

CHAPTER XXXI

OPERATIONS ON THE CHEST

WOUNDS OF THE LUNGS AND PLEURA

Wounds of the lungs and pleurae are commonly the result of stabs, bullet
wounds, tearing by the fractured ends of ribs, and surgical operations. The
dangers are hemorrhage, shock, pneumothorax and above all infection. The
shock is largely an incident of the pneumothorax; owing to pulmonary- retrac-
tion due to pneumothorax, the heart and great vessels lose their normal sup-
I)ort on one side, are displaced, often flop around and act in an ineflicient fashion.
The teaching of physiologists leaves the impression that the visceral and parietal
pleurae are kept in apposition entirely by atmospheric pressure; that puncture
of the pleura inevitably ])roduccs pneumothorax and more or less complete
retraction or collapse of the lung. This teaching has dominated surgery to too
great an extent. Undoubtedly atmospheric pressure is a very great factor in
retaining the normal ai)i)osition of the pleurae but, as Maccwen has shown, a
large flap of the chest wall, including the parietal pleura, may be lifted up, ex-
posing a corresponding surface of lung without pulmonary collapse. The failure

RESPIRATION WITH OPEN THORAX 287

of collapse is due to molecular adhesion between the two pleuraj aided by the
existence between them of a thin layer of serous fluid, i.e., the apposed surfaces
of pleura are moist. If the finger is passed around the wound and separates the
visceral from the parietal pleura air enters and a certain amount of collapse
occurs, but if the elastic chest wall is pressed inwards so that the parietal pleura
is allowed to come once more into free contact with the visceral, then the lung
again expands. These remarks of course apply only to the healthy pleura, as
in a pleura roughened by ridges and masses of exudates conditions are entirely
different.

The above principles and observations of Macewen's were the basis of suc-
cessful treatment in a number of serious wounds reported by him. (" Brit. Med.
Journ.," July 7, 1906.)

Elsberg (''Med. Record," May 23, 1908) finds that the weight of the heart
pulls it backwards and makes tense the pleural covering of the anterior medi-
astinum when the patient is in the dorsal decubitus and thus prediposes to
pneumothorax when the pleura is wounded. If the patient is placed in the
ventral position pneumothorax is much less likely to arise. Lilienthal has
applied Elsberg's findings with success in twenty-one cases in which the pleural
cavity was opened and no interference with the mechanism of respiration re-
sulted. [LiUenthal's cases comprised a number of empyemas, two liver ab-
scesses, five subphrenic abscesses and one left-sided bronchiectasis.]

Methods of Keeping up Respiration when the Thorax is Freely Opened. — I. For
many years the French have insisted that special means for keeping up respira-
tion are entirely unnecessary, and their experience during the Great War up-
holds them. Pierre Duval writes (Surg., Gyn. and Obst., Jan. 7, 1919) "Com-
plete pneumothorax is not associated with any particular danger, and, indeed,
it is necessary for the manipulation of the lung. Complete pneumothorax does
not cause any respiratory trouble or increase of arterial pressure, and causes
less shock than a laparotomy." The French practice of making a wide opening
in the chest allows any manipulation of the lung without danger.

Morris H. Clark (personal communication) agrees absolutely with the
French view. He uses gas oxygen anesthesia with the Connell apparatus ex-
actly as if the thorax was uninjured and has not encountered any trouble which
could conceivably have been lessened by the employment of differential or
intratracheal apparatus. If the surgeon desires any special inflation of the
lung, e.g., when the last sutures are being tied it is easy to produce any degree
of such by applying the face piece more firmly and either increasing the inflow
of the combined gases or decreasing the outflow from the mask.

II. Mechanical and according to the French view, unnecessary means of
keeping up respiration during operation. Many believe that when one side of
the thorax is freely opened respiration becomes much embarrassed; when
both sides are freely opened it becomes impossible under ordinary circum-
stances. Matas and a number of others devised more or less complicated means
by which air from a bellows, or its equivalent, could be pumped through the nose,
the mouth or a tracheal cannula alternately into and out from the lungs ("Trans.
Am. Surg. Assoc," vol. xix). Richter ("Surg., Gyn., Obstet.," Nov., 1908)
modified the pump method. In his apparatus the necessary air is stored in a

288 OPERATIONS ON THE CHEST

tank under high pressure. As required, air is conducted from the lank to a rub-
ber balloon where it can be kept at a moderate pressure. From the balloon the
air is led through a rubber tube to a tracheal cannula and so into the lungs. An
ingenious and simple electric valve permits air to flow into the lungs at proper
and regulated intervals, and between these intervals permits it to escape. An-
other device permits the administration of an anesthetic. Richter demon-
strated his method to the members of the Society of Chnical Surgery. Meltzer
and Auer have described a method of artificial respiration which they name
"respiration by the continuous intratracheal insufflation of air." A small tube
is passed through the larynx into the trachea almost to the bifurcation, and by
means of a foot-bellows or electric motor air mixed with ether is blown continu-
ously through the tube under pressure of 15 or 20 mm. of mercury. The
lungs are kept moderately distended, the blood is aerated and the excess air
escapes alongside the tube. The method has been used successfully by Carrel
and Elsberg ("Annals Surg.," July, 1910) in many operations on the thoracic
viscera. The author has used the Meltzer-Auer method in experimental work
on rabbits, using instead of the foot-bellows a simple hydrostatic air compressor
extemporized by Sutton. Elsberg suggests: "the tube that is to be introduced
into the trachea should be a fairly rigid one of rubber with an opening at its
lower end. It should be as long as an ordinary stomach-tube. Tubes of various
sizes should be kept on hand. The tube to be used in a given case should fill up
about one-half of the lumen of the trachea. One can obtain a sufficiently accu-
rate idea of the size to be used by estimating the diameter of the trachea at
the foot of the neck. " Lilienthal and Elsberg have applied the method success-
fully in the human being.

Lilienthal is no convert to the French view. He considers that the medi-
astinum can be so steadied by traction on the lung during operations on
certain war wounds that ordinary exploration and removal of foreign bodies
can be safely accomplished without any form of differential pressure. The
same is true in old infected conditions. In all other forms of thoracic surgery
including full exploration of the thorax in trauma, in resection of lobes and in
operations upon the oesophagus or other intrathoracic organs, he is convinced
that the omission of some form of differential pressure will greatly jeopardize the
patient. The apparatus is most simple. If ether is used it is put in a suitable
bottle with two short tubes penetrating the stopper but not extending below
the surface of the ether. A foot bellows or even a Paquelin bulb suffices to
furnish the current of air. A tube (about Fr. 14) leads from the bottle to the
patient, and should be marked 33^^ inches from its distal end. The tube is
introduced into one nostril not further than the mark. If Nitrous Oxide Oxygen
is used, no bellows is required, the force of the current being regulated by
means of a stop-cock, and the gas passes through a wash bottle.

Albert Ehrenfried ("Boston Med. and Surg. Journ.," April 13, 1911) endeav-
ored to construct a simple, portable apparatus independent of electric currents,
etc., by which ether might be administered according to the Meltzer-Auer
method.

The apparatus (Fig. 416) "consists of a Wolff bottle with three necks, sitting
within a copper water jacket, and a foot-bellows. By means of the cocks on the

INTRA-TRACHEAL ANESTHESIA

289

outside of the jacket, the stream of air from the bellows can be carried through
the hot water, over the top of the ether (contained in the Wolff bottle), or
through the ether when a particularly strong vapor is desired. Air and ether
vapor may be mixed in any proportion. Connected with the dehvery end of the
apparatus is a safety valve and pressure regulator consisting of a bottle of mer-
cury into which a tube is plunged. The depth of the tube in the mercury, which
is adjustable, represents the maximum of pressure which is allowed within the
apparatus; if for any reason, such as a spasm of the glottis, the pressure should
rise, the valve "blows off" automatically and danger from interstitial emphy-
sema is avoided. In our early experience we employed a dial manometre,
registering in millimetres of mercury, to record the pressure, but we have found

Fig. 416. — Ehrenfried's intratracheal etherization apparatus.

that the pressure bottle answers as well for all practical purposes. The appara-
tus is provided with a device to prevent droplets of condensed ether being car-
ried into the larynx. The air or mixture is supplied at a practically constant
temperature of about ten degrees above room temperature, if the operation is to
last over half or three-quarters of an hour, the contents of the water jacket should
be replaced. The air supplied may be filtered and moistened. For an intra-
tracheal tube we use a French lisle catheter, 22 to 24 F., moistened in hot water
to render it pliable, a new and sterile one for each case. Soft rubber tubes have
the advantage of standing sterilization by boiUng better, but they are less easy to
introduce. The chief difficulty with this method of anaesthesia so far has been
the introduction of the tube. We now use a simple introducer, a laryngeal for-
ceps with sleeves attached for grasping the tube near its extremity, similar in
principle to the introducer of Doyen. After considerable pains to produce the
proper curve — working on frozen sections and cadavers — we have made an in-

290 OPERATIONS ON THE CHEST

strument, Fig. 417, which can be guided into the larynx in a matter of seconds,
with the mouth-gag in place and the left forefinger on the epiglottis, without
the necessity of using a head mirror or electric illumination, or changing the
patient on the table to and from the Rose position, as is necessar\' with the direct
laryngoscope."

Samuel Robinson (" Surg., Gyn., Obstet.," May, 191 2) describes his appa-
ratus by which ether may be administered by insuflflation. He uses as tne intra-
tracheal tube a soft-rubber catheter introduced by means of Cotton's introducer,
Fig. 418. With the same apparatus positive pressure may be obtained by the
mask method (Robinson's mask or Habberley's intrabuccal clamp). Robinson
devised a positive and negative pressure cabinet, but finds cabinets cumber-
some, expensive and possessing no advantage over the mask.

Danis ("La Presse Med.," Dec. 25, 191 2) describes an hyper-pressure appa-
ratus very similar to Robinson's which has been used successfully by Lambotte.
The use of positive pressure by any mask method appeared to the author to be
dangerous on account of vomiting, but Robinson remarks that "its temporary
removal in case of such unusual emergencies as vomiting and instrumentation
has not been found to interfere with its successsful employment."

^^^^ws^

Fjg. 417. — Ehrenfrieds introducing Fig. 418. — Ehrenfried's modification of

forceps. Cotton-Boothly introducing cannula.

Sauerbruch was the first to devise a cabinet by means of which the thorax
could be freely opened and respiration kept up under the force of either negative
or positive pressure. Brauer constructed a rather clumsy apparatus for keeping
up respiration under positive pressure. Willy Meyer and his brother (an
engineer) have constructed a very efl5cient cabinet for both negative and positive
pressures. It would be out of place to describe here the structure and methods
for the employment of any of the pneumatic cabinets, each of which has its
advantages and disadvantages; it will be sufficient to give the principles on
which they work.

Negative Pressure Cabinet. — The surgeon, his assistants and the patient's
body are inside the cabinet. The patient's head protrudes through a hole in
the wall of the cabinet, his neck being surrounded by an air-tight collar. By
means of an air pump, controlled by a manometre, the air pressure inside the
cabinet is lowered sufficiently to permit of respiration after the thorax is opened.

Positive Pressure Cabinet. — Same as negative pressure cabinet except that the
patient's body is outside while his head and the anesthetist are inside the cabi-
net. By means of an air pump the pressure of the air inside the cabinet is
increased.

im;ni; 1 RA 1 INC. woinds 291

A. Treatment of Wounds Penetrating the Chest.— Treatment of wounds
penetrating the chesl varies, (</ ) with the character of the wound, (b) with the
surroundings of the patient and the facilities for operating and giving post-
operative care, (c) with the ideals and of course with the technical skill of the
surgeon.

A bad sucking wound* causes terrible respiratory and cardiac distress and
must be occluded in one way or another at once. If the circumstances permit,
this occlusion should be etTected by a formal and definite surgical operation
I)lanned to obviate infection and late complications but first of all to save life.

The ideals of some surgeons are to provide immediate safety hoping that
good fortune will ward off com{)lications or if complications arise that they may
be remedied later. Other surgeons having their eyes fixed on the late results
strive after perfection and, theoretically at least, operate freely on every chest
wound. On closer examination of the actual work of the latter class of surgeons
it will be found that they commonly mix their theoretical ideals with common
sense and modify their conduct accordingly.

G. E. Cask (Brit. Med. J., April 12, 1Q19) points out that in war the deaths
from chest wounds in patients who have been brought off the field occur in
Casualty Clearing Stations (Evacuation Hospitals) within a few hours, from
the severity of the wound, shock and hemorrhage, or after two or three days
from sepsis. In Base Hospitals the deaths are all from sepsis. The sources of
infection are {a) missiles, clothing, splinters of bone, etc., (b) sucking wounds
which always suck in infection, (c) an infected parietal wound from which in-
fection spreads inwards by continuity finding a suitable field for growth in a
hemothorax, (d) a foreign body in the lung. His indications for operation are
(a) Ragged wound of soft parts, (b) compound fracture of the ribs, (c) continued
bleeding internal or external, (d) Suction of air into thorax (open thorax), (e)
retention of large foreign body, (/) pain out of proportion to the apparent
severity of the wound; often this is due to an in-driven splinter of bone, (g)
Rapidly increasing pneumothorax due to a valvular opening into the pleura
(valvular pneumothorax).

Cask recommends operating as soon as possible after recovery from initial
shock.

There will almost always be a great difference between the wounds of civil
life and those so common in war. Fragments of shells, rocks, bone, clothing
and dirt of all kinds from the highly fertilized fields of France driven into the
thorax rendered the chest wounds of the Great War much more dangerous than
the injuries common in civil life and yet from the more serious wounds great
lessons may be learned regarding the care of the less serious.

In any serious chest wound an opiate is essential. Rest is obligatorv-. Do
not let the patient lie on the healthy side as to do so interferes with the respira-
tory movement of that part of the chest and also favors the entrance of air
into the wound and conduces to separation of the two layers of the wounded
pleura. Exercise pressure on the injured side of the chest and if necessary on

*A sucking wound is one in which the opening in the pleura is large enough to admit
air by suction in quantities as great or greater than that which enters the lung through
the larvnx.

292 OPERATIONS ON THE CHEST

the hypochondrium to support the diaphragm. If a sucking wound is present
occlude it with a moist pad until it can be properly treated.

Clean-cut stab wounds of the chest may generally be treated "expectantly,"
any complications being attended to as they arise. Most wounds of the chest
wall ought to be explored and devitalized tissues and foreign bodies removed,
in fact the classical "debridement" ought to be carried out. If one or more
ribs are injured their jagged ends should be pared and smoothed. If the pleura
has been opened and there is no evident injury to the lung or intrapleural
bleeding the pleural wound ought to be closed at once. Often closure of the
pleura alone is impossible, if this is so the sutures must include muscle as well,
or even pericostal sutures may be employed.

Through and through gunshot wounds may generally be left alone except
for debridement of the superficial wounds. Except in very severe wounds of the
chest wall any hemorrhage into the pleura usually comes from the lung and
not from the intercostal vessels. Hemorrhage into the closed pleura is either
fatal very promptly or not at all (except from infection); it practically never
kills after 72 hours.

If blood effused into the closed pleura remains sterile and is in quantity,
clot deposited on the \dsceral layer very rapidly becomes tough, compresses
the lung and prevents expansion. Later organization of the clot makes the
compression permanent. When the blood is chiefly fluid and there is little
clot, aspiration may be done on the second or third day with little or no danger
of the hemorrhage recurring and usually leads to cure.

As the diaphragm occupies an abnormally high position in hemothorax ex-
ploratory- aspiration should be done high up and not low as when for ordinary-
pleural effusion.

When the quantity of blood is small even if the proportion of clot is con-
siderable, aspiration sufl&ces, as the area of lung compressed is so small that the
patient by exercise so aids thoracic movements that the clot becomes absorbed.
If the hemothorax is large and several aspirations fail to produce recovery
there is excess of clot and thoracotomy with removal of the clot is obUgatory.
Should the thoracotomy be too long delayed and the clot become organized,
then decortication or its equivalent, viz. criss-cross incisions through the layer
of scar tissue imprisoning the lung, should be practiced. After treating the
hemothorax close the chest wall without drainage. If an infected hemothorax
is seen early. Cask advises major thoracotomy, cleansing of the cavity and
closure of the chest. He remarks that drainage of the chest is like amputa-
tion of a limb, sometimes necessary but still a surgical failure.

When the lung is much lacerated or gross masses of foreign bodies are driven
into it and are easily located thoracotomy is necessary. This may be done by
resection of a long segment of rib, preferably the fourth rib, from the mid-clavicu-
lar to the posterior axillary line (Lockwood, War Med., August, 1918.) A
rib spreader aids in giving good access.

Lilienthal (Journ. A. M. A., March 22, 191 9) prefers intercostal thoracotomy,
making a long intercostal incision usually in the seventh interspace and sepa-
rating the ribs from 3 to 5 inches by means of a powerful retractor. When the
injured lung is exposed, he seizes and brings it into the wound. As soon as the

PENETRATING WOUNDS 293

lung is stabilized by pulling on it in this purposeful fashion any dangerous
mediastinal trapping ceases.

Wounds of the lung should be treated by excising evidently devitalized
tissues and closing the wound with sutures. Closure of the visceral pleura is
very important.

If typical debridement is impossible because the wound is a tunnel, Cask
(Brit. Med. J., April 12, 1919) recommends cleaning the tunnel with gauze
and suturing the ends of the tunnel. If, as is uncommon, an open bronchus
is found at operation it should be crushed and ligated with catgut. Remove
all clots and foreign bodies from the pleural cavity with instruments and by
swabbing with most gauze. Just before closing the chest, systematically
swab the whole of the pleural cavity both visceral and parietal surfaces with
gauze wrung dry out of hot saline solution and then with gauze wrung out of
warmed ether.

Close the chest completely with sutures.

If there is much gaping of the parietal pleural wound the lung may be sutured
to it and the muscles sutured over the gap thus filled. The skin wound should
be carefully closed.

Before closing the thoracic wound Brewer (Personal communication) some-
times, guided by the hand inside the chest, rapidly incises the skin and resects
a short segment of a rib at a place suitable for drainage but does not penetrate
the pleura there. The object of this trivial procedure is that should it later
become necessary to drain the pleura it can be done without an anesthetic and
without disturbing the real thoracotomy incision.

Lockwood (Loc. cit.) recommends that "Injuries of the heart or pericardium
can be best dealt with by a parasternal flap of the fourth and fifth, or the fifth
and sixth, costal cartilages depending on the probable site of the lesion (the
divided cartilages unite rapidly) ; and this route, in addition, gives free access
to the pleural cavity.

Where the missile has passed across the pleural cavity and lodged in the
mediastinum, especially high up, it is wiser to enter the mediastinum through
the sternum. The missile should be removed, its bed and track thoroughly
cleaned, and the pleural opening closed to prevent any leakage from the medias-
tinum into the pleural cavity. This serves a double purpose — it obliterates a
pocket in which pleural effusion might accumulate, and shuts off from the pleural
cavity a source of reinfection. It is difficult to deal with the mediastinum
through the usual costal incision.

During the after treatment any accumulation of the fluid should be removed
by aspiration.

Do not let the patient lie on the healthy side. To do so directly interferes
with the motion of that part of the chest; it also favors the entrance of air into
the wound and conduces to separation of the two layers of the wounded pleura.

B. Treatment of Pneumothorax Resulting from Fracture of a Rib. — The
indications for operative treatment are great respiratory distress and cyanosis
with embarrassed heart action. The methods of treatment are two:

(a) Aspiration. — This gives immediate relief. If the wound in the lung
closes and becomes sealed against the further escape of air, the reHef is perma-

294 OPERATION'S ON THE CHEST

nent. If the lung wound remains open, e.g., from its size, from a shred of vis-
ceral pleura being pushed into it, etc., the symptoms will j)romptly recur and
operation becomes urgent.

(b) Expose the fractured rib or ribs by incision; excise enough of one or
more ribs to gain access to the wound in the lung. Keep up pressure on the
thoracic wall. An advantage of incomplete or of no anaesthesia is that the
patient may be made to cough, sneeze, struggle, etc., and so force the lung to-
ward? the wound. Treat the wound exactly as in the case of a stab wound.

C. Emphysema Resulting from a Fractured Rib.— The emphysema may or
may not be accompanied by marked pneumothorax. Macewen (loc. cit.) has
shown that the emphysema results from the lung tissue being hooked on to
the spiculae at the fractured end of the rib and a free path being established
between the injured lung and the lacerated subcutaneous tissues. Logically
the operative treatment is identical with that for any other lung wound.

OPERATIONS ON THE PLEUR.^L CAVITY

Empyema resulting from infected wounds and from disease of ribs, etc.,
calls for early operation first to treat the jirimary condition and second to treat
the empyema.

When empyema is an accident or epiphenomenon in the course of acute
pulmonary infections early radical operation is very objectionable.

Operation should never be adopted before the twelfth day of the disease
and only exceptionally as early as that (Dodge).

During the early stages the exudation is sero-fibrinous in broncho-pneu-
monia associated with hemolytic streptococci. If this exudation is causing
distress it may be removed by aspiration, repeated as may be necessary. Some
recommend that oxygen or filtered air be introduced to take the place of the
fluid removed. When the pulmonary lesions are well or nearly well and the
symptoms of slight dyspnoea with neither cyanosis nor bloody expectoration
are in direct proportion to the amount of fluid in the pleura, then a cutting
operation promises much and is obligatory. A respiratory rate of 45 to 50
per minute accompanied by notable cyanosis, oliguria and circulatory disturb-
ances usually contraindicates operation as the pulmonar\- trouble is the real
criminal and the pleuritic is of minor importance. In other words, if the pleural
effusion, whether it be sero-fibrinous or purulent, is merely a concomitant of a
general acute infection, operation is wrong until the primary and more serious
trouble is overcome when operation may become not merely beneficial but
imperative.

In ordinary pneumococcic j)neumonia empyema as a complication is usually
late and the pulmonary condition may well permit of its early drainage. .Aspira-
tion by itself is sometimes curative in such cases especially in children.

Exploratory FHmcture. — The existence of fluid in the pleural cavity is
diagnosed or suspected; by exploratory puncture its presence and character are
determined. Choose a point on the chest-wall corresponding to the location of
the suspected fluid. Fluoroscopy is often of great value in locating the fluid.
Clean the skin thoroughly. Choose a hypodermic syringe with a long and not

THORACENTESIS 295

too line needle and sterilize them. Insert the needle into the {)leural cavity
at a point just above a rib. This avoids danger of injuring the intercostal
vessels. Slowly withdraw the piston of the syringe. If fluid is found, preserve
it for examination; if it is not found, the operation should be repeated at several
p)oints and the needle examined after each withdrawal lest it should have be-
come plugged. No dressings are required.

Thoracentesis.— The object of the operation is the removal of fluid from
the pleural cavity. The operation may be: (a) Exploratory. The fluid with-
drawn is examined microscopically. If tuberculosis is suspected, the examina-
tion should include the inoculation of guinea-pigs, (b) Therapeutic. In adults
when the fluid is not infected the operation is curative. In children even when
the fluid is infected a cure often results.

Strict asepsis must be maintained otherwise a simple effusion into the pleural
cavity may be converted into an empyema, or to the bacteria which have
already produced an empyema there may be added others which may markedly
increase the intensity and gravity of the disease. The patient should be
placed in a semi-erect posture, if necessary being jfropped up with pillows. If
he is weak, give him a stimulant of strychnine or alcohol.

The favorite points for operation are the eighth intercostal space near the
angle of the scapula and the sixth near the midaxillary line. Remember that
in hemothorax the fluid is usually at a higher level than in hydro- or pyothorax.
Clean the patient's skin. If desired, inject a few drops of a 2 per cent, solution
of novocaine or procaine into the skin at a point over the rib near its upper
edge. With a fine knife make a puncture through the skin at this point. Pull
the skin-wound upwards so that the needle of a Potain aspirator (thoroughly
disinfected) can now be introduced and made to pass into the chest in contact
or nearly so with the upper edge of the rib. The object of puncturing the skin
with the knife is that, the skin being tough, so much force is required to push
the aspirating needle through it that, the skin once passed, the needle is liable
to be jerked into the tissues, x^nother reason is that disinfection of the deep
layers of the skin being practically impossible, the needle cutting its way
through may conceivably become infected and do harm.

In whatever way the skin is penetrated, the puncture through it should not
be opposite that through the deep structures; a valvular wound is desired. The
needle is made to hug the upper edge of a rib so as to avoid injuring intercostal
vessels. Having introduced the needle, aspiration is begun. If fluid does not
come, this may be due to the needle having become clogged with tissue or a clot
of fibrinous material. A stillette passed through the needle will free its lumen.
If obetruction to the lumen is not the cause of failure to obtain fluid, the needle
should be partially withdrawn and reintroduced in another direction. Working,
as one does, in the dark, several punctures may be necessary before the fluid is
found or one is satisfied that it is absent. Another cause of failure is discussed
under the name "pleurisy blocquees."

When the fluid flows, let it flow slowly. If the patient coughs or has a feel-
ing of oppression, stop the flow until he recovers. The same must be done if the
pulse alters markedly or the patient becomes faint. As the fluid escapes the
patient may be lowered in his bed. If the effusion is great, it is wise to stop

296 OPERATIONS ON THE CHEST

the operation' before the fluid is nearly all removed. The remainder may be
absorbed. The sudden complete emptying of the sac is likely to do harm.

Morriston Davies (Lancet, Dec. 28, 191 2; Brit. Med. Jr., April 25, 1914)
finding it impossible to remove any appreciable quantity of pleuritic fluid,
especially in cases where its presence would interfere with skiagraphy of the
lungs, has overcome all difficulties by replacing the abstracted fluid through the
introduction of oxygen. He draws oflf the fluid by an aspirator in the usual man-
ner but as soon as the first symptoms of drag on the intrathoracic organs are
noticed, viz., discomfort, pain or cough, he permits about 100 c.c. of oxygen to
flow into the chest through a needle introduced two or three interspaces above
the aspirating needle. The two processes of aspiration and oxygen replacement
are alternated until all the fluid is removed. The apparatus used for nitrogen
pneumothorax acts admirably for the introduction of the oxygen.

Kenneth Mackenzie (Trans. Am. Surg. Assoc, 1914) uses warm sterile
liquid paraffin instead of the oxygen. His technique seems unnecessarily elab-
orate but promises well. When it can be demonstrated that no more pus is
forming the parafSn may be^withdrawn very gradually — only two or four ounces
being removed at a time at intervals of two or three days governed by X-ray
examination until the pleura is free and occupied by a completely expanded lung.

Pleurisy Blocquees. — Occasionally all the physical signs of fluid being in
the pleura are present, the aspirating needle is inserted but no fluid flows.
Examination of the needle shows no plugging of its lumen. Dufour, in 1905,
showed that old pleuritic effusions exist which cannot be aspirated by ordinary
means while Mosny and Stern ("La Presse Med.," Dec. 11, 1909) demonstrated
the same regarding recent acute pleurisies. The reason for the failure of
aspiration is that the fluid happens to be in a cavity with rigid walls, e.g., a cavity
whose wall may consist of hepatized lung, the chest-wall and pleuritic adhesions.
If, as occasionally happens, the tension of the fluid is about equal to that of the
atmosphere, then only a small amount of the fluid-will escape through the as-
pirating needle; if the tension of the fluid is less than that of the atmosphere, no
fluid will escape. If a second hollow needle is passed alongside the aspirating
needle, atmospheric air will be admitted into the cavity and aspiration becomes
easy.

Thoracotomy. — The objects to be attained by thoracotomy are:

I. Exploration and the performance of various operations by the transpleural
route. For this purpose a long intercostal incision is excellent. Make a very
long incision in an intercostal space down to but not through the pleura. Open
the pleura in the same manner as the peritoneum is opened in laparotomy.
Le Fort (Rev. de Chir., May and June, 191 7) insists that the pleura be opened
widely, that collapse of the lung against the vertebrae is a fable only occurring
in cadavera, that a small pleural opening is dangerous as it may occasion a
condition identical to valvular pneumothorax. After the pleura is opened
Carrel's technique may be used (Trans. Am. Surg. Assoc, 1914, p. 452). "The
operating field was walled off by two kinds of towels. The first kind was made
of Japanese silk which had been previously boiled in water, dried, and sterilized
in the autoclave, like ordinary pieces of dressing. The second kind of towel was
composed of absorbent cotton and of black Japanese silk. These towels were

THORACOTOMY 297

made in the following way: Two pieces of fine black Japanese silk were sewed
together at the edges. Between these two pieces was placed a layer of absorbent
cotton about i cm. thick, and the whole towel was knotted throughout, thus
forming a pad. These towels were sterilized in the autoclave. Both kinds of
towel above described were used for walling off the operating field. When the
incision of the superficial part of the thoracic wall was completed and the hemo-
stasis secured, the pleural cavity was opened by means of a small incision made
in the middle of the intercostal space. A dry, white Japanese silk towel was
introduced into one end of the incision, while a second one was introduced at the
other end. These towels afterward served as a protection to the anterior and
posterior parts of the pleural cavity. Next, the incision of the thoracic wall was
completed and the thoracic cavity was opened wide, the lungs being meanwhile
completely protected by the towels already introduced. Immediately after
this the black silk and cotton-padded towels were laid on the upper and lower
edges of the wound and introduced into the cavity in such a manner that they
respectively protected the upper and lower parts of the pleura. Next, a Gosset
retractor was applied and the edges of the wound were retracted as much as was
necessary for the purpose of the operation. The edges of the padded towels
were arranged in such a way as to circumscribe the operating field and to leave
this alone exposed to the air and to the sight of the operator. Additional
padded towels could be used afterw^ard, if necessary, in order to secure a more
complete walling off of the operating field. By means of this procedure the
pleural cavity appeared to be almost completely protected against the infection
produced by the atmospheric germs as well as against all .possible infection or
irritation caused by the handling of the serous membrane by the hands of the
operators, by the rough sponging with gauze, and by other operative trauma-
tisms. Moreover, when hemorrhage occurred the blood was prevented from
flowing into other parts of the thoracic cavity."

The Friedrich, Sauerbruch, de Quervain or Lilienthal self-retaining retractors
or rib spreaders serve well to open the wound widely. After completing the
operation close the wound by interrupted buried sutures each of which sur-
rounds the rib above and below the intercostal wound (pericostal sutures). As
the last of these sutures is being tied have the anesthetist cause the lung to
expand so as to drive all air out of the pleural cavity or aspirate the air from the
cavity. Witzel has filled the pleura with boracic acid solution, closed the
wound and then removed the solution by aspiration.

II. The second and infinitely the more common object of thoracotomy is
to drain the pleural cavity. Local or general anesthesia may be employed,
preferably local. Make an incision two inches in length parallel to the ribs
at a point just anterior to the edge of the latissimus dorsi muscle and corre-
sponding to the sixth, seventh, or eighth intercostal space. Along the lower
border of the space cut through the intercostal muscles. Attend to hemostasis.
Make a small opening through the parietal pleura. Too rapid evacuation of the
pus is dangerous, as it too suddenly alters conditions of intrathoracic pressure.
As the pus flows, enlarge the opening with forceps or the finger. Explore the
empyema cavity with the finger and remove all shreds of tissue or clots of fibrin
floating in the cavity. If such are left behind, they are liable to interfere with

?98

OPERATIONS ON THK CHEST

(Irainaj^c and (k'lay rccowr}'. Drain by means of lubes ])assc'(l into the pk-ural
cavity. Not much of the tube should project into the pleura. The tubes
may be rigid or soft. To prevent the tube slipping into (he pleura either stitch
it to the skin or transfi.x it with a large safety-pin or l)otli. If necessary (it rarely
is necessary), partially close the skin-wound with sutures. .Surround the outer
end of the drain with stt'rile gauze in bird-nest fashion. This prevents direct
pressure on llic tube. Ai)])ly abundant dressings. Some surgeons place
oiled silk over the mouth of the drainage-tube to act as a valve, allowing the
escape but not the entrance of air into the pleura. This is unnecessary. After
the pleura has been penetrated, a counteropening may seem desirable. To
make this, pass a forceps through the wound, through the cavity, and with
its point elevate the tissues at the position selected. Cut down on the forceps
and push them through the new wound. Grasp a perforated rubber tube in
the jaws of the forceps and pull the tube through the cavity. This provides
efficient through-and-through drainage. Ochsner is a great advocate of
through-and-through drainage. If at any time it is desired to withdraw the

tube and introduce another, fasten a stout
thread to the end of it and in withdrawing
the tube pull the thread through the cavity;
with this thread in situ it is easy to introduce
another tube. Later the tube may be replaced
by a few strands of silkworm-gut. Tubular
drainage must be kept up until all discharge
has ceased. In cases of pneumococcic infection
recovery is usually rapid, the lung expanding and
obliterating the empyema cavity. When the
infection is streptococcic, many weeks may
elapse before the infected cavity becomes oblit-
erated. Some surgeons, to make drainage more
perfect and continuous, connect the drainage-
tube to a pipe passing through the dressings and attached to a Bunsen's
air pump (Fig. 419). This ingenious measure is not often required.
During the after-treatment of cases of thoracotomy the patient should be placed
in the position found at the operation to be most favorable for drainage. This
position, especially if disagreeable, need not be kept up continuously but adopted
at intervals for a short time. It is wise to encourage the patient to sit up and
move about at as early a date as possible. Fresh air is of great value in treatment.
Rutherford Morison thinks that an incision parallel to the ribs is likely
to kink the tube (a) during respiratory movements, {h) from altered position
after completion of operation. He operates as follows:

1. Verify presence of pus with hypodermic syringe.

2. Make a vertical incision down to rib and across intercostal space.

3. Push a sinus forceps (a closed, fine-pointed hemostat is satisfactory)
into pleural cavity. Alongside the forceps introduce a director.

4. Open the forceps parallel to the ribs and pull them out while open, but
leave the director in situ. (This method avoids hemorrhage.)

5. Guided by the director, introduce drainage-tube.

Fig. 419. — Bunsen's air pump.

THORACOT(JMY 299

Continue tubular drain until there is no more pus than can be accounted
for by external wound. After removal of tube introduce director daily so as
to discover if pus reforms necessitating reintroduction of tube.

Thoracotomy by Puncture. — Make a small incision through the skin. Intro-
duce a large trocar into the empyema cavity. Through the trocar pass a large
rubber catheter. Withdraw the trocar leaving the catheter in place. Con-
traction of the muscles around the catheter grip it until no air can enter along-
side it.

B. F. Stevens (Southwestern Med., May, 1919) advises that a few ounces
of pus be allowed to escape every two hours until in 24 hours almost all has
been evacuated. After this he advises the instillation of Dakin's solution every
two hours; the old solution being allowed to escape before the fresh is put in.
Except when being used by the attendant the catheter drain is to be kept
closed by a clamp. The claim is made that by this method pus can be got rid
of in from 3 to 10 days and that the entire treatment is usually completed
in 3 weeks.

W. T. Dodge (Journ. A. M. A., June 21, 1919) after great experience during
the epidemics of 1918 "relegates to the boneyard all of the many fancy treat-
ments of empyema evolved by the faddists who have been privileged to observe
a series of cases for a limited period of time." He has come back to the long
established methods of free drainage which if adequately carried out render
the use of antiseptics such as Dakin's solution entirely superfluous.

Moschowitz (Surg., Gyn. and Obst., April, 1919) is a strong upholder of
thoracotomy without rib resection, generally in the eighth interspace just behind
the posterior axillary line. When the patient is put to bed "a simple instilla-
tion and suction apparatus (Fig. 420) is attached to the drainage tube by means
of a T-tube; at a convenient point a second attachment is made for a bottle to
receive the discharge escaping from the empyema cavity. Once an hour, or
more or less frequently as indicated, the syphon part of the apparatus is dis-
continued by clamping, and the instilling part of the apparatus, a Dakin con-
tainer, is opened, and the requisite amount of solution is allowed to run in.
After the lapse of five minutes the suction apparatus is reopened, and the solu-
tion plus secretions syphoned out. The suction is continued until the next
period of instillation."

By the above means the cavity is kept perfectly dry and the wound does
not require to have the dressings changed for a week or 10 days. After this
period the apparatus and drainage tube are removed, the skin cleaned with
alcohol and the cavity is flushed with Dakin's solution through a soft rubber
catheter (about 2 2°F.) until the return flow is clean. During the flushing the
patient is turned from the lateral to the prone position and vice versa. After
this from i to 4 Carrel tubes are introduced to the various parts of the cavity;
a short drainage tube "with one fenestra guarded by a safety pin, so called
'safety valve,' is finally introduced, to permit a free escape of the Dakin solu-
tion and secretions." The vicinity of the wound is protected by sterile vaseline
gauze strips and the skin further away is covered by stiff zinc oxide ointment.
Dry gauze dressings are applied through which the Dakin tubes emerge above.
Hourly instillations of Dakin's solution are made in quantity equal to about

300

OPERATIONS ON THE CHEST

half the capacity of the cavity. Every 24 hours the dressings and tubes are
changed. When sterility is attained (smears and cultures from cavity) and
maintained for several days treatment is discontinued, the wound heals if left
alone and permanent recovery ensues. If the cavity has not become truly
sterile the wound will reopen.

In a few cases of healed empyema Moschowitz notes a very definite closed
pneumothorax which disappeared after about a month by expansion of the lung.

The cases which, according to Moschowitz cannot be remedied by long
continued Carrel-Dakin teratment are: (i) Cases complicated by large pleuro-
pulmonary fistulas. (2) Cases with retained foreign bodies, (3) cases with side
pockets or lateral branch sinuses (4) cases with necrotic ribs.

Fig. 420. — {Report U. S. Empyema Commission.)

Thoracotomy with resection of a segment of rib is usually much preferable
to simple intercostal incision. In the latter the space is limited, finger explora-
tion is difficult or impossible, and when the tube is introduced, it is very liable
to be pinched between the ribs and rendered useless. Removal of a segment of
one or more ribs does no permanent harm and the operation is exceedingly easy.
Excision of a segment of rib is rarely required in children and as rarely should it
be omitted in adults. In operating on non-localized empyema the incision may
be made over the sixth or seventh rib in the mid-axillary line, or over the ninth
rib just external to the angle of the scapula, which is the best position. In
cases of localized empyema the opening must of course be made over the encap-
sulated pus. When incision is made in the mid-axillary line, the patient must be
brought to the edge of the table over which the affected side may protrude a
little. When the posterior site of operation is chosen, place the patient, with the

COSTECTOMY 3OI

sound side uppermost, in a position midway between the lateral and ventral — i.e.,
lying half over on his belly. The sound side must never be undermost, other-
wise respiration will be impeded. The surgeon under these circumstances stands
in front of the patient and reaches the site of the operation by leaning over him.
These are the classical instructions always insisted on but rarely carried
out, except in trivial cases or by beginners who are much hampered by them.
They are impracticable. In Friedrich's most extensive pneumolysis, the
patient lies on the sound side. The researches of Schafer (Transactions,
Section on Surg, and Anat., American Med. Assoc, 1908) on artificial respiration
and the experiments and observations of Elsberg, clearly show that, when pos-
sible, the prone position is the position of choice for operations on the chest.
C. E. Corlette (The Med. Journ. of Australia, March i, 1919) strongly recom-
mends the semiprone position for operations for empyema and pulmonary hyda-
tids, with the side to be opened at the edge of the table and downwards. If
the operator is seated this posture is very convenient for operations on the
lower part of the thorax. In the case of hydatids, where drowning is a real

Fig. 421. — Rib shears.

peril, not only is this peril reduced to a minimum but the downward and out-
ward rush of water brings the parasitic cyst well into the wound and greatly
facilitates its extraction.

The Operation. — i. Make an incision two to three inches in length along the
long axis of the chosen rib and divide the periosteum along a line midway
between the upper and lower borders of the rib.

2. With a curved periosteal elevator separate the periosteum from the bone
both externally and internally. The intercostal vessels are separated from
the bone with the periosteum. In recent cases much care must be exercised
when detaching the periosteum from the deep surface of the bone lest the
pleura be prematurely opened; in cases of long duration there is so much
pleural thickening that no accident is likely to happen.

3. Divide the exposed rib at the posterior end of the wound with bone
forceps or rongeurs. For this purpose a costotome (Fig. 421) is convenient
but not necessary. Grasp the portion of bone to be removed in the Jaws of a
sequestrum forceps, steady and bring it forwards, and divide it anteriorly
with bone forceps. Two inches of bone should be removed.

4. Make a small incision through the deep layer of periosteum and the
pleura. Let the pus flow out slowly. Interrupt its flow from time to time

302 OPERATIONS OX THE CHEST

by plugging the wound with gauze. Too rapid evacuation means pulmo-
nary congestion, and this is liable to cause fatal anaemia of the brain. Proceed
as in thoracotomy. If the cavity is large, it is easy to resect portions of two
ribs subperiosteally through the same external incision. If this is done, the
intercostal muscles and vessels should be ligated behind and in front of the
pleural incisions and the two horizontal openings into the pleura united by
a vertical cut to form an I -shaped wound (Fig. 422).

When the effects of an empyema are very menacing Lilienthal performs a
simple thoracotomy under local anesthesia and introduces a drainage tube.

When this simple operation has led to im-
provement he makes an incision, under
local anaesthesia, usually along the seventh
interspace from the angle of the rib to its
costal cartilage. Before opening the pleura
he administers nitrous oxide and oxygen
and under that anesthetic opens the pleura
freely — introduces a rib spreader which
separates the seventh and eighth ribs for
a width of several inches and gives a
Fig. 422.— Thoracotomy. perfect view of the interior of the chest.

Adhesions between the visceral and costal
pleurse must not be attacked but, with the finger, the lung ought to be
separated from the diaphragm. In doing this it is not uncommon to open
abscesses which would otherwise have been overlooked. Should the lung
fail to expand, this failure is due to its being compressed and held down by
organized exudates on its pleura. Lilienthal now follows Fowler and Delorme
by incising the compressing membrane throughout the whole length of the lung
and strips it off. The lung now expands. If decortication seems too risky he
follows Ransohoff in making criss-cross incisions through the compressing mem-
brane and so obtains expansion. In closing the wound he sutures the divided
latissimus dorsi and serratus magnus but not the intercostal muscles.

This method of Lilienthal's appeals to the author as being conservatively
radical.

Chevrier*s Method. Principles. — The principles underlying drainage of the
pleura in empyema are admitted by all to be the insertion of a proper tube
through the chest wall at the lowest point. That this principle is not carried
into practice is shown by the various devices used to obtain siphonage of the
pus. A glance at Figs. 423, 424 and 425 will show why an opening in the
posterior axillary line at the level of the sixth rib or even one in the scapular
line, cannot give proper drainage whether the patient is recumbent or seated,
whereas an opening at the costal angle (Fig. 425) must permit sufficient
emptying of the vertebrocostal gutter in the recumbent posture.

The 'low point,' i.e., the proper site for pleural drainage, is in the costo-
vertebral gutter at the reflexion of the pleura from the chest wall on to the dia-
phragm. Normally the pleural reflexion is very low in the chest (about the
eleventh intercostal space) but in disease the costo-diaphragmatic cul-de-sac

C'lIEVRIKk S rUINCIPLES

303

is pushed upwards to a varying degree (Figs. 426 and 427) and in each case
must be found by exploration during the operation.

Step I. — Just external to the mass of the erector spinae muscles explore for

Fig. 423. — Segment of the 6th rib has been excised in posterior axillary line. Retention
of fluid when patient is recumbent. {Chevncr, La Pr. Med., Jan. 9, 1919.)

pus with an aspirating needle. This is best done under guidance of the fluoro-
scope as this permits the puncture being made "if not at the exact inferior limit
of the effusion at least in its lower zone.'

Fig. 424. — Segment of the 6th rib has been excised in posterior axillary line. Retention of
fluid when patient is erect. (Chevrier, La Pr. Med., Jan. 9, 1919.)

Step 2. — ^Leaving the needle in place make an incision over the rib immedi-
ately above the puncture, the patient being in the lateral decubitus lying on

304

OPERATIONS ON THE. CHEST

the healthy side. The incision must begin at the outer border of the spinal
mass of muscles and run outwards j)ara]lel to the rib. Incise the latissimus

Fig. 425. — Diagram showing retention of fluid when opening is made in posterior axillary
line or in scapular line. No retention when opening is at the bottom of the vertebro-costal
gutter. {Chevrier, La Pr. Med., Jan. 9, 1919.)

dorsi and sometimes the serratus posticus inferior, over the rib. Expose the
external fibres of the ilio-costal muscle at the median end of the wound, and

r ■ -'^'^ y.

Fig. 426. — Diagram showing the
normal subpleural areolar tissue between
the pleural reflexion and the diaphragm.
{Chevrier^ La Pr. Med., Jan. 9, 1919.)

Fig. 427. — Diagram showing elevation
of the pleural cul-de-sac due to (a) oedema
and infiltration of the subpleural areolar
tissue and (b) thickening of the pleura
by false membranes. {Chevrier, La Pr.
Med., Jan. 9, 1919.)

beginning at this landmark divide the periosteum of the rib. Excise a segment
of rib. Incise the pleura. With the finger plug the opening so as to regulate

BERARD S OPERATION 305

the escape of pus and so prevent coughing and other rellexes due to too rapid
evacuation. As pus ceases to flow turn the patient gradually on to his back
until evacuation is complete when he is to be returned to the lateral decubitus.

Step 3. — Explore the pleura with the finger and find the low point. Guided
by the finger inside the chest, open the thorax at this point and if necessary
excise a segment of rib. Through this second opening introduce two short
tubes of wide caliber. Dress but do not drain the first opening.

Step 4. — Disinfection of the Pleura. — Many surgeons having opened the
chest in the classical site (6th rib; posterior axillary hne) introduce Dakin's
solution through small tubes. The opening being ill-suited for drainage per-
mits retention of the solution which bathes the parts below the opening but
not those at a higher level. Chevrier advises the use of gaseous disinfection
which reaches every part of the cavity and obviates the use of the Carrel tubes.

Conduct compressed air or better oxygen from a cyhnder to the bottom of a
flask containing ether or ether with a little formalin. Let the air bubble through
the ether and conduct it thus charged with volatile antiseptic, into the pleural
cavity.

Berard and Dunet (La Pr. Med., April 3, 1919) consider that except in the
tuberculous, slow recovery means defective drainage and emphasize the im-
portance of considering the posture which will be assumed by the patient after
operation before selecting the site for drainage. Most patients early assume the
sitting posture and for such they find the low point in the pleura to be anterior
or antero-lateral at the level of the loth or nth rib about 5 inches from the
middle Hne.

Berard's Operation. Step i. — Open the pleura in the ninth interspace in
the posterior axillary hne except in sacculated empyema where the incision is
made over the pus as found by the exploring needle. Let the pus escape slowly.
If the condition of the patient is precarious do not proceed further for a few
days. If the condition of the patient permits proceed at once to

Step 2. — Through the opening pass a curved forceps through the empyema
cavity to what would be the low point if the patient were sitting. This point
varies, e.g., pneumococcal infection as a rule produces much false membrane
and adhesion with obliteration of parts of the pleural cavity while streptococcal
infection does not. Guided by the forceps excise a segment of rib at the low
poinfei. Remove any masses of fibrin,ous material. Introduce one or two large
drains.

Step 3. — Introduce one or more Carrel tubes through the original incision.
Apply dressings. Connect the drains by tubing to a receiver. Keep the patient
absolutely quiet for 24 hours. Dress the wound after the lapse of 24 hours.
If the discharge is pure pus irrigation will be of value. Dakin's solution, nitrate
of silver or salt solution may be employed through the Carrel tubes. About
150 or 200 c.c. may be used every 3 hours except at night. Each day remove,
clean and replace both the Carrel and drainage tubes.

If an empyema persists for a very long time or if, after an apparent cure the
drainage track reopens several factors may be to blame, (i) Defective drain-
age. (2) Imperfect sterilization. (3) Presence of foreign bodies in the pleura,
e.g., lost drainage tube, etc. (4) Osteomyelitis of ribs. (5) Secondary en-
20

306 OPERATJOXS ON THE CHEST

capsulaled abscesses of the pleura which have escaped drainage. (6) Sub-
pleural pulmonary abscesses such as Moschowitz considers ihe cause of most,
if not of all empyemata. (7) Small intrapulmonary abscesses draining into
the pleura giving rise to pleuro-pulmonary fistulae. (8) Broncho-cutaneous
listulae where a portion of lung, the site of an open bronchus, has become ad-
herent to the chest wall near the point of drainage and the tract between the
bronchus and the skin has become covered by epithelium.

In all these conditions it may be necessary to perform some free exploratory
operation such as Lilienthal's and during the operation correct the conditions
present. Pleuro-pulmonary fistulae often heal of themselves or after steriliza-
tion and perhaps direct suture. To obliterate a broncho-cutaneous fistula
requires mobilization of the affected portion of the lung by Schede's thoraco-
plasty or some modification thereof, plus excision of the fistulous tract and
closure of the open bronchus, but as Lilienthal writes ''lung fistulas from tuber-
culosis, bronchiectasis or multiple abscess of the lung should be let alone, for
they constitute safety valves." . . . "Plastic closure of lung fistulae is indi-
cated when secretion is scanty? Encapsulated abscesses of the pleura at some
distance from the original empyema region require direct and efficient drainage
through an opening made by resecting a segment of rib. Reaccumulation of
pus in empyema demands proper drainage and as already stated a formal ex-
ploratory operation may be necessary.

The cure of an empyema by drainage depends, first, on the free escape of
the pus; and second, on expansion of the lung obliterating the pleural
cavity with or without more or less complete adhesion of the parietal and visceral
layers of the pleura. When the lung is unable to expand and approach the
chest-wall, obliteration of the cavity may be obtained by bringing the chest
wall to the lung. To accomplish this is the object of thoracoplasty.

Fluoroscopy has superseded all other means of observing the expansile
power of the lungs.

Wilm's Operation for Empyema.—See p. 318.

Estlanders Operation. — Make a subperiosteal resection of three or four ribs
(about 4 inches of each) through separate incisions, exactly as in thoracotomy
with resection of rib. Instead of using separate skin-incisions the ribs may be
exposed by a U-,T-, H-, or I-shaped incision, the soft parts being reflected as a
flap or flaps, and then the ribs resected subperiosteally. This operation permits
a falling-in of the chest-wall, but in many cases the parietal pleura is so thick
and hard that it is inelastic, and the desired retraction of the chest cannot take
place. To obtain proper retraction the following procedure has been adopted:

Schede's Operation (Thoracoplasty).— Beginning at the origin of the pec-
toralis major at the level of the axilla make an incision which goes downwards
in a curve to the bottom of the pleural sac, — i.e., the tenth rib in the poste-
rior axillary line, crosses the chest- wall from the front to the back, and ascends
to the level of the second rib at a point between the spine and the scapula.
Reflect upwards the huge flap thus outlined, and include in it all the tissues
superficial to the ribs and intercostal muscles. Resect subperiosteally all the
ribs over the cavity, from their tubercles to their insertion into the costal
cartilages. To do this it is best to divide the rib at its middle with bone for-

TlIOkACOl'LASTV 307

ceps, and, grasping the divided end of one of the fragments with sequestrum
forceps, dissect it out of its periosteal bed. The other fragment is removed
in the same fashion.

Bardenheuer has been compelled to excise even the first rib, the clavicle, and the scapula
before he could obtain a satisfactory result.

Make a large incision through the thickened pleura to permit of thorough
exploration. This exploration tells how many ribs must be excised and to
what extent. Excise all the periosteum, intercostal muscles, and thickened
pleura over the empyema cavity. There is not liable to be much hemorrhage
from the intercostal vessels, owing to their being more or less obliterated by
the disease, but the patients are usually debilitated, the operation is very severe,
and hence it is necessary to clamp and ligate all the intercostal vessels. Hem-
ostasis must be very carefully attended to. Some surgeons carefully scrape
away all diseased granulation tissue, but all that is necessary is gentle wiping
with gauze pads. Replace the flap of soft parts. This flap, at least if the
disease has been extensive, will not by any means cover the defect, as its under
or raw surface must be in contact with the outer surface of the retracted lung.
Fasten the flap in position with sutures and properly applied gauze pads, so
as to insure good contact between flap and lung. The remainder of the cavity
must be filled with sterile (not iodoform) gauze and may subsequently be
covered by Thiersch's skin-grafts or by flaps of skin. No poisonous antiseptics
should be used during the operation, and the use of iodoform gauze is forbidden,
owing to the great absorbing power of the tissues in question. Karewski
finds vioform gauze as efficacious as iodoform, and perfectly safe as regards
poisoning. Instead of replacing the reflected flap, Cheyne and Burchard
recommend packing the whole cavity with gauze for a time, to permit of free
drainage and of the formation of a layer of granulations on the deep surface of
the flap.

As has been said, the operation is very severe, and the patients are always
debilitated; hence is is often wise to refrain from completing the operation
at one sitting, but to proceed step by step, e.g., excising the ribs and indurated
pleura from over the lower part of the empyema, and after this procedure
has been recovered from, to advance higher.

The incision described is that of Schede, but an infinite variety of cuts have
been advocated; as Kiimmel says, almost )^ the letters of the alphabet have
been imitated in forming incisions.

Delorme, Fowler, Beck, and others believe that the obstruction to oblitera-
tion of the empyema cavity is not so much the rigid chest-wall as the stiff, indu-
rated, shrunken visceral pleura which imprisons and compresses the lung.
These surgeons temporarily resect the thoracic wall, free the lung from its prison
by "decortication," and close the chest. Jordan and Krause combine the
method of decortication with Schede's operation. Most surgeons use decortica-
tion as an aid to incision of the thoracic wall, but discard the temporary resection.

PHilmonary Decortication. — George R. Fowler ("Med. News," June 15,
1901; "Am. Year-Book of Med. and Surg.," 1902) performed this operation in
1893 with very gratifying results. He writes: "An elliptical-shaped incision

308 OPERATIONS ON THE CHEST

was made to include the orifice of the sinus, the soft parts cleared, and about 3}'^
inches each of the fifth and sixth ribs removed .... Commencing at the
site of the opening in the chest-wall, the pleura was isolated by blunt dissection
in the direction of the diaphragm until the latter was reached. It was then
peeled off the latter until its limit towards the median line was reached, where
it was found to rest against the displaced pericardium, from which, after much
difficulty, it was finally detached. This dissection was greatly impeded by the
movements of the diaphragm as well as those of the heart. The dissection was
completed by lifting the mass and finally detaching it from the lung above.
Considerable expansion of the lung followed at once, and in the course of twenty-
eight days this was so far complete that the normal vesicular murmur was pres-
ent to the level of the seventh rib. . . . Save for a slight sinking-in of the
chest-wall at the site of the resection of the ribs there is nothing to suggest the
previous existence of an empyema."

Fowler formulates the following conclusions:

"i. Decortication of the lung is an operation adapted to all cases of old
empyema in which extensive and preoperatively discoverable tuberculous lesions
of the lungs are not present, and in which the patient's condition will permit of a
major operation.

"2. It may be advantageously substituted for Estlander's operation. . . .

"3. It should replace Schede's operation in all cases.

"4. The method by extirpation of the diseased portion of the pleural mem-
brane, including the visceral, cortical, and diaphragmatic portions, is the opera-
tion of choice.

" 5. Failing this, visceral pleurectomy should be selected.

" 6. Pleurotomy, with simple detachment of the visceral layer of the diseased
pleural membrane, gives sufficiently good results to warrant the surgeon in
resorting to this procedure in cases in which the condition of the patient will not
permit of the application of the other and more desirable methods.

"7. Whatever operative method is adopted, as complete access to the cavity
of the chest as possible should be obtained, and rapid closure of the opening in
the chest-wall afterwards secured, since the complete re-expansion of the lung
must depend largely upon the normal respiratory movements.

"8. Pulmonary or respiratory exercises should not be neglected in the after-
treatment. ..."

Delorme in 1894 performed an operation very similar to that of Fowler
("Amer. Year-Book of Med. and Surg.," 1902), and did it successfully under
spinal cocainization. Out of twenty-nine cases of decortication by the Fowler
method the functional results were eleven cured, six improved, nine unimproved,
three died; as regards the cure of the empyema, seventeen were cured, nine un-
improved, three died.

Delorme has devised a method of temporary resection of the chest-wall, by
forming and reflecting a flap consisting of the whole chest-wall; this being done,
he decorticates the lung, cleans the empyema cavity, and replaces the flap of
chest-wall, providing of course for drainage. This operation has not found
much favor.

Roux in operating finds that a long incision through the indurated visceral
pleura answers the same purpose as decortication.

PULMONARY DECORTICATION AND DISCISSION

309

Ransohoff (Transactions Am. Surg. Assoc, 1914) makes use of discission,
i.e., a number of criss-cross incisions through the sclerosed visceral pleura and
finds this thoroughly satisfactory.

Lilienthal's Major Noncollapsing Thoracoplasty (Annals of Surg., July,
1919).* Place the patient on his sound side over a pillow to give a scoliotic
posture. Hips flexed. Pillow between the flexed knees.

Step I. — ^In the sixth or seventh interspace make an incision from the costal
angle to the cartilage. Parts of the latissimus dorsi and serratus magnus are
divided. If possible avoid the old drainage wound. Divide the intercostal
structures in the middle of the wound for about two inches close to the upper

Fig. 428. — {Lilienthal).

border of the lower rib. Enlarge the intercostal incision in both directions
until large enough to permit separation of the ribs by blunt traction and exposing
enough of the interior to work safely and keep clear of the lung. Enlarge the
wound to the full size of the skin incision. Separate the ribs slowly with a rib
retractor. Usually a separation of three inches is possible. In old empyema
cases the chest wall is so fixed by fibrous tissue that it is necessary to divide
from one to three ribs upwards (occasionally downwards) at the posterior end
of the wound. The blades of the retractor can now be separated 6 inches or
more (Fig. 428). (When ribs have been divided it is wise to cut away about 3^2
or ^ inches of the anterior portion of each to prevent postoperative pain and
trauma by the grinding together of the cut ends.)

*Anesthesia — intrapharyngeal (p. 288).

3IO OPERATIONS ON THE CHEST

Step 2. — Every pari of the empyema cavity lies exposed. Incise the vis-
ceral pleura from apex to base but do not wound the lung. This incision widens
as the lung expands. Peel off the visceral pleura or if this is too difficult make
numerous criss-cross incisions through the visceral pleura (Ransohoff's discis-
sion) which permits thorough expansion. Inspect the whole cavity, hunting
for secondary pockets. Treat with great respect adhesions of the lower lobe
to the diaphragm as the attenuated flat pulmonary flap is often mistaken for
the diaphragm or vice versa. As a rule it is unnecessary to peel any part of
the lung from the chest wall and dangerous because of hemorrhage and opening
avenues for infection.

Step 3. — When it is evident that no more expansion can be secured, clean the
original drainage tract and pull a tube through it from within out. Suture the
large wound in three layers using chromicized catgut for the buried sutures.
Do not use pericostal sutures, even although, as is not uncommon, it is impossi-
ble to bring the muscles close together. Drainage from the imperfectly closed
muscle wound takes place into the thorax and thence out by the tube.

After Treatment. — Begin blowing exercises early, even within 24 hours.
After 3 days treat the cavity by the Carrel-Dakin method injecting not more
than one-half ounce of fluid every two hours. The usual time of heahng is
about four weeks from the day of operation. In a personal communication
Lilienthal reported 41 cases with one death. In two or three cases not enough
time had elapsed to justify an opinion as to permanent result, in all the others
a cure was obtained.

Roux-Berger finds that secondary retraction and immobilization of the
lung are liable to occur after decortication. Therefore after freeing the lung
thoroughly by an operation entirely similar to Lilienthal's he fixes the lung to
the chest wall (pneumopexy) by strong and ample sutures. When this is done
drainage is permissible if desirable.

The after-tjreatment of cases in which any of the ordinary methods of
thoracoplasty has been used is prolonged ; often a year or more elapses before a
cure is obtained, and during this time several subsidiary and plastic operations
may be necessary. One would naturally expect that ultimately great
deformity, especially scoliosis, would be present, and that the lung deprived
of its thoracic wall would be useless. This is, however, not the case. Wonder-
fully little deformity persists; the lung expands and becomes a useful organ.
In many cases there is very evident reformation of ribs. As Karewski says,
we must not be too sparing in removing large portions of ribs, especially in
children, when this is demanded, as the lungs can still expand, and thus thoracic
deformity may be avoided or reduced to a minimum.

Resection of the thoracic wall does not per se cause much deformity. The
deformity depends on the amount of intrathoracic changes. It is not the re-
moval of the chest-wall but the shrinking of its contents which is to blame
(Th. Gluck, Archiv fur klin. Chir.," Ixxxiii, 587).

When empyema affects both pleural cavities the following operations may be
performed: (i) Double aspiration; (2) incision on one side, aspiration on the
other; (3) incision on both sides; (4) resection and aspiration; (5) resection and
incision; (6) resection on both sides (resection may include decortication).

ARTIFH'IAI. PNF.UMOTHORAX 31I

Hellin ("Berliner klin. Woch.," 1905, No. 45) recommends the operation of
incision with drainage in double empyema; operation to be limited to one side
at a time, and aspiration to be done one or two days prior to the incision.
Local anaesthesia is usually sufficient.

OPERATIVE TREATMENT OF PHTHISIS PULMONALIS

Excision of portions of the lung for tuberculosis has been of little or no value.
The same is true regarding the treatment of phthisical cavities by means of aspi-
ration and of injections. When nature cures tuberculosis she does so by con-
verting the granulation tissue into mature scar tissue. If a phthisical cavity
becomes obliterated, it is by the contraction of scar tissue, and this contraction
causes a deformity or sinking in of the chest-wall.

Establishment of Artificial Pneumothorax. — In pulmonary tuberculosis if
the visceral and parietal pleurae are not too much adherent the lung may be col-
lapsed and put at rest, temporarily, by filling the pleural cavity with some non-
irritating gas which is not too readily absorbed. Carson in 1840 suggested the
treatment but his work was forgotten until Forlanini and Murphy independently
adopted the same idea and recommended the use of nitrogen. Brauer enthu-
siastically advocated the method. Nitrogen displacement is of special value in
early progressive lesions, in cases where there is persistent fever, where there is
profuse or repeated hemorrhage and where there is cavity formation in one lung.

The dangers incident to the operation are (a) shock. This is most notice-
able in early cases and may be lessened by the careful use of local anaesthesia ;
(b) embolism from puncture of a vein; (c) when the disease is very extensive, a
comparatively small injection of gas may cause suffocation as the functional
capacity of the lung is very small.

In cases where the pleura is widely and strongly adherent the pleural cavity
is so obliterated that the operation is impossible; in other cases, where there are
localized adhesions, introduction of gas may be of great value but it is difficult to
place the point of the needle in the pleural cavity and to be sure that it is there.
Brauer, under local anaesthesia, makes an incision down to the pleura and inspects
it. A transparent pleura with the lung surface moving to and fro beneath it
exposes a field in which it is easy to complete the injection without danger to the
lung. Most operators discard the exploratory incision and content themselves
with thoracentesis. It is wise to keep the patient quietly in bed for at least
twenty-four hours and to give a hypodermic injection of morphine gr. 3^^ with
atropine gr. H5O) about half an hour before the operation.

The best site for puncturing the chest is somewhere in the anterior or mid-
axillary line in the fifth, sixth, or seventh intercostal space. The patient is
usually placed in a semi-recumbent position and turned slightly on to the sound
side. Novocaine is used as the local anesthetic and special attention must
be given to anesthetizing the pleura. The proper use of a local anesthetic
is of very great importance in preventing pleural reflex and shock. In
very nervous patients suffering from early unilateral disease Woodcock and
Clark (Brit. Med. J., Dec. 12, 1914) advise that, at the first sitting , after going
through all the ritual of preparation nothing be done beyond injecting the local
anesthetic. After four days the process is carried further and the nitrogen

312 OPERATIONS ON THE CHEST

needle is pushed in until oscillation of the manometre shows that it is in the
pleural cavity. At the third sitting a small amount of gas is introduced.

After the anesthetic has been injected, puncture the skin with a tenotome
and introduce the nitrogen needle. Floyd's needle is good (Fig. 429). The
puncture must be made slowly and deliberately until digital sense indicates that
the correct depth has been reached when the trocar is to be withdrawn, the mid-
dle cock closed and the lateral opening connected with the manometre of Sam-
uel Robinson's apparatus (Fig. 430). Before making this connection, isolate the
manometre from the nitrogen circuit. If the needle is in the pleural cavity the
negative intrathoracic pressure is indicated by the manometre and as this pres-
sure varies with the respiratory movements so also does the manometre oscil-
late. "If the needle point is partly obstructed by contact with the adhesions or
lung tissue, this oscillation may not be more than 0.5 cm. Such trifling oscil-
lation is also found when the pleural space entered is one of small capacity on

Fig. 429. — (5. Robinson. Art/:. In:. J/u/./

account of neighboring adhesions; but whether this oscillation be a complete or
restricted one, its presence is an unerring guide that nitrogen may then be safely
introduced. If the oscillation has been small, the amount of nitrogen injected is
correspondingly low. A free oscillation of from 3 to 4 cm. is evidence of greater
lung mobility, and the extent of the pneumothorax produced is correspondingly
greater" (Robinson, Arch. Int. Med., IX, 467). The needle may require con-
siderable manipulation or its site of insertion may require to be changed before
the pleural cavity is safely penetrated. As soon as it is certain that the needle is
in the pleura, close its connections with the manometre and open those with the
nitrogen bottle and permit the nitrogen to flow slowly into the chest. The
amount of nitrogen introduced varies with the case and with the ideas of the
surgeon. Forlanini begins with a very small injection, Robinson with a larger.
"If the nitrogen flow under moderate pressure is apparently unrestricted, 600
to 800 or even 1000 c.c. may be injected at the first operation" (Robinson).
The feelings of the patient and any symptoms of distress, etc., which he may
manifest must guide us frequently as to the amount of injection. Several injec-
tions at intervals of a week or of several weeks may be necessary before a com-
plete pneumothorax is established.

Morriston Davies writes (Brit. Med. J., April 25, 1914): "^ly experience is
that the nitrogen is absorbed from the pleural cavity much more quickly during

NITROGEN INJECTIONS

313

the earlier than during the later months of treatment, and it is essential therefore
that the first few refills should be done at more frequent intervals than the sub-
sequent ones. During the first six months of the treatment 1 run a fresh supply
of nitrogen every six weeks, but after that I allow an interval of eight weeks to
elapse. There is no necessity for the patient to be confined to bed at these times,
but I make him lie down for three or four hours after the injection. Those who
are at work are allowed to return to it the next day, and suffer little or no incon-
venience from the increase in pressure. The amount of nitrogen required to

Fig. 430.- — (5. Robinson, Arch. Int. Med.)

replace that which has been absorbed varies from 500 to 1000 c.c. At the end of
a year I allow the lung to re-expand so as to be able to make fresh clinical
and radiographical observations, but as a rule it is advisable to maintain the dis-
placement for at least eighteen months. If, during the earlier period of time, the
lung is allowed to expand and the two pleural membranes to come into contact
with each other, there is considerable risk that they will become adherent."

Figure 430, showing Robinson's apparatus, illustrates the principles em-
ployed in all forms of apparatus. Two bottles of 3500 c.c. capacity are em-
ployed. One is stationary and filled with water containing 2 drams of pyrogallic
acid to take up any oxygen which may enter in conjunction with nitrogen.
Nitrogen gas is then forced into the stationary bottle {A) displacing the water
back to bottle {B). At completion of this displacement the apparatus is ready

314 OPERATIOXS OX THE CHEST

for use. On opening certain cocks the water in bottle B replaces the nitrogen in
bottle A, gradually filling it. The difiference in the water levels of the two
bottles represents the pressure under which the nitrogen is injected, the rapidity
of its injection being regulated by the size of the opening in any one of the
cocks. When bottle B is full, the maximum pressure is obtained, amounting
to about 14 c.c. of water. As the water levels approach one another bottle B
may be raised as in Fig. 430, thus maintaining the pressure until most of the
nitrogen has been displaced, when the pressure is necessarily reduced. With
this hydrostatic mechanism the pressure may be varied at will, never attain-
ing the dangerous limit. The arrangement of cocks d, e, and / corresponds to
the substitution of a three-way cock at point g. In other words, with cock
d closed and e and / open, a direct connection is established between the
thoracic cavity and the manometre. With cock / closed and c, d, and e open,
connection is made between the confined nitrogen and the manometre, thus
recording the pressure represented by the difference in water levels of bottles
A and B. With cock e closed and all others open the nitrogen passes directly
from bottle A into the pleural cavity.

Numerous attempts have been made to permit atmospheric pressure to
obliterate phthisical cavities by the resection of the bony chest-wall directly
over the cavities. These attempts have failed because of insufficient sinking
in of the chest-wall.

Friedrich (in conjunction with his colleague Brauer), recognizing the danger
of pneumothorax, and that adhesions between the lung and the chest-wall can
easily prevent sufficient collapse of the lung when gases are put into the pleura,
came to the conclusion that a very free removal of the rigid chest-wall without
opening the pleura would be of value. This procedure he has carried out and
has named pneumolysis. The cases in which pneumolysis is justifiable must
present the following conditions: (a) The disease must be mostly confined to one
lung; the opposite lung can rarely be intact, (b) The disease must be progressing
in spite of proper and thorough medical and climatic treatment. (Friedrich's
cases were sent from sanatoriums where they had been under observation for
several months or years.) (c) The general condition must be fair in order to
withstand the severe operation.

In most of the cases operated on by Friedrich from 120 to 200 c.c. of sputum
containing bacilli was expectorated in 24 hours, and fever was present up to the
time of operation.

Preparatory Treatment. — For three days administer digitalis hypodermatic-
ally. Attend to the bowels without weakening the patient. Give nutritious,
easily digested food. In adults (not in the young) administer morphine an hour
before operation.

The Operation. — AnoBsthesia. — In adults inject as much as 500 c.c. or more of
Schleich's No. 2 solution but minus morphine and plus 8 drops of adrenalin
to the 100 c.c. The injection is made along the line of incision and under the
flap to be elevated. Most of the solution escapes during the operation. Some-
times Friedrich lightly freezes the skin along the line of incision with a spray
of ethyl chloride. After the skin and muscle flap is reflected chloroform is
administered.

PNEUMOLYSIS

315

In the young (under sixteen years) chloroform is used from the beginning in
von Braun's apparatus. In a case seen by the author only seven grams of
chloroform sufl'iced.

Fig. 431. — (Friedrich.)

Fig. 432.^ — (Friedrich.)

Lay the patient on his sound side. Let an assistant hold the arm (well
protected) and be ready to elevate it over the patient's head.

Step I. — Make the huge U-shaped incision shown in Figs. 431 and 432.
It the female the breast is avoided. (Fig. 433.)

3l6 OPERATIONS ON THE CHEST

Step 2. — Reflect the flap outlined. The flap contains skin, all the muscles
down to the ribs, and the scapula. Obtain free access to every rib from the
tenth up to and including the second.

Step 3. — If local anaesthesia has been used, administer chloroform now.

Step 4. — Beginning at the tenth rib proceed as follows: (a) Reflect the
periosteum upwards and downwards from the whole external surface of the
rib. {b) Near the middle of the rib separate the periosteum from the lower edge
of the bone (for this purpose a nick with a knife is usually necessary before

Fig. 433. — {Friedrich.)

the elevator can pass under the rib). With gauze, finger and elevator carefully
separate the periosteum plus the intercostal vessels from the groove under the
rib. Complete the separation of the periosteum from the deep surface of the
rib, and pass Friedrich's curved elevator completely around the rib. The
curved elevator being round the rib, pull it (the elevator) with force back to or
beyond the angle of the rib and forwards to the junction of the rib and costal
cartilage. Divide the rib at its junction with the cartilage bj^ means of a
costotome. Seize the end of the rib and pull it outwards. Pass a finger along
the visceral side of the rib to its head, to protect the pleura. Twist the rib
until it comes away. (Sometimes the head of the rib is torn from its connec-
tions; sometimes the neck of the bone is fractured.)

PNEUMOLYSIS 317

Step 5. — Repeat Step 4 on each rib until the second is removed.

Step 6. — With gauze and sharp dissection remove the intercostal muscles
from the pleura. The twisting away of the ribs obliterates the intercostal
arteries.

(Duration of operation up to end of Step 6 was twenty-five minutes in
the case seen by the author.)

Step 7. — Apply ligatures. Replace the flap and unite the divided muscles
with catgut. Place a drain along the deep wound corresponding to the heads

Fig. 434. — {Friedrich.)

of the ribs. Close the skin wound. Apply abundant dressings. Opera-
tion on the right side is much more dangerous than on the left because of
cardiac dislocation.

After-treatment. — Administer hypodermatically i c.c. camphor oil forty per
cent. (40 per cent.) every hour by day and every two hours by night. Give
digitalis freely. Each night inject i3^ L. salt solution in the inguinal region.
The salt solution has a most favorable influence on respiration. Administer
oxygen frequently.

Of eight cases only two died and these had advanced secondary lesions
elsewhere.

Of course, after recovery, medical and climatic treatment must be continued.

3l8 OPERATIONS OX THE CHEST

Figs. 433 and 434 show the extent of compensatory emphj-sema established
in the sound lung and the great displacement of the heart.

In a few weeks the sputum has diminished from 150 or 200 c.c. to 20 or even
5 c.c. and the patients have lost their fever and gained weight. The operation
is sub jiidice but seems to be of considerable promise.

Wilms' Operation. — (Wilms. "!Muench. med. Woch.," 191 1, No. 15; Kolb,
"Muench. med. Woch.,'" 1911, No. 47.) In cases of unilateral chronic tuber-
culosis of the upper lobes of the lung and in total empyema Wilms endeavors to
diminish the thoracic cavity by resecting 3-4 cm. of several ribs near their
angles, supplemented when necessary by resection of the costal cartilages.
The weight of the arm, among other factors, causes very great lessening of the
upper thoracic cavity after operation; the lower thorax is not so well obliterated,
hence in empyema it may be necessary to excise completely some of the lower
ribs in a secondary operation.

Wilms' operation like Friedrich's aims at pneumolysis and obHteration of
the pleural cavity, while Freund's operation of chondrotomy aims at restora-
tion or improvement of thoracic motion and at an increased thoracic ca\'ity.

Use a local anesthetic (Wilms).

Step I. — Make an incision parallel to the spine, over the angles of the ribs,
from the first rib downwards as far as may be necessary. Reflect the skin so as
to expose about 4 cm. of the subjacent muscles.

Step 2. — Split the fibres of the trapezius and rhomboideus muscles over the
second rib. Retract the muscle vigorously so as to expose about 4 cm. of the
first, second, and third ribs. Excise subperiosteally about 3-4 cm. of these
ribs. In similar fashion split the muscles over the fifth rib and through that
opening excise 3-4 cm. of the fourth, fifth and sixth ribs. SpUt the muscles
over the seventh rib and excise through this opening portions from any of the
lower ribs which prevent falling in of the chest- wall.

Step 3. — Make an incision parallel to and 1-2 cm. from the edge of the ster-
num and excise the whole of the costal cartilages of the ribs which have been
divided posteriorly.

Step 4. — Apply dressings held in place by adhesive straps firmly applied.
Have the patient lie on the atfected side.

Sauerbruch's operation is very similar to that of Wilms'. The incision
is made about 3 finger-breadths external to the vertebral spines, its lower end
being extended outwards above the tenth rib. Through this incision the
scapula is reflected outwards and portions of ribs are resected from the ninth and
tenth upwards to and including the first. Of the lower ribs, 6 to 10 cm. of the
upper 3 to 6 cm. should be removed. It is necessary to resect the ribs in the
back close to the transverse processes of the corresponding vertebrae and it is
important to resect small portions of the tenth or even of the eleventh rib since
only in this way can the diaphragm be relaxed and also mobilized and the lung
deprived of its inspiratory power (Henschen, Trans. Am. Surg. Assoc, 1914).
Sauerbruch (Technik der Thoraxchirurgie) has also modified the Friedrich opera-
tion by operating in two stages. He first resects the ribs from the fourth or
fifth to the eighth exactly as in Friedrich's method. After a few weeks he
resects the remaining upper ribs as follows : Place the patient on his back with

LIGATION PIILMONARY ARTERY .S ' 9

the shoulders sHghtly elevated. Abduct and elevate the arm as much as possible.
Make a skin incision from without inwards along the clavicle. Continue its
inner end downwards corresponding to the course of the internal mammary
artery. Retlect the flap of skin and pectoralis outwards so as to expose the
inner two-thirds of the upper ribs. Subperiosteally resect the second rib as
extensively as possible — without injuring the pleura. This permits the apex
of the lung to sink inwards away from the first rib. After raising the periosteum
carefully and slowly, gnaw through the first rib with a narrow-bladed rongeur*
forceps, at the same time pushing the subclavian vein with the finger out of
harm's way. After dividing of the rib remove as much as possible of its median
and lateral segments. Resect the third and fourth ribs. Replace the reflected
flap and suture it.

Tuffier, Extrapleural Implantation of Fat.^ — Lipotamponade. — In cases of
apical tuberculosis Tuffier operates as follows: Make a free incision through a
suitable intercostal space down to but not through the parietal pleura. By
blunt dissection separate the unopened pleura, corresponding to the apex, from
the endothoracic fascia. Push the apex of the lung, covered by the pleura,
downwards, thus creating a large extrapleural cavity. Fill this cavity with a
free, i.e., non-pedunculated mass of fat. Close the wound. Tuffier has found
the operation useful and Wilms has had similar results. Instead of fat, Baer
has used paraffin for the tamponade. Wilms thinks that in chronic phthisis
with contraction the apical compression is insufficient; therefore he combines
it with his own operation of rib resection in the lower thorax.

Ligation of Branches of the Pulmonary Artery .^When one of the principal
branches of the pulmonary artery is tied there results induration and later
contraction of the territory supplied, but without pneumonia. Sauerbruch has
taken advantage of this in the treatment of bronchiectasis. To get the full
benefit of this therapy it is necessary to complement it by subsequently mobiliz-
ing part of the chest-wall by means of a more or less limited resection of ribs.
The arterial branches going to the left lower and right upper lobes of the lungs
are specially suitable for ligation (Schumacher). To ligate the artery of the left
lower lobe, place the patient on his right side with a pillow so placed as to make
the left chest very prominent. Pull the left arm upwards and backwards.
Make a long incision in the fifth intercostal space. Use differential pressure ap-
paratus or intratracheal insufflation. Be specially careful in opening the pleura
because of the probable presence of adhesions. Separate the upper and lower
lobes of the lung in the interlobar fissure and expose the pedicle of the lower
lobe in which there lie the pulmonary artery and vein and the bronchus. The
bronchus lies between the two vessels and the artery is the most superficial.
Do not depend on pulsation in orientation as it is fallacious. Once the artery
is found pass a ligature round it from the bronchus side. For one or two days
after operation the breathing is shallow because of the pain.

Willy Meyer has experimentally ligated the pulmonary artery within the
pericardium so as to avoid the difficulties of Sauerbruch's method when adhe-
sions are present (Trans. Am. Surg. Assoc, 1913). Such operations are some-
times supplemented with unilateral section of the phrenic nerve in the neck

320 OPERATIONS OX THE CHEST

whereb}- half the diaphragm is paralyzed and pushed up into the chest by the
intra-abdominal pressure.

Exposure of the Phrenic Nerve in the Neck.^ — Make an incision along the
posterior edge of the lower two-thirds of the stcrnomastoid muscle. Doubly
ligate and divide the external jugular vein. Retract the stcrnomastoid for-
wards. Recognize the scalenus anticus muscle as it runs downwards to be
inserted into the scalene tubercle on the first rib. Low down in front of this
muscle is the subclavian vein; behind the muscle is the subclavian artery. The
phrenic nerve runs from above downwards and inwards obliquely on the an-
terior or superficial surface of the scalenus anticus and is somewhat overlapped
by the internal jugular vein.

FREUND'S OPERATION FOR ALVEOLAR PULMONARY EMPHY-
SEMA AND APIC.\L PHTHISIS

In 1859 Freund demonstrated two important conditions of the thorax
which were primar}^ (direct or indirect) causes of pulmonary disease.

1. Impeded development of the first costal cartilage caused stenosis of the
upper aperture of the thorax and this symmetrical or asymmetrical stenosis
influenced the structure and function of the apex of the lung so as to render
it susceptible to tuberculosis. If pseudarthrosis developed in this stenosed and
immobile costal ring and permitted motion, then a natural cure of the apical
tuberculosis supervened. For fifty years Freund urged operation to produce
such pseudarthrosis and for fifty years his colleagues shook their heads to his
pleadings.

2. Degeneration of the costal cartilages causing their enlargement and
immobility in a position of inspiration (previously observed by Dupuytren)
caused a widening of the lower thoracic opening and a flattening and atrophy
of the diaphragm.

The resulting permanent dilatation of the thorax led to permanent disten-
tion of the lung, i.e., to alveolar emphysema.

Freund formulated the following indications for operation: When steno-
sis of the upper aperture is demonstrated and there is repeated catarrhal trouble
in the apex of the lung, operation is proper as a prophylactic measure; when
under similar conditions an apical tuberculosis is present but does not extend
below the second rib, then a curative operation is indicated.

An operation is indicated in the early stages or in fully developed alveolar
emphysema before the occurrence of secondary affections with atrophy and
great rarefication of the lung tissue and atrophy of the diaphragm, when rigid
dilatation of the chest-wall is demonstrable. ("Archiv fiir klin. Chir.," xcii,

974-)

Von Hansemann ("Archiv fiir klin. Chir.,'' xcii, 993) considers Freund's
operation very advisable in typical cases of apical phthisis where there is
stenosis of the upper opening of the thorax and where the disease does not
extend lower than the second or third rib.

Mohr emphasizes the fact that Freund's operation, in alveolar emphysema,
is directed not against the pulmonary dilatation but against the dilated and
rigid thorax which causes the emphysema. Operation must be followed by

FREUND S OPERATION

321

proper gymnastic exercises so that the muscles used in respiration receive proper
education and training. Before deciding on operation it is important to study
the condition of the heart, etc., lest relief of the thoracic rigidity might affect
disastrously cardiac compensation. Mohr's experience with Freund's opera-
tion is considerable and he has been much impressed with its value.

Freund's suggestion has been carried out successfully by O. Hildebrand,
Bramann and Haasler, Passler and Seidel, Goodman and Wachsmann,
Friedrich, etc.

The value of Freund's operation was substantiated by the reports of many
operators at the German Surgical Congress of 1910.

The operation may be done under local or general anaesthesia. Cardiac
insufficiency, asthma, chronic bronchitis and albuminuria according to Friedrich
are not necessarily contraindications to operation.

Fig. 435. — Freund's operation.

The Operation.

Step I. — Make the somewhat curved incision A B (Fig. 435). Expose the
ribs and costal cartilages for i3^ to 2}^ inches at their junction.

Step 2. — Excise about i]4, to 23^^ inches of the ribs and cartilages at their
junction. This is done to the 2d, 3d, 4th, 5th, and 6th ribs.

When the operation is done for apical phthisis the first rib ought also to be
removed.

Carefully remove the periosteum and perichondrium corresponding to the
excised portion of rib. This is done to prevent reformation of rib. Andrews
obliterates the groove left by each cartilage with a circular stitch of catgut in
order to prevent reformation of cartilage from fragments of perichondrium
which may have escaped removal. He removes only segments of four ribs.

Axhausen ("Zentralblatt fiir Chir.," May 14, 1910) notes the difi&culty of
excising the periosteum and perichondrium left after removal of the ribs, and
21

322 OPERATIONS ON THE CHEST

suggests overcoming this difficulty by applying the thermocautery to the mem-
brane instead of endeavoring to excise it.

On purely theoretical grounds it seems to the author that it would be wise
to reflect a flap of periosteum, base outwards, from the anterior surface of the
ribs, corresponding to the segment to be removed, and after removal of the
segment of rib to carefully cover the cut end of the rib with the periosteal flap.

In one of Friedrich's cases (local anaesthesia) the patient drew attention
to the immediate relief obtained in his diaphragmatic respiration as soon as a
rib was divided.

E. Douay (These de Doctorat. Paris, Ref. Journ. de Chir., XV, 303, Sept.,
1 919) denies Freund's theories regarding the causes of emphysema. In his
opinion the patients are suffering from a thoraco-visceral dyspneic syndrome
with associated alterations in the thorax, lungs and heart. If rigid dilatation
of the thorax is an element in the respiratory embarrassment of the emj)hy-
sematous, a much more important factor is dilatation of the right heart of
which the first sign is dilatation of the right auricle. Douay (supported by
Delbet) considers operation proper (i). In emphysema with considerable
dilatation of the thorax and diaphragmatic embarrassment. (2) In emphysema
with partial thoracic rigidity due to sterno-chondral ankylosis. (3) In emphy-
sema with circulatory disturbances and cyanosis due to dilatation of the heart
especially auricular, whether thoracic dilatation or rigidity be present or
absent.

When operation is performed for dilatation of the right auricle it should
consist of excision of the 3rd, 4th, 5th and occasionally the 2nd, and 6th costal
cartilages along with their peri-chondrium.

Henschen ("Archiv fiir klin. Chir.,' xcvi, Hft. 4) considers Freund's chon-
drotomy the logical operation in cases of thoracic stenosis where the stenosis is
due to ossification of the first costal cartilage and explains the location of apical
tuberculosis in adults. This form of stenosis Henschen calls "Hart's anomaly
of the aperture." It differs essentially from Freund's anomaly where a primary
want of development of the cartilage, or of the rib itself, substitutes an antero-
posterior oval for the normal transverse oval of the thoracic aperture, and where
a flattening of the paravertebral portions of the rib causes subapical compression
of the lung with all its ill effects. For this condition Henschen advises para-
vertebral decompressive excision of the first rib.

Henschen's Operation. — Place the patient in the semiprone position with
the healthy side undermost. Put a pillow under the upper chest in such a
manner that the arm (of the affected side) can be laid over it and strongly pulled
outwards and downwards, the pillow acting as a fulcrum to the arm.

2. From the dorsal spine of the sixth and seventh cervical vertebrae make an
incision through the skin outwards to the acromial end of the clavicle. At a
point on this line 3 to 4 finger-breadths external to the spines of the vertebrae
make an incision parallel to the vertebra and about 3 inches long. Part of this
vertical cut is above and part below the horizontal incision. Reflect the skin
flaps thus outlined.

3. Split the exposed portion of the trapezius in the line of the horizontal
wound; divide the rhomboid and the superior serratus posticus; divide fully

COSTAL OSTEITIS 323

half of the levator anguli scapuli. With a retractor pull the upper angle of the
scapula strongly downwards.

4. With the finger identify the tubercle of the first rib and bluntly isolate
a segment of the rib for a distance of about 2-3 cm. outwards from the tubercle.
Subperiosteally resect this segment of rib. If the second rib aids in producing
the stenosis excise part of it also through the same wound. Apply a thermo-
cautery to the periosteum to prevent reformation of bone.

5. Attend to hemostasis. Close the wound. Dress'.

Torek's Interpleural Pneumolysis (Surg., Gyn., Obst., July, 1914, p. i). —
When injections of nitrogen are unavailable because of the presence of adhesions,
Torek endeavors to produce collapse of the lung without the dangers of the
Friedrich operation. He operates as follows: Anaesthesia by intratracheal
insufllation. Trendelenburg's posture to prevent discharges, possibly expressed
from the diseased lung, gravitating into the healthy lung.

Step I. — Make a 6-inch incision through the 6th or 7th intercostal space
at the postero-lateral aspect of the chest. Attend to hemostasis before the
pleura is incised.

Step 2. — Incise the parietal pleura. Separate the ribs with retractors.
Gently with the finger, and later with the whole hand, separate the adhesions
between the visceral and parietal pleurae. Some firm strands may require
cutting. When the separation is completed the lung will collapse as much as
the degree of its infiltration or consolidation permits.

If any superficial pulmonary cavities have been opened during the opera-
tion demonstrate their openings, if necessary, by having the anesthetist inflate
the lung. Close any such openings by inversion sutures after the lung has
collapsed again.

Step 3. — Close the pleural cavity without drainage. Close the chest by
pericostal sutures. Close the skin wound.

As the air in the pleural cavity may become absorbed it may be necessary
subsequently to fill the cavity with nitrogen gas.

OPERATIVE TREATMENT OF COSTAL TUBERCULOUS OSTEITIS
AND OF THE RESULTING ABSCESSES

The most common and least efl&cacious treatment of the above affection
is incision, thorough scraping with a sharp spoon, and iodoformization. This
treatment is often insufficient, and when we remember that the excision of a
segment of a rib is easy and harmless, then we can have little hesitation in
adopting more radical and effectual methods.

Let it be assumed that we have to treat an unopened abscess, not adher-
ent to the skin, originating from a tuberculous focus in a rib. Cheyne rec-
ommends an operation on the following lines: Make a vertical or oblique
incision through the skin over the abscess. The incision ought to extend
at either end beyond the abscess itself. Retract the edges of the wound and
dissect back the skin from over the abscess until the whole swelling is freely
exposed. Instead of the above, a curved incision may be used and a more
or less U-shaped flap of skin elevated to expose the swelling. If possible,
without rupturing the abscess, dissect it free from its surroundings except where

324 OPERATIONS ON THE CHEST

it is attached to the offending rib. Expose the offending rib or ribs at each
side of the abscess and subperiosteally divide them in such a manner that
the whole mass, abscess cavity and rib, is removed en masse, leaving the pos-
terior layer of periosteum in situ. On the normal cadaver this operation
is difficult to do without puncturing the pleura, but in cases in which it is in-
dicated, although caution must be exercised to avoid this accident, the accident
is unlikely to happen, as the disease has caused thickening of the tissues. After
removal of the abscess and segment of rib, examine carefully the remaining
periosteum ; if it is diseased, curette and swab it with liquid carbolic acid (neu-
tralizing the acid by wiping with alcohol) or cautiously excise the diseased
tissue. Attend to hemostasis and close the wound, after having provided for
drainage. If it is impossible to excise the abscess intact, evacuate it either
by incision and careful cleansing or by aspiration or puncture. If aspiration
or puncture has been employed, close the puncture in the abscess wall with a
clamp or a purse-string suture before continuing the dissection. The same
principles of treatment must be applied in cases of osseous disease with sinus
formation.

When an infective disease, such as tuberculosis or typhoid, attacks one
or more of the costal cartilages, repeated operations may be necessary before
recovery takes place. Roux considered such cases almost incurable until
he attacked them as follows: Through healthy tissue make an incision all
around the focus of disease. Divide the skin, muscles, cartilage, and, if neces-
sary, the bone. When this cut has become sclerosed, proceed to excise the
disease. The wall of sclerotic tissue provided by the primary operation pre-
vents spread of the disease in the now resistant cartilage ("Rev. de Chir.,"
No., 1904).

Axhausen ("Archiv fiir klin. Chir.," xcix, 219) after removing the disease
covers the healthy stump of cartilage either with a pedunculated flap of muscle
or by inverting the skin wound over the cartilage and suturing the skin to the
tissues under the cartilage. The whole principle of treatment is to leave no
dead space opposite the divided costal cartilage. Experience shows that cover-
ing the end of the cartilage with flaps of perichondrium does not fulfil the re-
quirements. Costal cartilage transplanted to repair deformities in the nose
and elsewhere, easily survives, but it is always in complete apposition with the
surrounding tissues, i.e., it does not abut on dead spaces.

Moschcowitz (Annals Surg., Aug., 1918) urges removal of the whole costal
cartilage which is diseased so that not even a trace of exposed cartilage is \asible
because cartilage exposure in an infected wound does not heal and practicaly
always forms a sinus. If the disease and infection is slight the surgeon may
do less excision and close the wound without drainage, especially without gauze
drainage.

EXCISION OF TUMORS OF THE CHEST- WALL AND OF THE

PLEURA

Malignant tumors of the thoracic wall are seldom attacked unless — e.g.,
in the course of an amputation of the breast — a tumor is accidentally found
to be attached to the thorax, a state of affairs not known before the operation

EXCISION TUMORS 325

was begun. Parham has successfully removed a sarcoma of the chest-wall.
Rixford ("Annals of Surg.," 1906, No. i) has removed several carcinomata
affecting the chest-wall. Deruginsky ("Annals of Surg.," 1906, No. 5) re-
sected a portion of the chest-wall and the diaphragm for primary sarcoma of
the pleura; the patient survived long enough to die from recurrence. Osteo-
mata of the ribs ought, other things being favorable, always to be removed,
because of the disastrous effects of their growth. The technique of the operation
is very similar to that for the removal of tuberculous foci, and is along the fol-
lowing lines:

1. Make an incision all around the tumor, preserving as much skin as possi-
ble without cutting too near the disease.

2. Free the tumor from its surroundings, sacrificing all muscular tissue
attached to it.

3. Subperiosteally divide all the ribs to which the tumor is adherent.

4. Note if the pleura is adherent to the tumor; if it is, then excise the ad-
herent portions along with the tumor. Endeavor to avoid the sudden entrance
of air into the pleura. Let the primary opening into the pleura be small, so
that the air enters slowly; with a moist pad of gauze close the opening at inter-
vals so that the conditions of internal and external pressure may have time to
adjust themselves. As the pleural wound is enlarged, progressively pack
gauze (sterile) into the pleural cavity. Many French surgeons advise wide
opening of the pleura at once. The gauze packs shut off the rest of the cavity
from the field of operation. Before the pleura is opened, warn the anesthetist
to let the patient come out of deep anaesthesia. Coughing on the part of the
patient is now desirable, as the violent distention of the lung helps to guard
against dangerous pneumothorax. When the packing of gauze has been
thoroughly done, violent disturbances of respiration do not continue long.
After the tumor has been removed, the gauze must be withdrawn and the lung,
which is generally "coughed into" the wound, is caught and fixed to the thorax
with a few stitches. The pneumopexy is of special importance when part of the
lung demands removal.

When a segment of lung is affected by the tumor, it, of course, is adher-
ent to it, and thus it is easy to apply sutures all around the diseased area.
Dollinger advises that pneumothorax be slowly produced the day prior to
operation. Delageniere, after taking similar precautions, has operated for
two hours in the open thorax without ill effect. The safety of slowly produced
pneumothorax is evidenced by J. B. Murphy's work on phthisis pulmonaUs.
One of the many methods of operating under differential pressure may be
adopted with good effect. After removal of all the disease, even perhaps of
part of the diaphragm, close the wound with sutures, providing efl&cient drainage.

If so much skin has been removed that complete closure is impossible,
and if there has been no suturing of the lung to the thoracic wall (pneumo-
pexy), part at least of the gauze packing must be left in place until adhesions
form. In every case the dressings must be hberal, air-tight, and left undisturbed
as long as possible. Emmet Rixford recommends closure of the wound, under
the above circumstances, by means of a flap taken from the abdomen or from
the chest-wall of the opposite side. The lung soon expands, and air left in the

326 OPERATIONS ON THE CHEST

pleura rapidly disappears. (The preceding description of excision of tumors is
largely taken from Karevvski's admirable clinical lectures.) Ri.xford's paper on
** Excision of Portions of the Chest-wall for Malignant Tumors" ("Annals of
Surgery," Jan., 1906) substantiates in almost every particular the advice given
above.

Pneumotomy. — Incision of the lung may be demanded for the removal of
foreign bodies (see p. 292) or to provide for drainage in cases of pulmonary
gangrene, abscess (whether tuberculous or j)yogenic in origin), and large bron-
chiectatic cavities; also for the treatment of echinococcic cysts.

Operation is clearly indicated when the gangrenous area or the abscess
is limited in extent, not multiple and is fairly accessible. It is usually con-
sidered improper to operate when the aflfected lung is widely diseased — e.g.,
when there are large bronchiectatic cavities requiring drainage in both upper
and lower lobes — but Th. Gluck's experience shows that such may properly
be attacked. The mortality of pulmonary gangrene treated non-surgically
is 80 per cent.; treated surgically, 29 per cent. (McArthur).

G. Picot considers the mortality more than 75 per cent, without operation.
When operation is performed early, some statistics show a mortality of but 17
per cent., but operation should only be undertaken where there is a single, cir-
cumscribed focus, and the patient has good resisting power. Picot considers
"radiography preceded by radioscopy" to be the most valuable method of
diagnosis, as exploratory puncture is fallacious and dangerous, while ordinary
clinical tests have led to innumerable errors in localization.

The abscess is carefully localized by the usual methods of physical diagno-
sis. During the first week of the existence of gangrene the X-ray will show
a shadow, but after this time putrefaction leads to cavity formation and the
rays show a light area. After cleaning the skin over the site of the lesion it
is commonly advised to explore in the following manner: The long and
delicate needle of an exploring syringe is pushed in the direction in which
the pus is believed to exist. The needle ought to be attached to the syringe
by means of rubber tubing which has been divided and reunited by the in-
terposition of a small glass bulb or tube. When the point of the needle has
penetrated the lung to the suspected area, slight suction is made with the
syringe. If any pus is present, it will be noticed in the glass placed in the
tubing. If no pus is found, make the needle penetrate more deeply and repeat
the suction. After every change in the position of the needle make the suction
test with the syringe. When the piston of the syringe has been pulled out to its
full extent, clamp the rubber tube, detach the syringe, push the piston down,
attach the syringe to the tube, remove the clamp, and proceed as before. It
may be necessary to push the needle in various directions before the pus is found.
Having found the abscess by the above means, leavie the needle in situ and pro-
ceed to expose the abscess.

Most experienced surgeons are afraid of infecting the pleura if they use
the exploring needle in the above manner. Expose the aflfected area by sub-
periosteally removing a segment of one or more ribs, palpate the uninjured
pleura, noting if motion and friction are absent and if it is grayish-yellow
in color or infiltrated (signs of adhesions). McArthur advises that a fine

PNEUMOTOMY 327

exploring needle be inserted for i cm. (% inch) or less; if no adhesions are
present the moving lung will cause the needle to rock; if adhesions are present
the lung cannot slide on the parietal pleura, hence the needle will not rock.
Note that this needle is not being used to explore for pus, but for adhesions.
In the absence of adhesions it is advised never to use the needle to hunt for pus,
because of the danger of infecting the pleura. If adhesions are present and
palpation shows that sohd — i.e., diseased — lung is opposite the wound, either
search for the pus with an aspirating needle (if pus is found leave the needle
in situ until a free opening is made into the abscess) or at once penetrate the
diseased area with a closed sinus forceps or with a Paquelin cautery heated to a
dull red color. When the Paquelin cautery enters the cavity not only will pus
flow, but smoke will be inhaled and exhaled. The principal advantage gained
from the use of the cautery is that the walls of the channel made by it are sealed
against absorption of the pus coming from the opened abscess. When the
cavity has been penetrated, pass in the finger, explore and open secondary
cavities, gently remove with the finger and gauze loose sloughs and debris. Do
not break down any bands felt traversing the cavity, such may be blood-vessels.
Do not douche the cavity; douching is well calculated to spread infection to other
parts of the lung or to drown the patient. Do not use peroxide of hydrogen,
the explosive frothing of this drug has all the evils of the douche. Intro-
duce a loose gauze pack. If iodoform is used in the gauze let it be in feeble
quantity, as it is liable to be rapidly absorbed and cause poisoning. Instead
of gauze a split rubber tube — preferably covered with gauze — may be used.
The tube unless soft or protected may cause pressure, necrosis and hemor-
rhage. A roll of rubber dam is probably the best drain.

If when the pleura is exposed the adhesions do not appear so strong as
to be above suspicion, reinforce them by a few catgut stitches uniting the pa-
rietal and visceral pleura around the operative area. A patient of L. L. Mc-
Arthur seemed to be progressing favorably when he began to cough severely,
ruptured the pleural adhesions, infected the healthy pleura and died from the
infection. It is a good plan to expose the pleura (excising the necessary seg-
ments of rib and also of intercostal muscles) under local anaesthesia. If the
pleura is not adherent, the patient can easily force his lung into contact with
the parietal pleura where it can readily be fixed by a few catgut sutures. A
layer of gauze is now laid into the wound and the skin wound closed. After
a few days the wound is reopened, the gauze removed and the pus sought.

Adhesions being present, "how shall we look for the disease area in the
lung if it is not immediately before us? Circumscribed gangrene in the lung is
always surrounded by a zone of infiltrated inflammatory tissue — nature's bar-
rier to the progress of the disease — so with the knife and finger we will explore
any indurated area that may be present. If this fails to reveal the disease we
will use the exploring or aspirating needle, and, by passing it in various directions
in the lung, judge from the feeling imparted to the fingers the character of the
tissue the point is traversing, and also from the discharges the needle may bring
away. If this gives us negative results it is best to discontinue any further
search, and complete the operation by leaving a drainage-tube in the incision
in the lung. All hope of evacuating the septic material need not yet be aban-

328 OPERATIONS ON THE CHEST

doned, for several cases have been reported where the pus has found its way
to the drainage-tube within a few days, and the patient has ultimately made a
good recovery."

If, after subperiosteal resection of the ribs, the pleura is found to be non-
adherent, adhesions must be provided, otherwise as soon as the pleural cavity
is opened a dangerous condition of pneumothorax obtains. The formation
of adhesions may be stimulated by the application of irritants, such as chlo-
ride of zinc, to the outer surface of the unopened parietal pleura. This is
rather a blind method of reaching the goal. Most surgeons proceed some-
what as follows: A fully curved needle, armed with a thick silk or catgut
suture, is passed through the unopened pleura, made to pick up as large a
bite of the lung and visceral pleura as is possible, and brought out again through
the parietal pleura. Much gentleness must be exercised in tying the sutures as
the pulmonary tissue is friable. From two to four sutures will generally be
found ample to secure apposition of the two pleural layers. The parietal
pleura is weak, therefore the sutures should catch other tissues as well. The
sutures may be made to penetrate a large gauze pad (four thicknesses) laid on
the outside of the chest, with an opening in the centre to permit of subsequent
operation. The subsequent steps of the operation should be carried out, in the
manner already described, after the lapse of a week.

Should the case be one of such urgency as to warrant incurring the extra
risk, one must surround the diseased area by a row of interrupted "back-
stitch" or interlocking sutures of catgut, uniting the parietes to the visceral
pleura and lung. Do not take too deep a "bite" of lung with the needle.
If pleural suturing is, from any cause, impossible, pack the pleural cavity
as it is opened with gauze, as in the case of appendicitis; a smaller amount of
gauze may suffice if the gauze packing is sutured with catgut into the pleural
opening. It has been claimed that aseptic silk sutures applied to the non-
infected pleura do not produce enough irritation to ensure the formation of
effective adhesions. Silk sutures soaked in turpentine have been employed
and found to be satisfactory.

After the pus has been evacuated, provision must be made for drainage.
This is best done by leaving the wound wide open and packing with sterile
gauze (iodoform gauze is liable to lead to poisoning). Rubber tubes may be
used if surrounded by gauze. Tubes unprotected by gauze occasionally cause
erosion of blood-vessels. Rubber dam is safe and efficient. When there is
much loss of lung substance and there is not sufficient compensatory distention
of the remainder to fill the resulting void in the thorax, the treatment must be
similar to that of old empyema, viz., resection of an appropriate amount of
thoracic wall. Lung wounds heal slowly and form but few granulations.
Epidermization progresses from the skin alone; any growth of epithelium from
divided bronchi leads to persistent fistulae being formed. As soon as retraction
or dragging inwards of the external soft parts ceases to progress satisfactorily,
recovery may be hastened by the use of skin-flaps obtained in the neighborhood.
If bronchial fistulae persist, th^ may be closed by the application of the cautery.
It must be remembered, however, that a persistent bronchial fistula may be,

PNEUMECTOMY 329

in reality, beneficial in that, it gives vent to discharges which would otherwise
be retained and cause serious trouble.

In j)ulmonary hydatids C. E. Corlette places the patient in the semi-prone
position (see p. 302) and excises about 10 cm. of two ribs including the perios-
teum. After incising the adherent pleura and exposing the adventitious cap-
sule of the hydatid he anchors the latter by stay sutures and opens it. (In the
lung the cysts are simple, i.e., have no daughter cysts.) After evacuating the
contents and mopping the cavity dry, he closes the opening in the pleura and
capsule with sutures and closes the wound without drainage.

Pneumectomy. — Th. Gluck, as early as 1882, elaborated the following
method of excising one lung or part thereof. After opening the thorax by the
removal of a segment from one or more ribs, grasp the lung with a clamp and pull
a cone of it through the opening in the thorax. Apply a ligature behind the
clamp, pull more of the lung through the wound and apply another clamp.
Repeat this process of pulling the lung outwards with a clamp and ligating until
the desired amount of lung is herniated or until the pulmonary root is reached.
Cut away the lung distal to the last ligature, leaving about one inch of lung tis-
sue protruding from the ligature. Suture the cut surface of the stump with
interlocking stitches of catgut.

Gluck ("Archiv fiir klin. Chir.," Ixxxiii, 592) reports the following two cases
on which he operated using the clamp and ligature method.

R. P., thirteen years, March 3, 1899. Multiple, fetid bronchiectasis of left
lung. Resection of the sixth to tenth ribs. Resection of the upper lobe and
total pneumectomy of the lower lobe of the left lung. Before operation an
enormous amount of gangrenous material was discharged each day, after opera-
tion the discharge was not worth noticing and had no bad smell. The patient
felt well, ran about and played with other children. In October, 1899, the
thoracic wound was not completely healed; an operation was undertaken to
close the wound and the patient died from unexpected collapse and heart failure
(Herztod). Autopsy showed chronic interstitial and parenchymatous myo-
carditis. The bronchiectatic process had been completely removed and the
limg wound had healed. Heidenhain has resected the lower lobe (left) of a
lung — the seat of bronchiectatic cavities — with success.

Gliick's second case is most important. The patient suffered in 1896 from
lymphangitis migrans and thrombo-phlebitis of the left and subsequently of the
right lower extremities. In May, 1897, there were left-sided pulmonary in-
farcts; the left pleura was twice punctured and large amounts of exudates
removed. Recovery in July, 1897. In April, 1899, septic phlegmon extensor
aspect of right forearm, which was nearly healed in July, when there was a chill
with 41.5° (Fh. 106.7) of fever. Pyemia developed requiring radical opera-
tion for right axillary abscess and phlegmon of chest- wall (twice); evacuation
abscess on sternum; transverse drainage, right ankle-joint; operation, left
pleural empyema (twice). In spite of extensive resection of ribs and evacua-
tion of pus from the pleura elastic fibres were found in the putrid discharges.
January 3, 1900, there were bloody sputum, dyspnoea and extreme weakness.
The thorax was opened widely, the enormously thickened and degenerated
pleura was resected and the whole lower lobe of the left lung was removed with

33'=> OPERATIONS ON THE CHEST

the aid of clamps and ligatures. During the after-treatment the patient could
breathe freely and comfortably through the wound when his mouth and nose
were closed. Healing was completed in nine months. Nine years after opera-
tion the scar is on a level with the skin; and in spite of the extensive resection of
ribs there is neither deformity of the thorax nor spine. The diaphragm has
pushed upwards and the upper lobe of the lung is vicariously expanded.
In pneumectomy closure of the divided bronchi is always a difBculty. Willy
Meyer has overcome this difficulty by separating the peribronchial vessels from
the bronchi and ligating them, then by crushing the stiff bronchi with an angio-
tribe he is able to treat it by ligature and inversion sutures like the stump in
appendectomy.

Extrapleural Resection of Lung fTuffier, International Congress, London,
1913). — Suitable in cases of apical tuberculosis. •

Open the thorax widely in the second intercostal space but do not incise
the pleura. Separate the 2nd and 3rd ribs with suitable retractors or spreaders.

With the finger gently separate the parietal pleura from the chest wall until
the whole apex of the lung plus the corresponding parietal pleura, is freed.

Ligate the lung beyond the disease and cut away the affected apex. Let
the stump drop back into the thorax. Close the chest without drainage.

EXPOSURE OF THE PERICARDIUM AND OF THE HEART

Operations on the Orifices of the Heart. — The investigations of Carrel and
his disciples have achieved so much that no great boldness is required to proph-
esy that the surgeon will, before long, aid in the therapeutics of certain lesions
of the cardiac orifices. The following paragraphs are based on the publications
of Carrel and'Tufl&er (Annals Surg., July, 1914; La Presse Med. 4, March, 1914).
The lesions which ought to be susceptible to surgical aid are:

1. Mitral stenoses. In these the free borders of the valves are alone affected,
the valves themselves, the cardiac muscle and the peripheral circulation remain-
ing for a long time in good condition.

2. Aortic stenoses may occupy three positions, viz., valvular, supra-aortic
and infra-aortic; of these only the valvular are likely to be amenable to surgical
intervention. Valvular lesions are characterized by adhesions, thickenings and
deformations of the borders of the valves, forming a simple indurated ring.
Exceptionally the lesion affects the fibrous circle at the base of the valves.

3. Stenoses of the pulmonary artery are similar to those of the aorta, but the
artery itself is dilated above the stenosis, this being due to a loss of elasticity in its
walls.

4. Congenital tricuspid stenoses show similar characteristics and are pecu-
liarly suited to operative treatment because of the integrity of the heart.

Although an orificial lesion is anatomically suitable for operation, and
although the cardiac muscle and vessels are sufficiently healthy to give hope of
success, yet operation is not justifiable unless the disease by its persistence and
progressiveness inevitably will early give rise to grave or mortal troubles. Such
indications for operative treatment are rare.

A pure mitral stenosis in a young subject with a healthy heart, in which the
trouble is progressive as shown by functional symptoms, and which will cer-

OPERATIONS ON HEART 33 1

tainly be fatal, is a proper case for operation. Some slowly advancing aortic
stenoses with hypertrophy of the left ventricle may also be considered mechani-
cal lesions susceptible of treatment by enlargement of the orifice.

Stenoses of the pulmonary artery when isolated and independent of any other
cardiac malformation are almost always soon fatal from pulmonary tuberculosis.
It is not likely that lesions causing insufficiency of the cardiac orifices will be
suitable for operation.

Special Dangers in Cardiac Operations. — (o) Injury to the coronary vessels.

The coronary vein may be tied with impunity but not near its main trunk.

Injuries to the peripheral parts of the coronary arteries are well borne.
Near the origin of the arteries even a prick with the finest needle gives rise to
serious symptoms. Ligation of the artery proximal to its bifurcation is always
promptly fatal.

{h) The only bleeding which is difficult to arrest is that from the left auricle.
This is due to the thinness and friability of its walls.

(c) The entry of air into the right ventricle with consequent pulmonary
"air embolism" is not of the gravest moment, but its entry into the left ventri-
cle leads to fatal embolism in the coronary arteries. Air in the heart is removed
by aspiration. '

{d) The danger zones of the heart are:

1. The coronary vessels between their origin and their first divisions must
not be touched.

2. The inter-auricular septum is so sensitive that the least injury to it causes
arrest of the heart in diastole.

3. Section of the auriculo-ventricular septum causes immediate arrest of the
left ventricle in diastole. In the auriculo-ventricular region near the left border
of the heart there is a sort of vital node, injury to which is dangerous or mortal,
even a slight pressure here excites an extrasystole.

4. At the junction of the middle and upper thirds of the anterior longitudinal
groove there is a point at which mechanical irritation can cause sudden arrest of
the heart.

5. The motor stimulus of the heart originates at the base of the right auricle
near the venous orifices. This is a very dangerous zone.

For cardiac operations, anaesthesia is produced with ether given by the
Meltzer-Auer method. The thoracic cavity is opened, the operative field is
walled off with "oil silk and cotton knotted compresses," the pericardium is
opened and the heart exposed. A Doyen forceps (jaws protected by rubber
tubing) is used to compress the pedicle of the heart. The heart is not dislocated
but the pericardial wound must be large enough to give free access. One blade
of the clamp is introduced into the pericardium under the pedicle and directed
from the right to the left side by the finger. At this moment (without any
compression) over-ventilate the blood by the Meltzer-Auer method and then
rapidly close the clamp and without a moment's delay proceed with the
operation. The pedicle may be clamped for two and a half (2^) or three (3)
minutes with safety.

Exposure of the Aortic and Pulmonary Orifices. — For the pulmonary orifice
make the incision on the left side of the artery at the junction of the anterior and

332 OPERATIONS ON THE CHEST

left sigmoid valves. The incision is made by means of scissors of unequal
blades, the longer blade being pointed. With this the vessel is punctured before
the cut is made. Exposure may be efifected by a cut in the artery alone; usually
in experiments the incision was about 4 cm. long, half of which was on the pul-
monary artery and half on the ventricle. Here the branches of the coronary
artery are small and can be cut without danger.

For the aortic valves make the incision on the right side of the aorta be-
tween the mouths of the right and left coronary arteries, generally directly
above the middle of the right valve.

When the operation has been completed, suture the wound with a continu-
ous suture of No. i Chinese silk sterilized in vaseline. Introduce through the
line of suture a curved cannula connected with an aspirator and suck out the
air from the heart. Remove the pedicle clamp.

What operations may be performed on the valves? Carrel has cauterized
the valves and has dilated the orifices with the finger. TuflSer performed this
operation on a patient with amelioration of symptoms. Sir Lauder Brunton,
Harvey Cushing and others have divided valves by special long delicate teno-
tome-like instruments introduced at a distance. Tuffier remarks: "if one
divides the valvular diaphragm without resecting a portion of it, it is necessary
to fix one of the lateral valves to the ventricular wall with a silk suture in order
to prevent coalescence and secondary reunion of their borders." Such opera-
tions may be named internal valvulotomy. External valvulotomy with patch-
ing of the vessel is being done very successfully in animals without clamping the
pedicle of the heart.

Carrel thus describes the operation: "A piece of vena cava or of any other
vein, preserved in cold storage, was cut into the shape of a rectangular flap about
2.5 by 2 cm. This flap was put on the anterior part of the pulmonary artery
in such a way that its middle corresponded about to the pulmonary orifice, the
lower part being on the surface of the ventricular wall. Then the two lateral
sides and the upper side were fixed to the surface of the heart and the pulmonary
artery by means of a continuous suture. The longer blade of the scissors was
introduced underneath the lower side of the flap and the sharp point was intro-
duced into the lumen of the pulmonary orifice. Then the wall was cut and dark
blood escaped between the surface of the heart and the lower part of the flap,
but the hemorrhage was immediately controlled by the index-finger of the opera-
tor which compressed the flap down on the wound. The fourth side of the flap
was next fixed to the surface of the heart by a continuous suture. The flap
immediately appeared distended by dark blood, and it was assumed that in case
of stenosis of the pulmonary orifice this operation would permit of a dilatation of
that orifice. The operation was performed without stopping the circulation
of the heart. The operation would be rendered easier by clamping the pedicle
of the heart for a very short time. Although this is a more dangerous procedure,
it is probable that it would simplify the operation." In their experiments on
dogs Carrel and Tuffier opened the thorax by an incision from the sternum
(internal mammary vessels ligated and divided) to the posterior part of the
axilla, in the second or third intercostal space. The second space was chosen
when access to the great vessels was desired.

OPERATIONS ON HEART 333

It is not necessary to resect any ribs. The pleura is incised and the ribs
separated by a mechanical self-retaining retractor. Once pneumothorax is
established respiration by means of the Meltzer-Auer apparatus is easy. The
pleura is protected by compresses of fine vaselinized silk.

H. M. W. Gray (Birkbeck and Lorimer, Brit. Med. J., Oct., 1915) has
removed a bullet from the cavity of the right ventricle. The patient died
four days after operation from multiple pulmonary infarction. The operation
was performed under morphine and local anaesthesia (eucaine i per cent.; potas-
sium sulph. 3-^ per cent.; adrenalin). The pericardium was widely exposed by
reflecting a large flap of sternum and costal cartilages. The right pleura was
opened and the lung collapsed causing respiratory trouble and anxiety for
about one minute. The pericardium was freely opened. During palpation
of the heart a beat was missed occasionally when the upper and back part
of the interventricular septum was touched. The heart was held forwards by
a stitch passed through the muscle of the right ventricle. Palpation showing the
bullet to be loose in the ventricle it was coaxed away from the neighborhood
of the coronary vessels and grasped between the finger and thumb. Two
stitches were inserted into the muscle wall over the bullet, a half inch incision
made and the bullet extracted. The sutures were tied and an extra running
stitch applied. The pericardial cavity was freed of blood clot, filled with
saline solution to expel air, and sutured. The right pleural cavity was filled
with saline solution and the pleural wound sutured. While the wound was
being closed the chest was aspirated.

Scalene (Ref. Internat. Abstract of Surg., June, 191 9, 471). — As a result of
experiments comes to the following conclusions:

"A projectile remaining in any part of the heart affects its functioning even
if the patient does not feel any disturbance.

"Extraction does not in all cases lead to recovery from the disturbances,
especially when anatomic alterations have taken place.

"From the operative point of view it is necessary to distinguish projectiles
embedded in the myocardium from those free in the heart cavities. Projectiles
in the myocardium which do not cause disturbances ought to be left alone.
Operation might increase the anatomic alterations due to the projectile, the
result being a diffuse myocarditis, a lesion of the nerves or the production of
adhesions.

"Extraction is indicated in the case of projectiles in the myocardium which
cause disturbances not referable to anatomic alterations but to severe nerve
lesions not otherwise susceptible to treatment.

"In view of the danger of embolus, extraction is indicated in the case of
projectiles free in the circulatory system.

"In every case the advantages of a cardiotomy ought to be carefully weighed
against the dangers and results to be derived from non-intervention."

Statistics of 16 cases of projectiles in the heart wall treated surgically give
14 recoveries and 2 deaths while 23 cases in which no operation was performed
all recovered. In spite of these figures Duval considers that the ultimate dan-
gers arising from the presence of a projectile in the wall of the heart justifies its
removal (Soc. de Chir., Paris, 1919).

334 OPERATIONS ON THE CHEST

Pericardiocentesis. — This operation is indicated both as a means of diag-
nosis and of treatment. For diagnostic purposes we may use an exploring
or hypodermic syringe provided with a long needle; for purposes of treatment
an aspirator is required. When the pericardial effusion is non-infective, a cure
may be obtained by simple paracentesis. In performing this operation, the
fluid must be withdrawn slowly and the suction stopped, temporarily, whenever
there is any pulmonary or cardiac distress. It is unnecessary and imprudent
completely to evacuate the fluid. The usual site for introducing the aspirat-
ing needle is in the fourth or fifth intercostal space, one inch to the left of the
sternum. A better position is in the sixth intercostal space immediately to
the left of the edge of the sternum. This last position gives the greatest se-
curity against injury to the internal mammary artery, to the pleura, and to
the heart itself.

G. Blechman (Internat. Abstracts, July, 1914) disapproves of the above
methods as being likely to puncture the heart or pleura. He recommends Mar-
fan's method. Introduce a lumbar puncture needle in the middle line immedi-
ately below the xiphoid cartilage. Pass the needle obliquely from below upward
for 2 cm. along the posterior surface of the sternum, then somewhat obliquely
backwards passing into the gap in the sternal insertion of the diaphragm so as to
penetrate the pericardium at its base. Blechman used this method successfully
seventeen times on one patient.

In cases of pericarditis with effusion, even suppurative, Weil and Loiseleur
(La Pr. Med., Dec. 28, 1916) recommend aspiration of the fluid and injection,
of air equal in amount to the volume of fluid withdrawn. Repeated aspirations
and injections may be necessary, and may be aided in their execution by the use
of the fluoroscope to detect isolated pockets of effusion. When producing
pleural pneumothorax, one can well introduce the air at the same time that
any present effusion is being aspirated but in producing pericardial pneumo-
thorax one is compelled to aspirate first and then pump the air in. Weil and
Loiseleur write "one injects ordinary atmospheric air without any special fil-
tration After having removed the liquid with Potain's aspirator, one re-
verses the stop-cock on the pump and so can inject air. ... To measure
the quantity of air being injected one counts the number of strokes of the piston.
(The capacity of the pump is about 30 c.c.)"

When there is an infective exudate in the pericardium, operation is clearly
indicated. The. same is true in all cases of wounds in the cardiac region when
there is marked respiratory distress with cyanosis or there is collapse with
anaemia and corresponding changes in the pulse, accompanied by the physical
signs of pericardiac effusion (Kocher).

Many methods have been devised by which to expose the pericardium and
heart: of these. Ware gives an excellent account in the "Annals of Surgery"
(October, 1899), but almost all of them, e.g., those of Po^rez, Niuni, etc.,
assume that one desires to expose the whole pericardial sac in every case and
that a lesser procedure will never be efl5cient. Such operations consist in the
formation and reflection of large flaps consisting of the skin, muscles, costal
cartilages, and sternum. They require much technical skill for their perform-
ance. Wounds of the pericardium and heart call for immediate attention, and

PERICARDIOTOMY 335

no extremely difficult and unnecessarily complicated method should be
taught.

Pericardiotomy. Method A. — (i) Make an incision down to the bone from
the middle line of the sternum outwards towards the left side, at the level and
following the line of the sixth costal cartilage. If required, the incision may
extend to the left mammary line. (2) Separate the perichondrium and all the
soft parts from the sixth costal cartilage and excise the cartilage. This exposes
the triangular muscle of the sternum with the mammary vessels, which are
ligated if necessary. Divide the tendinous insertion of the triangular muscle
into the sternum. The dense, glistening pericardium now lies exposed, and if
drainage alone is required, it may be opened and the operation is complete. If
more room is required: (3) From the sternal end of the horizontal incision cut
upwards in the midsternal line to the desired extent (usually to the level of
the second rib). (4) Separate the periosteum and soft structures from the
sternum to the left of the median line. Divide the fifth, fourth, and third left
costal cartilages at their insertions into the sternum. (5) Through the hori-
zontal wound push the exposed margin of pleura outwards. Gradually lift up
the fifth and even the fourth and third costal cartilages, slowly and gently push-
ing back the pleura from their deep surface. (6) After separating the flap from
the pleura, fracture or divide the costal cartilages in the flap, at their junction
with the corresponding ribs. When this is done, the flap can be completely
reflected. (7) Split the pericardium along the sternal margin and laterally
along the fifth interspace. This gives access to the heart from the auricles to
the apex of the ventricles. If more room is desired (8) excise a sufficient por-
tion of the sternum by means of ronguer or bone forceps.

The pericardium being open, wipe away blood-clots which may be present;
search for and suture with catgut or silk any cardiac wounds. Do not include
in the suture a coronary artery. Close the pericardial wound with or without
drainage. Suture or drain any pleural wounds which may be present. Don't
waste time by trying to evacuate thoroughly blood from the pleural cavity;
nature may generally be relied upon to attend to that better than can the
surgeon.

Method B. Median Thoraco-abdominal Pericardiotomy . — Duval and Barasto
(La Pr. Med., Aug. 29, 1919).

^tep I. — ^Make a median incision from the level of the third rib to a point
midway between the ensiform cartilage and the umbilicus. The incision pene-
trates to the bone and to, but not through the peritoneum, in the linea alba.

Step 2. — With a knife detach the recti-muscles from the ensiform. Divide
the attachments of the diaphragm to the posterior surface of the ensiform ex-
actly in the middle line. Push two fingers upwards behind the ensiform keeping
them in contact with the posterior surface of the bone until the level of the
third rib is reached. This separates the pericardium from the sternum. When
pulling the fingers out separate them slightly so as to push the two pleurae from
the sternum and costal cartilages.

Step 3. — Divide the sternum along the middle line with strong bone forceps
up to the level of the third rib. Opposite the third rib divide the sternum
transversely. Separate the two parts of the sternum with strong hooks.

336 OPERATIONS ON THE CHEST

Step 4. — Open the peritoneum in the middle Une. Open the pericardium
immediately above the diaphragm and a little to the left (the pleurae arc well
separated here).

Step. 5. — Note the diaphragm forming a partition between the peritoneum
and pericardium. Divide this partition up to the coronar>' ligament. While
doing this gently support the inferior border of the heart. With the hooks
lift up the two segments of the sternum. This is like opening a book and the
ventricles, auricles, large vessels and the anterior and posterior surfaces of the
heart are widely exposed without delivery of this organ, without traction or
torsion and the two hands of the operator are free to carry out any necessary
maneuvres on the heart under guidance of the eye.

Step 6. — Suture the diaphragm from the abdominal side. Close the ab-
domen. Replace the sternal flaps unthout bone suture. Suture the skin. This
operation has been used in the successful extraction of a bullet from the peri-
cardial segment of the inferior vena cava. Barbier and Goujon (Ref. Internat.
Abst. of Surg., June, 191 9) successfully extracted a projectile from the posterior
wall of the heart midway between apex and base by the thoraco-abdominal
route.

TuUy Vaughan ("Journ. A. M. A.," Feb. 6, 1909) has collected statistics
of 150 patients operated on for wounds of the heart and comes to the following
conclusions:

"i. There is no longer any question as to the propriety of the operation,
since 35 per cent, of the patients recover, compared with 15 per cent, (according
to Holmes and Fisher, 1881) of recoveries after non-operative treatment — a
gain of 20 per cent.

" 2. The mortality is practically the same that it was twelve years ago, when
the operation was first introduced, and it behooves the surgeon to study the
matter and find a means of improvement.

"3. The two great causes of death are hemorrhage and inflammation of the
pleura or pericardium. Probably little more can be done than has been done
to prevent death from hemorrhage, but inasmuch as more than half the pa-
tients who survive twenty hours have infection.

"4. There is room for great improvement in preventing infection. Besides
the observance of strict asepsis the question of opening the pleura and of drain-
age of pleura or pericardium acting as predisposing cause of infection is of "the
greatest importance.

"5. As a rule, therefore, the pericardium and pleura should not be drained."
The principles of operation on pericardiac and cardiac wounds may be
summarized as follows: (i) Cleanse. (2) Enlarge the external wound. (3)
Freely expose the injured pericardium by excision of portions of the ribs and
sternum or by the median thoraco-abdominal route. (4) Attend to
hemostasis. (5) Open the pericardium and remove effused blood. (6) Attend
to cardiac wounds if present. (7) Close the wounds in pericardium and in
pleura if such be ptesent. (8) Close external wound with or preferably without
drainage.

In suppurative pericarditis Mintz's operation seems very practical and not
difl5cult ("Zent. fur Chir.," No. 30, 1912). Make an incision along the lower

CARDIOLYSIS 337

edge of the seventh costal cartilage. Separate the lower edge of the cartilage
from its connections but do not open the peritoneum. With a periosteal
elevator separate the cartilage from its posterior connections. Divide the
cartilage near the sternum and also at a suitable point externally. The anterior
surface of the cartilage is not denuded. Reflect upwards the flap thus formed
and so expose the pericardium. Blechman recommends Larrey's method of
left subchondral incision as giving easy access to the pericardium through the
epigastrium especially in children. This operation seems practically the same
as Mintz's.

Cardiolysis or Pericardiolysis. — When the heart becomes adherent firmly
to its pericardial pouch, and that in turn to the sternum, etc., a distressing and
very fatal series of conditions arise. In such cases the heart fails, because with
every systole it must needs pull in along with it the osseous thoracic wall. No
heart can long stand the strain of such excessive overwork. Two methods of
operative treatment have been advised.

Delorme's Operation.— (A) The operation is particularly indicated (a) when
there are adhesions of rheumatic origin with dilatation, hypertrophy and ori-
ficial lesions and a fortiori without such lesions, (b) When there are tuber-
culous adhesions specially as localized lesions, analogous to those of the other
serous cavities, joints, etc. (Delorme).

The Operation. — Expose the pericardium by excising the fifth or sixth costal
cartilage from the sternal insertion outwards for from 6 to 8 cm. If the adhe-
sions correspond to the origin of the great vessels, excise like portions of the
fourth and third cartilages. So far the operation is exploratory. If the ad-
hesions are solid, extensive but separable, reflect a flap of thoracic wall corre-
sponding to the fourth, fifth, and sixth cartilages and having its base external.
Great care is required to avoid opening the pleura. The parietal pericardium
having been exposed incise it through the whole length exposed. Separate the
adhesions with the fingers or blunt pointed scissors. Do any cutting necessary
at the expense of the pericardium and under guidance of the eye. Leave in-
accessible and very resistant adhesions alone. If the adhesions are too intimate
for separation be content with section of the pericardium along its anterior
diaphragmatic attachments from the left sternal border to the apex of the
heart avoiding in'ury to the left phrenic nerve.

(B) Pericardiolysis. — Petersen and Simon have successfully (three cases)
carried out an operation suggested by L. Brauer. The object of the operation
is not to free the heart from the adhesions, but to render these harmless. It is
unnecessary to describe the steps of the procedure, which consist in the reflec-
tion of a flap of skin and muscle, the exposure of those ribs and that part of the
sternum which impede, by their rigidity, the heart's action, and the excision of
these bony or cartilaginous structures to any extent required. It is advised to
excise the periosteum of the posterior surface of the sternum, lest new bone be
formed. This is the most difiicult step in the operation. Very careful hemo-
stasis is essential, because, when operated on, the patient is usually very weak,
but his circulation soon regains strength, and hence hemorrhage and the forma-
tion of a hematoma may supervene. Petersen advises that we should begin

$$S OPERATIONS ON THE CHEST

the operation by excising three ribs, and then, if necessary, remove a portion of
the sternum also.

P. Lecene ("Archives des mal. du Coeur, des Vaisseaux et du Sang.,"
Dec, 1909; "La Presse Med.," April 23, 1910) has collected twenty cases
of pericardiolysis performed by various German and English surgeons where
there was no operative mortality and the results were notable and durable.
After operation the heart became regular, dyspnoea ceased and the various
forms of visceral stasis gradually became less, suffering disappeared and a
relatively active life became possible.

Alexander Morison ("Lancet," July 4, 1908 and Nov. 20, 1909) advised
thoracostomy (pericardiolysis) in a case of excessive cardiac hypertrophy in
aortic valvular disease associated with severe and frequent attacks of pain but
with >io costo-pericardial adhesions. Mr. Stabb operated for Morison and the
results was most satisfactory. The reasoning of Morison in his paper is most
convincing. (See Douay's remarks, p. 322.)

Milton's Method of Exposing the Anterior Mediastinum (H. Milton,
Lancet, ]March 27, 1897). — Make a median incision from the cricoid to the
ensiform. Expose the trachea. Carefully divide all the attachments to the
sternal notch — while doing this make the knife absolutely hug the bone. If
necessary nick the sternal attachments of the sternomastoids. Pass the
finger gently behind the sternum from above downwards as far as possible.
Either beginning at the sternal notch or at a trephine opening made through
the body of the sternum near the ensiform cartilage split the sternum vertically
with chisel or saw or both. Separate the ensiform from the body of the sternum.
With strong sharp hooks separate the two halves of the sternum for about i
cm. This space permits the division, under guidance of the eye, of obstruc-
tions to a further separation of 5 or 6 cm. This permits free exploration of
the anterior mediastinum and through it of the other mediastina. The bone
wound is easily closed by wires passed through holes bored in the bone.

Lilienthal (Surg., Gyn. & Obst.) successfully removed a mediastinal thyroid
by Milton's method.

In performing Milton's operation it is not always necessary or proper to
divide the whole of the sternum; division of the manubrium is often sufficient.

Milton's method will prove of service in operations upon the thymus.
Kocher exposes the upper mediastinum by reflecting outwards a trap door
flap consisting of skin and manubrium sterni.

Exposure of cervico-mediastinal space may be necessary in the treatment
of lesions of the lower neck behind the clavicle or of the upper anterior medias-
tinum. Such lesions include aneurisms of the great vessels arising from the
arch of the aorta.

Le Fort's Method. Anatomy. — The clavicle articulates with the sternum
and first rib. The sterno-hyoid and sternothyroid muscles are inserted into
the posterior surface of the clavicle, sternum, costo-clavicular ligament, cartilage
of the first and even of the second rib. Thus there is a thick buttress of muscle
and aponeurosis between the bones and the vessels, nerves and pleurae.

The Operation. — Place patient in the dorsal decubitus with a long pillow
between the scapulae to make the shoulders fall backwards.

MEDIASTINUM 339

Step I. — From the level of the first intercostal space make an incision
10-12 cm. (4-4/^ in.) long, upwards in the median line. This incision pene-
trates to the bone where it is over the sternum, and through the skin higher up.
From the lower end of the vertical incision make a cut outwards along the
middle of the first intercostal space until the deltoid is reached. Split the
pectoralis major and expose the intercostal muscles.

Step 2. — Expose the anterior surface of the sterno-mastoid. With finger
or closed scissors separate the posterior surface of tjie sterno-mastoid from the
anterior surface of the sterno-hyoid and sterno-thyroid, thus exposing the in-
sertion of these latter muscles into the posterior surface of the sternum and
sterno-costo-clavicular articulation. Hugging the bone divide these insertions
as well as the insertion of the deep cervical fascia. This is the only delicate
step in the operation and a strongly curved rugine is a great aid in effecting it.
Continue the separation of the soft parts downwards and outwards from the
posterior surfaces of the sternum, the inner end of the clavicle and the first
costal cartilage until the finger reaches the posterior surface of the first inter-
costal space.

Step 3. — With the fingers raise the tissues in the supra-sternal space and
divide them. This means division of the anastomosis of the anterior jugular
veins which is of little importance and they are the only vessels sacrificed during
the operation.

Divide the upper part of the manubrium sterni on the middle line down to
the level of the first intercostal space. Bone cutting forceps are suitable for
this purpose.

Step 4. — ^Thoroughly clear the inner portion of the first intercostal space
both on its anterior and posterior surfaces. With a rugine or elevator free the
border of the sternum between the first and second ribs until the blade of a
bone cutting forceps can be insinuated behind the sternum without injury to
the internal mammary vessels. Divide the sternum horizontally until the
vertical line of section is met.

Step 5. — Raise the mobilized segment of sternum along with the clavicle
and first rib and continue the separation of the soft parts posteriorly. As the
flap is raised divide the muscles of the first intercostal space bit by bit to a
point near the axillary vein.

The flap can now be retracted or reflected upwards and outwards without
impeding the subclavian or axillary vessels and without injury to the internal
mammary vessels.

The large vessels of the neck and the mediastinal organs are hidden by the
infrahyoid muscles, the cervical fascia, the remnants of the thymus, much con-
nective tissue and the pleura. The trunk of the innominate vein is recognizable.
Further exposure of vessels and organs may be secured through the cervical or
the mediastinal route in the latter with or without opening pleura.

(a) Cervical Route. — Incise the deep fascia along the external border of the
sterno-hyoid. This gives easy access to the deep planes and vessels of the neck.
Remember that the fascia is inserted into the innominate vein and avoid
injuring that vessel.

{h) Extra-plenral Mediastinal Route. — Penetrate the connective tissue and

340

OPERATIONS ON THE CHEST

retract the pleura. It is easy to expose the origin of the carotids, subclavians,
innominates, the vagus, convexity of the arch of the aorta, the recurrent lar}Ti-
geals, trachea and oesophagus.

(c) Transpleural Route. — Open the pleura at the first intercostal space.
Especially on the left side it is very easy to reach the origin of the great vessels
which are clearly visible through the parietal pleura. This route has the ad-
vantage of avoiding exposure of the vagus, cardiac and phrenic nerves.

Step 6. — Replace the flap. Suture of the bone is optional. Suture the
intercostal space, the pectoralis major and the fascia. Close the wound.

R. Le P'ort (Rev. de Chir., LIII, No. 5 and 6, 191 7) has studied the best
methods for the removal of foreign bodies in the mediastinum and finds the
anterior transpleural route the best both for the anterior and the posterior
mediastinum.

Fig. 436. — (Schwartz.)

If the foreign body is deeply situated at the level of the third rib posterior
to the sternal border, maximal excision of the third rib with maximal retraction
by means of rib spreaders gives a wound 16 cm. long by 8 cm. wide, i.e., an area
of 85 cm.^ While a flap containing the 3-4-5 ribs can be made with its upper
border 16 cm. long, lower 20 cm., inner 1 1 cm., i.e., an area of 198 cm.* is exposed.

In the lower chest the best exposure is given by means of a flap (Delorme's).
Wide access may be obtained to both surfaces of the heart, to the aorta (ascend-
ing, transverse, descending) from its origin to the diaphragm, to the pulmonary
vessels, the trachea and the oesophagus, in a word, to the whole mediastinum
from clavicle to diaphragm and from the sternum to the spine, between the
third and twelfth dorsal vertebrae.

The exposure is made as follows:

Choose the appropriate ribs to be mobilized.

At the points A, B, C, D on the chosen ribs divide the bones subperiosteally
(Fig. 436) (Chir. du Thorax, Schwartz). Trace the flap XVZW. Open the
pleura along the lines XY and WZ. Divide the ribs, intercostal structyres

MEDIASTINUM

and pleura along the line YZ. Reflect the flap outwards,
thoracic operation is finished, replace the flap and suture.

341
When the intra-

OPERATIONS ON THE POSTERIOR MEDIASTINUM*

As the type of operations on the posterior mediastinum, one may take
that of Nassilov, a description of which was published in 1888 and in 1899 by
Stoyanov. The following description closely follows that of Nassilov: Place
the patient in the ventral or semiventral position. Make an incision at least
three inches in length along a line parallel to the vertebral column, and four
finger-breadths from it. From each end of the vertical cut make a horizontal
incision towards the spine. Reflect towards the spine the musculo-cutaneous
flap thus delimited. Resect the exposed portions of ribs subperiosteally. This
requires great care because of the danger of puncturing the pleura. Should

Fig. 437. — {Schwartz.)

any pleural wound be inflicted, suture it immediately. The ribs should be
resected close to the spine, as this gives most valuable room. The superior
portion of the oesophagus (above the arch of the aorta— Bryant) is accessible
after excision of portions of the third, fourth, fifth and sixth ribs on the
left side; the inferior portion after resection of three or more of the lower ribs on
the right side. Attend to hemostasis. Carefully separate with the fingers the
posterior portion of the pleura from the remnants of the excised ribs attached
to the spine. When operating on the left side, push the lung forwards with
the palm of the hand and fingers; this exposes the thoracic aorta, to the right
of which lies the oesophagus. The oesophagus may be recognized by palpation,
and if necessary by a sound being passed into it from the mouth. By blunt
dissection with a grooved director separate the loose cellular tissue which en-
compasses the aorta, the large and small azygos veins, the pneumogastric
nerves, and the thoracic duct. The oesophagus is now disengaged from its
surroundings.

The accompanying figure 437 shows something of the anatomical diffi-
*See also section on posterior bronchotomy, p. 1244, and Le Fort's method, p. 340.

342 OPERATIONS ON THE CHEST

culties of the operation if the first rib is not divided. Resection of the first
rib permits much greater exposure of the mediastinum.

If the operation is for the removal of a foreign body from the thoracic gullet,
the oesophageal wall is caught with two forceps and divided between them
over the body, which is removed with forceps. The oesophageal wound may
or may not be sutured; certainly free drainage of the wounded posterior medi-
astinum is a necessity. Small, apparently localized, cancers of the oesophagus
may possibly be excised after exposure in the above manner. Inflammatory
lesions of the posterior mediastinum may be exposed by Nassilov's operation
and subjected to proper surgical treatment.

PART III.-THE ABDOMEN

CHAPTER XXXII

LAPAROTOMY ; CELIOTOMY ; ABDOMINAL SECTION

POSITION OF PATIENT DURING OPERATION

For most laparotomies the dorsal decubitus is used. When a patient lies
on his back on an operating table there is always a strain exercised on the lumbo-
sacral region, which strain subsequently manifests itself by greater or less pain
in the back. This is avoided by supporting the small of the back by a small
pillow, or better by so arranging the table that the thighs are slightly flexed on the
pelvis and the knees moderately bent. This latter posture is particularly valu-
able in that it relaxes the abdomen and decreases intra-abdominal pressure. On
a properly constructed table it does not interfere with obtaining the Trendelen-
burg posture and, according to Emmet Rixford, it does away with the necessity
of adopting the Robson position in operations upon the biliary passages.
Rixford has devised a table which enables the upper trunk to be slightly elevated
thus increasing the benefit to be obtained from flexing the lower extremities.

During operations on the lower abdomen good exposure of the operative
field may be obtained by elevating the lower end of the table, preferably with
simultaneous slight flexion at the hips and knees (Trendelenburg's position).
An inclination of 45° may be used.

When Trendelenburg's position is used the patient should be prevented
from sliding along the inclined table by means of shoulder braces and never
by letting the knees be flexed over the foot end of the table, which increases
intra-abdominal pressure objectionably.

During operations in the region of the gall-bladder the intestines may be
kept out of the way by placing a sand-bag about five inches in diameter under
the back, opposite the lower dorsal vertebrae. (Robson's position.)

METHODS OF OPENING THE ABDOMEN

The patient, anesthetized, is placed on the operating table. The limbs and
chest are well protected with blankets. The operating-room and table are well
heated. The field of operation is cleansed and surrounded by sterile cloths
or towels. A good incision must (a) give proper access to the disease to be
investigated and treated and ought to be capable of any necessary enlargement;
(ft) be capable of easy and efficient closure with the least possible danger of
subsequent hernia or paralysis.

A longitudinal incision in the linea alba is classical, is easily enlarged and
injures no important vessels and nerves. Unfortunately hernia is a frequent

343

344

laparotomy; celiotomy; abdominal section

sequel as only thin layers of aponeurosis can be coapted. To avoid this
objection tlic cut is usually made slightly to one side of the linea alba, the
sheath of the rectus is opened, the muscle either split or pulled aside and the
tissues behind are cut. A longitudinal cut above the umbilicus is difficult to
close because of tension. The fibres of the transversalis muscle are continued
internal to the outer edge of the rectus and acting through the posterior sheath
of the rectus makes suture of this structure very difficult and insecure.

— _iir+

hypo^dstric

Fig. 438. — {Fannctt. By permission of the British Journal of Surgery.)

Vertical incisions through the rectus or at its outer margin destroy its nerve
supply to a greater or less extent and ought to produce an objectionable paral-
ysis of that muscle. Practically one finds few cases of serious paralytic lesions
following the long vertical wounds so commonly used in surgery of the gall-
bladder and appendix, but when they do occur the surgeon wishes he had spared
the nerves. For certain pieces of intra-abdominal work incisions like that
of Mc Arthur and McBurney for appendectomy are ideal as in them the different

INCISIONS

345

layers of flat muscles and aponeuroses are split one after the other in the direc-
tion of their fibres and the nerves are not cut.

When one remembers that the aponeuroses of the abdominal wall are the
tendons of the flat muscles (oblique and transverse), and that these are inserted
into their fellows on the opposite side, one must realize that a so-called longi-
tudinal incision is physiologically transverse, in that it cuts the aponeuroses
(tendons) more or less transversely. This applies particularly to division of
the rectus sheath but not to that of the recti muscles. Transverse division
of the rectus muscle particularly
above the umbilicus does not seem
to weaken the muscle greatly, it
rather merely adds a new inscriptio
tendinecB. The so-called transverse
incisions of the abdominal wall are
usually more or less oblique or curved
so as to run parallel to the course of
the nerves (Fig. 438). The addi-
tion of a short vertical cut in the
middle line is often useful and does
not materially add to the difficulty
of closure.

In the lower abdomen an incision
after the plan of Pfannenstiel is often
very useful in gaining access to the
pelvis. A curved transverse incision
(convexity downwards) divides the
skin and aponeurosis; the aponeuro-
sis is dissected from the recti and
retracted upwards and downwards,
the recti are separated and the peri-
toneum is opened. Closure is easy
and very secure. (For articles on
transverse incisions, see Kocher
Operationslehre; Rockey, N. Y. Med.
Rec, Nov. 4, 1905; Maylard, Brit. Med. J., ii, 1907; Assmy. Beitr. z. klin. Chir.,
xxiii; E. Boeckmann, St. Paul Med. J., June, 1910; Sprengel, Archiv f. klin.
Chir., xcii; Fritz Konig, Zent. F. Chir., April 20, 1912; Farr., Journ. Lancet,
Nov. I, 1912; C. A. Pannett, Trans. Surg. Sect. R. Soc, Med., Oct. 14, 1914.)

(A) Median Incisions. — In the middle line, either above or below the
umbilicus, make an incision through the skin and subcutaneous tissues. The
length of the incision varies according to circumstances, but to begin with is
usually about three inches. In the linea alba divide the firm structures con-
stituting the essential belly- wall. As a rule, hemorrhage will be trifling and
may be disregarded, but if any vessels bleed amazingly, apply clamps or liga-
tures before opening the peritoneum. Pick up a small fold of peritoneum in
forceps and cautiously make a very small incision through it. When satisfied
that the peritoneum is opened, catch each side of the peritoneal wound in a

SKIN
.ANT.FASIA.

RECTI.
POST FASCIA
is-PERITONEUM.

Fig. 441.
Figs. 439, 440 and 441. — Chevrier's incision.

346 laparotomy; celiotomy; abdominal section

hemostat and by crossing the forceps, temporarily, close the belly until the hands
can be once more rinsed, first in an antiseptic solution and then in water or
salt solution. Enlarge the peritoneal wound; introduce the finger to explore.
Enlarge the incision with scissors, if such enlargement be necessary to permit
of further operative procedures.

If it be necessary to enlarge the incision beyond the umbilicus, cut around
that structure generally to its left side, or even excise it, since it is not suitable
for suturing and it is impossible thoroughly to cleanse it.

(B) Chevrier's Incision.— Incise the skin in the middle line and expose
the anterior layer of the rectus sheath. Reflect the skin to one side so as to
lay bare the fascia for distance of 3-^ to ^4: inch from the middle line. Incise
the fascia about 3'^ inch from the middle line and reflect the fascial flap A,
B, C, D, the pedicle of which corresponds to the middle line (Fig. 439).
Reflect the flap a little beyond the middle line so as to expose the median
border and a little of the opposite rectus muscle.

Retract the rectus so as to expose the posterior layer of the rectus sheath.
Incise the sheath. In closing the wound proceed as follows: Suture the wound
in the posterior layer of the sheath. In order to keep this line of suture from
sliding towards the middle line, introduce at each end the sutures XX' and
YY' which penetrate the anterior layer of tne sheath, the rectus muscle and the
upper and lower ends of the sutured wound. Tie sutures XX' and Y Y' only
after suture of the anterior layer of the sheath.

Suture the edge (EF) of the defect in the anterior fascia to the base (AD)
of the flap (A, B, C, D, Fig. 440). Tie the sutures XX' and YY'. Suture
the edge (BC) of the flap A, B, C, D, to the surface of the fascia along the line
Z, Z, Z (Fig. 440). Close the skin wound.

The result of the procedure is shown in Fig. 441.

(C) Lennander's Method. — (Kammerer; Battle; Jaboulay.) Make a ver-
tical incision a short distance to the right or left of the median line, exposing the
anterior surface of the rectus. Incise the anterior layer of the rectus sheath.

Retract the inner edge of the rectus out-
wards, exposing the posterior layer of its
sheath, and incise that layer. Open the peri-
toneum. Note that the rectus muscle itself
is neither incised nor split, and hence its
Fig. 442.— Rectus incision. nerve-supply is not injured in the slightest.

In closing the wound, remember to suture
each layer of the rectus sheath separately (Fig. 442). A similiar incision
may be made about three-fourths of an inch internal to the outer edge of the
rectus, the sheath opened, the muscle retracted inwards, and the abdomen
penetrated. This outer incision is very commonly used for exposing the
vermiform appendix but it of course may injure the nerves.

(Dj Vertical Incision through the Rectus.^This incision is excellent. Make
a vertical incision to one side of the median line down to and through the
anterior layer of the rectus sheath. Split the rectus muscle by blunt dissection.
Divide the posterior layer of sheath and open the abdomen.

CLOSURE .U3DOMEN 347

(E) Vertical Incision at the Outer Edge of the Rectus. — This requires no
special description.

(F) Transverse Incision. — As has already been stated the general direction
of these incisions is transverse, but as a rule they are really oblique, curved or
even angular. The direction of any part of the cut depends principally on the
course of the nerves. In the region of the gall-bladder the incision usually
runs more or less parallel to the costal margin, though when dividing the rectus
muscle the author prefers to cut at right angles to its fibres. In exposing the
stomach the incison may be curved (convexity upwards), both recti being di-
vided, or it may be transverse, one or both recti being divided in whole or in
part. The incisions when prolonged beyond the recti ought always to split the
fibres of the external oblique and not cut them transversely to their course.
Such incisions are of the gridiron type like the McArthur-McBurney incision.
In the lower abdomen the incisions are usually curved with convexity
downwards.

As an example of transverse incision the method may be taken by which
the author often exposes the right iliac region in cases of chronic appendicitis
when considerable exploration is necessary. Make an incision in the inter-
spinous line from the linea alba to the outer edge of the rectus and expose the
rectus sheath. Introduce and loosely tie two lines of interrupted catgut stitches
transversely through the rectus sheath and underlying muscle. Divide the
sheath between these lines of sutures. Cut through the rectus muscle deliber-
ately so as to expose the deep epigastric vessels. It is almost always necessary,
to ligate and divide these vessels. Open the peritoneum. If it is necessary to
enlarge the wound laterally, this is easily done in the gridiron fashion. If
median enlargement is required, the other rectus muscle may be divided without
ill result. Closure of the above wound is very easy and secure. The method is
not suitable in the presence of acute infective lesions.

It is specially above the umbilicus that transverse incisions are very useful.

(G) Oblique Incisions.— In the lower half of the abdominal wall, when it
is desired to operate remote from the median line, incisions are recommended
running obliquely from above downwards and inwards — i.e., in the direction
of the fibres of the external oblique muscle. Such avoid division of important
motor nerves and permit of splitting instead of dividing the external oblique
muscle. (See Chapter on "Appendicitis.")

METHODS OF CLOSING THE ABDOMEN

The great object to be attained in closing the abdomen is the prevention
of subsequent hernia. In the attempt to gain this end, surgeons have adopted
a vast number of methods of suture. A study of the annexed diagrams (Figs.
443 to 450) will explain the suture methods more clearly than any printed
description. The buried sutures uniting peritoneum or fascia are best intro-
duced with full curved or short straight needles, and may be catgut, silk, silk-
worm-gut, or silver wire. The writer prefers some form of catgut, either
mildly chromicized or iodized. Kocher thinks silk the only proper material.
In the Johns Hopkins clinic silver wire is used. Other surgeons prefer silk-

348

laparotomy; celiotomy; abdominal section

worm-gut, tendon, aluminium-bronze wire, etc. When properly used, each
material does good work. Some surgeons, e.g., Jonnesco, object to the use
of absorbable sutures, of non-absorbable buried sutures, and yet desire to close
the abdominal wound in layers. For this reason thev have devised more or

Fig. 445.

Fig. 447.

Fig. 444.

Fig. 449.

Fig. 450.

Fig. 451. — Jonnesco's method (modified).

less complicated means of suturing, so that they can remove the stitches when
they have served their purpose (Figs. 451, 452, 453, 454).

In not extremely rare instances a wound does not heal by the time catgut
sutures are absorbed. This peculiarity has caused a number of disasters.

AFTER TREATMENT

349

It is wise to reinforce the catgut sutures by two, three or four silkworm-gut
relaxation stitches.

The inexperienced surgeon, after completing a prolonged operation on an
exhausted individual, sometimes forgets that it is better to have a post-operative
hernia in a living patient than a perfectly closed wound in a corpse. Under
some circumstances it is wise to put in as few stitches as possible, and these in
the quickest manner possible.

A.C43

Fig. 453. — Davison's method.

A. Slip-knot to prevent suture being pulled through
the tissues. The free end of the suture is left projecting
from the wound, and when pulled upon unties the slip-knot
and so permits extraction of the suture. B. Slip-knot
tied when suture is in place. Untie the same way as A.

Fig. 454.

Continuous sutures fixed by
pad of gauze at A.

When drainage has been used, it is good practice to place sutures in position
for the closure of the opening left by the removal of the drain and tighten and
tie these subsequently.

When drainage is necessary it is often wise to establish it through a special
incision or stab, and then close the primary wound completely. The means
used to provide drainage is liable to cause trouble in the main wound.

DRESSINGS

After completion Of the operation, cover the wound with a number of pads
of-sterOe absorbent gauze; over these place a liberal quantity of sterile ab-
sorbent cotton. Keep the dressings in place with a binder, or preferably by
strips of adhesive plaster. Abundant dressings, snugly applied, support the
intra-abdominal blood-vessels and prevent the patient from bleeding into his
own veins after large tumors have been removed. Under ordinary circum-
stances the author has discarded the use of all dressings contenting himself with
painting the wound daily with alcohol or a weak solution of iodine. A sterile
towel may be throwm over the abdomen, it rarely remains in position.

TREATMENT AFTER LAPAROTOMY

Return the patient to bed. A small pillow may be placed under the head,
but for a short time the head must not be elevated. If there is much pain give
an efficient dose of an opiate, as suffering and restlessness are greater evils
than are the noxious effects of the opiate itself. Rectal instillations of salt
solution are of great value in relieving thirst and in providing the patient with

350 laparotomy; celiotomy; abdominal section

needed liquid. An enema consisting of soda bicarb, o'lv in S^iii of water is
valuable immediately after operation. If the rectum is irritable, hypodermocly-
sis is often valuable. Washing the mouth with water is of value in relieving
thirst and is very grateful to the patient. A. J. Ochsner stimulates secretion
of saliva by letting the patient use chewing gum or hold some object like the
stone of a plum in his mouth. The increased flow of saliva lessens thirst and
lessens the dangers of parotitis. One must remember, however, that a too
protracted increased flow of saliva may ultimately increase the thirst. As soon
as nausea passes off, begin giving small doses of water, preferably hot, by the
mouth. If this is well borne the patient may soon be permitted to drink two
or more pints per day. Orange juice is greatly appreciated by most patients,
and to it a little egg albumen may be added with advantage. In most cases
liquid nourishment may be given sparingly in 12 or 24 hours after operation.
The author in recent years has become more and more liberal in permitting
food to, but not forcing it upon his patients after laparotomy.

If "gas pains" give trouble an enema of soap suds gives relief. When there
is difliculty in expelling flatus a rectal tube should be introduced and left in
place. Wetherill long ago urged that post operation catharsis be discarded.
The writer has adopted that wise man's views and usually leaves the bowels at
rest for some days unless special indications calling for their evacuation arise.
If it is necessary to move the bowels pituitrin is of great value.

A few years ago many surgeons considered it essential to keep patients in
the dorsal position for a long time after laparotomy. This is cruel and in-
jurious. Permit the patient to lie in whatever position is comfortable so long
as it does not exert tension on the wound. After certain operations — e.g.,
those on the stomach and those for peritonitis — the above rule may not prevail.
After operations on the upper half of the abdomen it is permissible to allow the
patient to sit up early, as the sitting posture does not increase tension on the
wound to any great extent. After operations on the lower half of the belly,
the sitting posture means increased tension on the wound and hence increased
risk of hernia, therefore the author usuallv in clean cases adheres more or less
closely to the rules formulated for the after-treatment of hernia operations.
When drainage has been instituted the Fowler position may be imperative.
The tendency of surgeons is towards letting the patients sit up and move
about at an early date, even a very early date, after operation, but to the
author it appears risky as tension on a wound insuflaciently solidified is well
calculated to cause hernia. When the abdomen has been opened by the grid-
iron method of McArthur and ]McBurney, the above remarks do not apply.
The avoidance of tympany during convalescence is of great importance for
the same reason, viz., the tension it exerts on the wound.

The stomach tube is of enormous value after laparotomy. If nausea is pro-
longed the stomach ought to be washed out. If there is any evidence of
beginning acute dilatation of the stomach lavage is imperative. Half an hour
before passing the tube in a nervous patient it is well to give }'i gr. morph.
hypodermatically and immediately before the operation the fauces should be
sprayed or swabbed with cocaine.

GASTRO-INTESTINAL OPERATIONS

351

* GASTRO-INTESTINAL OPERATIONS

Before describing the individual operations performed on the gastro-in-
testinal canal it will be convenient to consider the means at our disposal for
preventing the escape of its contents from an incised gut and of closing in-
testinal openings by means of sutures. Some special means of suturing
will be described later, along with the operations
for which they were devised.

Preparation of a Loop of Gut for Incision. —
With the finger and thumb express the contents
of the selected portion of gut either upwards or
downwards so as to leave that portion empty.
Prevent the return of the contents to the loop
of gut by appropriate clamps, applied above
and below. When available, the best clamps
are the fingers of an assistant exercising pressure

Fig. 455. — Murphy's clamp.

Fig. 456. — Pean's clamp.

on the gut. The objections to this are that the fingers are liable to take up too
much room, and that the hands of the assistant become so fatigued that he
can give but little assistance during the rest of the operation. If plenty
of help is at hand, of course the latter objection loses its weight. Murphy's clamps

(Fig. 455) are excellent. It is entirely unnecessary
to protect the blades of this clamp with rubber
tubing.

Pean has suggested a most convenient intestinal
clamp (Fig. 456) and one which is always ready. To
the proximal side of the catch of an ordinary hemo-

FiG. 457. — Maylard's clamp.

Fig. 458. — Doyen's clamp.

Static forceps tie the end of a soft-rubber catheter or piece of drainage-tube.
Pass the point of the forceps behind the gut and through the mesentery close
to the gut. Open the forceps. Place the free end of the rubber tubing over
the front of the gut; stretch the tubing and catch it in the jaws of the forceps.

352

laparotomy; celiotomy; abdominal section

The result is that the gut is clamped by the rubber in front pressing towards
the forceps behind.

Passage of intestinal contents may be stopped by tying around the gut strips
of gauze or pieces of coarse silk or catgut. Of course, before they can surround
the gut they must perforate the mesentery. Do not tie such materials tightly
as little pressure is necessary and much is injurious.

Maylard extemporizes an excellent clamp by covering the blades of a
dissecting forceps with rubber tubing. When the blades have been made to

Fig: 459. Fig. 460.

Figs. 459 and 460. — Lembert suture.

grasp the intestine, their points are kept together by a segment of tubing
slipped over them (Fig. 457).

All the above clamps are good for the prevention of escape of intestinal
contents, but certain clamps with long blades (protected by rubber tubing)
not only serve this purpose but control hemorrhage and may be employed as
handles by which the segments of gut can be held steadily in a position con-
venient for suturing, etc. Such clamps are: Doyen's (Fig. 458), Hartmann's,
Moynihan's, Harrington's, Scudder's, etc. A clamp good for gastro-enteros-
tomv is good for most intestinal work.

Fig. 461. — Lembert suture.

Intestinal Suture. — The most common material for intestinal suture is fine
twisted silk — preferably black. The disadvantage of silk is that when wet
it is difficult to pass through the eye of a fine needle. To avoid this difficulty
a sufficiency of needles should be threaded before sterilization is begun. The
author generally uses fine waxed silk or linen. Fine chromicized or
tanned catgut is excellent. The best needles are the ordinary seamstress'
needles, about one and a quarter inches in length. Various curved needles
(without any cutting-edge) are useful and can be obtained in any good
instrument store.

LEMBERT SUTURE

353

The intestinal wall consists of the following tunics: the serosa, the musculosa,
the submucosa, and the mucosa. The submucosa is the firm, thin tunic
which is used in making sausages. It provides the most
reliable hold for a suture.

Lembert Suture. — This is the basis of almost all methods
of intestinal suture. Its aim is to close an intestinal wound
by turning the cut edges inwards and bringing the serosa of
one side into apposition with that of the other side.
Halsted has shown that it is wise to include tJie submucosa
in the stitch. When a not too sharp needle is introduced
through the serosa and musculosa, its advance is easy, but
when it reaches the submucosa, a slightly increased resist-
ance is perceptible. It is said to be easy to pick up some
of the submucosa on the point of the needle without pene-
trating the mucosa. The author has frequently endeavored
to insert Lembert sutures involving the serosa and mus-
culosa alone, but they always tore out; the picking up of

Fig. 462. — Mattress
suture. {Monod and
Vanverts.)

Fig. 463. — Alfred H. Gould's mattress stitch.

Note that the loop is reversed. This results in the rolling in of the peritoneum on the side

of the loop — B drawn to A.

a few fibres of the submucosa without letting the
needle pass into the mucosa seems to be an ''iridescent
dream." The blood-vessels lie in the submucosa, and
in suturing unless the thread is passed under the vessels
(i.e., nearer the mucosa) the stitches will exercise no
pressure upon them and thus serious hemorrhage may,
and sometimes does occur. In inserting sutures the
surgeon should see to it that each stitch embraces firm
tissue and will not cut out, and that each stitch goes under
any visible vessel in its track. If these two rules are
observed good results will be obtained no matter if the
thread does pass through the deeper layers of the
mucosa. The author knows of one or more cases in
which the operator took special pains to insert the
sutures through the serosa and musculosa alone and

nearly lost the patient from hemorrhage. The introduction of the suture is

sufficiently shown in Figs. 459, 460, and 461.

Fig. 464. — Dupuy-
tren's suture. {Esmarch
and Kowalzig.)

354

laparotomy; celiotomy; abdominal section

Halsted's Quilted Suture. — This is in principle identical with Lembert's.
The suture is introduced after the U fashion (Fig. 4O2). Gould's mattress
suture with reversed loop is admirable (Fig. 463).

Dupuylren's suture (Fig. 464), or continuous Lembert, can be easily and
quickly applied, and when properly used, is a most excellent procedure.
In America it is curious to notice that most eastern operators use the inter-
rupted suture, while the Westerners favor the continuous. The results
seem as good whichever method is' employed; hence the continuous being

Fig. 465.

Fig. 466.

Fig. 467.

Fig. 468.

Fig. 469.

Fig. 470. — Cushing's suture.

Fig. 471. — Gely's suture.

the easier to apply, it seems to the author to be the better. It is important
to observe the blood-vessels running towards the wound in the gut, and to
pass the needle under such, so that when the edges of the sound are inverted
by the tightening of the sutures, these constrict the vessels and so prevent
hemorrhage. If one fears that a continuous suture will act as a purse-string
and cause contraction, one may obviate this danger (if danger it be) by occas-
ionally interrupting the suture by fixing it with a knot (interrupted continuous
suture).

EXPLORATORY GASTROTOMY 355

Several methods of closing an intestinal wound by different layers of suture
have been devised. Some of these are illustrated in Figs. 465, 466, 467, 468,
and 469.

Through-and-through Sutures. — When closing a wound or uniting divided
ends of gut there is often considerable hemorrhage and some danger of the line
of Lembert sutures becoming infected by intestinal contents. To control
hemorrhage nothing is better than to unite the edges of the wound with a
continuous stitch of catgut penetrating all the thickness of the gut-wall. This
line of suture is at once covered and hidden by a row of Lembert or Dupuytren
sutures, and serves to protect the latter from infection. Cushing's and Gely's
methods of suture are sufficiently explained by Figs. 470 and 471.

CHAPTER XXXIII
THE STOMACH

Exploratory Operation on the Stomach. — At least one day prior to opera-
tion thoroughly wash out the stomach with warm water. Repeat this lavage
immediately before the operation. Be careful to empty the stomach com-
pletely. If the stomach has been for a long time much dilated, do not empty
it during the first lavage. Under these circumstances preparation should
consume several days. If the organ is suddenly or rapidly cleaned, tetany
is very liable to develop. In dehydrated patients, i.e., those who pass not
more than 500 c.c. of urine in twenty-four hours, it is of vital importance to
supply fluid to the tissues. This may be accomplished by means of Murphy's
proctoclysis or by giving hypodermically from 40 to 60 ounces of saline solution
per diem for several days before operation.

When diseased, the stomach almost always lies at a lower level than in
health, hence the incision need not be so near the ensiform cartilage as might
be imagined from a study of normal anatomy.

Having opened the abdominal cavity, introduce the finger and palpate
the stomach and its surroundings. This is often sufficient for diagnosis.
If it is not sufficient, pull the stomach into the abdominal wound, surround
it with warm pads, and inspect the anterior gastric wall. If a pyloric stenosis
is suspected, invaginate a part of the stomach-wall with the finger so that
the finger penetrates and palpates the pylorus. Gentleness must be employed.
If exploration of the posterior wall is necessary it may be exposed through
several routes, (i) Gastro-hepatic route. Tear a hole through the gastro-
hepatic omentum. This permits finger exploration but does not give free
access. (2) Trans-mesocolic route. This is the same route as used in posterior
gastro-enterostomy and is efficient. (3) Gastro-colic route. Make an incision
parallel to the greater curvature through the gastro-colic omentum being careful
to avoid injury to the gastro-epiploic vessels. This method requires the liga-
tion of a number of branches of the gastro-epiploics but gives excellent access to
the stomach. Care must be taken lest the vessels in the mesocolon be acci-
centally injured. After completing the active operation suture the wound in
the omentum or stitch the divided omentum to the stomach. (4) Intercolo-

356 THF STOMACH

epiploic route. Separate the great omentum from the transverse colon by cut-
ting an opening in the serous membrane of the transverse colon at its junction
with the great omentum and separate the omentum from the colon (see
p. 404). This gives good exposure of the stomach, duodenum and
pancreas. Pauchet and Sherwood Dunn strongly advise the inter-colo-
epiploic route in the treatment of posterior gastric and duodenal ulcers and
in bullet wounds of the posterior wall of the stomach. If it is desirable
to explore the interior of the stomach, e.g., for ulcers, pack the abdominal
cavity around the stomach with warm gauze pads. It is universally ad-
vised to count the pads before beginning the operation. This is a good
rule. A rather better precaution against losing and leaving a pad in the
belly cavity is to have 6 inches of soft tape sewed to each pad, and as the
pads are introduced into the belly to let the tape emerge from the wound
and be anchored by a hemostat. The tapes emerging through the wound
are never in the way. The pads used should be large. Those 24 inches long
by 6 inches wide are good. The writer makes it a rule never to place a pad in
the abdomen without an anchor affixed, and never to use pieces of gauze for
sponging inside the cavity unless they are held in sponge forceps. These
rules are simple, and hence efficient. Masson (Jour. A. M. A., May 31, 1919)
advises that a metal ring be placed round the base of the tape and firmly stitched
both to the sponge (gauze pad) and to the tape. If any doubt regarding the
sponge count arises a roentgenogram will clear it up at once.

Have an assistant pick up a fold of the anterior wall of the stomach. In-
cise this fold in a direction at right angles to the long axis of the organ. If
there is fluid in the stomach and its walls are not weakened too much by
disease, introduce a blunt tube and empty the viscus. Introduce the finger
into and palpate the stomach. Retract the edges of the wound and inspect
the interior. In doing this a cylindrical rectal speculum provided with a dia-
phragm and 2)-^ inches long by i)-^ in diameter is of great aid and permits
inspection of the duodenum through the pylorus. Close the gastric wound
by sutures of catgut involving the whole thickness of the wall; this row of
sutures to be inverted or buried by a series of Lembert or continuous Lembert
stitches of fine chromic gut. Close the abdomen. Return the patient to bed.
Keep him warm.

Thirst, and later hunger, may be relieved by warm water or nutrient ene-

mata. If possible, do not give anything by the mouth for at least twelve

hours, and then only water. Remember that the danger arising from giving

drink or food by the stomach in such cases is really not from its leaking through

the wound, but from vomiting being set up by its presence, and also from its

stimulating effect giving rise to peristalsis, etc.* Hypodermoclysis or rectal

instillation of salt solution is of inestimable value in these cases. It is desirable

that the stomach rest until repair is advanced. If there is much pain, morphine

in an efficient dose should be given. If possible to avoid the use of morphine

without cruelty, do so, but when its employment is decided on, administer in

one dose enough to insure the effects desired.

* Possibly too much weight is given to the dangers of early feeding. Roux is extremely
heterodox, feeding his gastro-enterostomy patients with almost anything they desire as soon
as they desire it.

GASTROSTOMY 357

Exploratory operations are strongly indicated "in cases of rapidly de-
veloping cachexia and emaciation with the symptoms of chronic gastritis
and absence of HCl. Tentative treatment should not be prolonged over
three weeks. It is not near so serious a fault to have caused the opening
of a stomach and found nothing operable, as to permit a case to continue
and find out at the autopsy only that it was a circumscribed carcinoma, the
removal of which might have prolonged life for years." (Hemmeter, "Dis.
of Stom.," p. 358.)

Operating for Cardiospasm. — Mikulicz observed a number of cases in
which the patients suffered severely from oesophageal obstruction due to
muscular spasm at \^e oesophageal-gastric junction. When milder means
of treatment failed he obtained complete cure by opening the stomach, pass-
ing an instrument like a glove stretcher into the oesophagus through the
stomach and thus forcibly stretching the muscle at fault. Briinig has opened
the blades of the Mikulicz's forceps as much as 2}^ inches (6 cm.) with ex-
cellent results.

Dilatation by means of air or water bags introduced through the mouth has
practically entirely displaced the Mikulicz operation. See Plummer, "Journ.
A. M. A.," Aug. 15, 1908.

Gastrostomy. — The object of gastrostomy is to make a convenient fistula
into the stomach through which nourishment can be administered. (Esoph-
ageal stenosis is the indication for the operation, hence we have usually to
do with emaciated and weak patients. The simplest method of operating
is the worst. It consists in performing an exploratory gastrotomy and sutur-
ing the stomach wound to that in the parietes. The objection to the above
method is that it permits a constant escape of the gastric juices. All the
other methods of gastrostomy are attempts to avoid the above-mentioned fault.

(A) Gastrostomy with Formation of Sphincter (Hartmann ; Terrier ; Jaboulay ,
etc.). — By percussion and palpation define the lower edge of the liver in the
epigastrium.

Step I. — Make a vertical incision i to i}'^ inches to the left of the median
line, beginning at the lower edge of the liver and running downwards for about
2H to 3 inches. Divide the anterior layer of the muscular sheath and split
the rectus itself, but do not yet divide the posterior layer of the sheath.

Step 2. — Retract the wound inwards and thus expose the posterior layer of
the rectus sheath and divide it along with the peritoneum near the median line.

Step 3. — Introduce the finger and pass it up under the left lobe of the liver

to the portal fissure, and follow the gastro-hepatic omentum to the lesser

curvature of the stomach. (Maylard, "Surgery

of the Alimentary Canal.") This avoids all ^^^^^rr::^^^ !^^^

danger of mistakmg colon for stomach. Pick up ^^-::^:^ir:^^^^^^^^g.

the anterior wall of the stomach and pull a cone ^^^^^^^

of it through the wound. Close all the excess of ^ ' ^

, , tiG. 472. — Gastrostomy,

peritoneal wound.

Step 4. — -Remove retractors and permit the rectus muscle to resume its

normal position (Fig. 472).

Step 5. — Close all excess of abdominal wound and suture the protruding cone

358

THE STOMACH

of Stomach to the skin. Open the protruding portion of stomach and intro-
duce a soft catheter into it.

Steps I and 2 may be varied as follows: Divide the anterior layer of rectus
sheath along the line of the skin-incision; retract it inwards, i.e., to the right;
retract the whole rectus muscle outwards, exposing and dividing the posterior
layer of sheath and the peritoneum near the median line; pull out the cone
of stomach; split the rectus muscle along the line of the skin-incision and
separate the internal portion from its posterior layer of sheath; pull the cone
of stomach through the bridge of muscle thus formed and suture to the skin
(Figs. 473 and 474).

Figs. 473 and 474. — Hartmann-Terrier-Jaboulay gastrostomy. (Monod and Vanverls.)

(B) Frank's Operation. — Step i. — Beginning near the lower edge of the
liver, make an incision downwards and towards the left, parallel to and one
inch below the left costal cartilages. Length of incision, 2 to 3 inches.

Step 2. — Through the incision pull out a cone of stomach from as near
its cardiac end as is possible without too much tension.

Step 3. — Make a second skin-incision, about 1}^ inches in length, parallel
to the first and situated over the left costal cartilages. Undermine the skin
between the two incisions and pull the cone of stomach through the tunnel
thus formed. Suture the stomach to the skin at the second incision.

Step 4. — Close the first wound without exerting too much pressure on the
cone of stomach which traverses it. Open the apex of the stomach cone.
The result is an oblique valvular fistula.

Frank's operation has the disadvantage that, the stomach being small,
the peculiar formation of the fistula causes a deformity which seriously in-
terferes with the carrying on of the normal functions.

(C) WitzeVs Operation. — The object of this operation is to form an efficient
fistula between the stomach and the skin and to make it oblique, so as to
prevent leakage of gastric juices. In time the obliquity is lost, but yet leakage
does not take place.

GASTROSTOMY

359

The Operation. — ^Open the abdomen through the rectus muscle by a two-
inch vertical incision to the left of the middle line. From the junction of the
body of the stomach and its pyloric portion pull into the wound a fold of the
stomach near the greater curvature, and here make a small incision, about the
calibre of a lead-pencil, through the serosa and musculosa. Pick up the mucosa
with forceps and open the stomach cavity. Take a soft-rubber catheter, about
No. 25 Fr.; close one end of the catheter or tube with a clamp and introduce
the other end into the stomach. Cochem writes the author that he once found

Figs. 475 and 476.— Witzel's gastrostomy.

the catheter here recommended became so easily clogged with food that the
operation was a failure until he substituted a catheter of the largest size. Fix
the tube to the gastric wound with one or more catgut structures. Lay the
proximal portion of the tube on the surface of the stomach and bury it by a row
of Lembert or continuous Lembert sutures, as shown in Figs. 475 and 476.
This forms a canal in the stomach- wall. The canal should be i^ inches in
length or longer. Unite, with sutures, the outer opening of the canal to the

Figs. 477 and 478. — Stamm-Kader gastrostomy.

parietal peritoneum. Bring the free portion of the tube out through the ab-
dominal wound. Close the excess of abdominal wound. Over the portion of
the tube external to the abdomen slide a short segment of a larger tube fitting
snuglv to the main tube. This outer ring of tubing is pushed up to beside the
skin, and through it is passed a safety-pin to prevent the drain from penetrating
too far into the stomach. If the safety-pin was introduced into the main tube,
stomach contents could leak out alongside of it and irritate.

(D) Stamm-Kader Operation. — Expose and open the stomach as in the
Witzel operation. Introduce a rubber tube and, with catgut, suture the edge

360

THE STOMACH

of the gastric wound to the tul)e. With fine chromicized catgut suture the
gastric serosa, about }^ inch distant from the wound, to the side of the tube
all around it a short distance from the wound (Figs. 477 and 478). Insert a
second row of these serous sutures. This causes an inversion or invagina-
tion of the stomach-wall, which serves as an efficient valve. With Lembert
sutures unite the stomach around the tube to the parietal peritoneum. Bring
the outer portion of the tube through the abdominal wound at a convenient
point. Close the excess of abdominal wound. The Stamm-Kader operation
is the only one applicable when the stomach is much diminished in size. It
is an excellent, perhaps the best, method of operating.

An easier method of performing the operation is as follows:
Introduce a purse-string suture of catgut all around a small opening in
the stomach-wall exactly as when a Murphy button is to be used. Through
the opening pass the bulb of a Pezzer's self-retaining catheter into the stomach.
Pull the catgut suture snugly round the shaft of the catheter and tie it. In-
troduce a purse-string suture of chromicized catgut in the stomach-wall round
and about J^ inch distant from the catheter. As this suture is tightened push
the catheter inwards and invert or invaginate the stomach-wall. Tie the
suture but leave its ends long. Using the catheter as a handle pull the stomach
up against the abdominal wall. With a needle fix the long ends of the purse-
string suture to the peritoneum or the fascia of the abdominal wall. If de-
sired introduce one or two sutures to unite the stomach, near the gastrostomy
opening, to the peritoneum. (This is usually superfluous.) Close the ab-
dominal wound. The catheter protrudes through the abdominal w-all and
aids in keeping the stomach in contact with it

When the catheter has served its purpose it may be cut off flush with
the skin and its bulbous end permitted to drop back into the stomach.

(E) H. H. Janeway's Gastrostomy (Journ. A. M. A., July 12, 1913). —
Step I. — Make a vertical incision through the inner third of the left rectus
muscle beginning at a point about i3^ inches below the costal margin. Open
the abdomen.*

Step 2. — Pull out of the wound a fold of the anterior wall of the stomach
slightly to the right of the abdominal incision and anchor it with forceps.

Make an incision into the stomach about
i^ inches in length along a line slightly
oblique from above and the left to the right
and downwards. This incision is nearly
transverse to the long axis of the body.
At each end of the incision make a cut about
^ inch long directed towards the greater
curvature.

Step 3. — Make traction upwards at the
point X (Fig. 479). Unite the edges X A C
E of the gastric wound to the edges X B D F.
The result is a tube about 2 inches in length and lined with gastric mucosa.

Step 4. — Method A. — Suture the base of the new canal to the margin of the
rectus sheath and its tip to the skin.

Fig. 479.

GASTROPEXY

361

Method B. — Invert the base of the canal for a short distance into the stomach
so as to form a valve. Treat the rest of the tube as in Method A.

The canal if made as described has an oblique direction toward tshe left
and is therefore in itself valvular. It is completely lined by mucosa and hence
continuous catheterization is not necessary in order to keep it open.

After-treatment. — It is better to administer nourishment per rectum for a
few days after the operation, lest vomiting be set up. If the patient is urgently
in need of nourishment, it may, however, be at once introduced by the catheter
into the stomach. For weeks after operation the diet should be liquid; later
solid food well broken up or chewed by the patient may be permitted.

Gastroplication. — This operation is occasionally performed in cases of
gastric dilatation. It is exceedingly simple and has for its object the diminu-
tion in size of the stomach.

Step I. — Open the abdomen and expose the stomach.

Step 2. — Into the anterior surface of the stomach introduce several rows
of exaggerated Lembert sutures or some modification thereof. The result
is an invagination of segments of the stomach-wall and consequent decrease
in calibre (Fig. 480).

This operation is not curative, in that the cause of the trouble is not touched,
and relapse is the rule.

Fig. 480. — Gastroplication.
{Monod and Vanverts.)

Fig. 481. — Buret's gastropexy.
(Monod and Vanverts.)

Gastropexy. — This operation has been performed when, on account of
gastroptosis, the patient has become a chronic invalid; suffers severely; is
much emaciated, and none of these conditions is satisfactorily relieved by
the ordinary non-operative methods of treatment. The object of the opera-
tion is to restore the stomach to, and retain it in, its normal position, and
thus prevent dragging upon the gastro-hepatic omentum and pressure upon
the intestines and pelvic organs, as well as obstruction to the onward passage
of food from the stomach offered by kinking of the duodenum. The condition
present is usually one of general visceral ptosis, hence the operation is commonly
futile.

Duret's Operation. — Step i. — Make an incision in the median line. Open

362 THE STOMACH

the peritoneum and expose the stomach in the lower part of the wound. Ex-
pose but do not open the peritoneum in the ujiper part of the wound.

Step 2. — Insert a continuous suture on the modified Lembert plan, so as
to unite the stomach and upper undivided portion of peritoneum. When this
suture is in place, make both ends of it penetrate the fibromuscular belly-wall
and tie them there (Fig. 481).
Step 3. — Close the wound.

Rovsing^s Operation. — Step i. — Make a median incision from the ensiform
cartilage to the umbilicus.

Step 2. — With the finger pull the stomach upwards to its normal level.
Examine the pylorus for stenosis, etc.

Step 3. — Introduce fairly stout silk sutures as in Fig. 482. Do not tie
them until the surfaces of the stomach and parietal peritoneum are scarified
where they are to be apposed and the belly-wall is sutured.

Step 4.- — Close the abdominal wound and place on it a pad of gauze or
a plate of glass covered with sterile gauze the dimensions of which are a little
greater than the stomach-surface which has to be fixed. Over the gauze pad

or glass plate tie the sutures suspending the
stomach. These sutures are left in situ for three
or four weeks.

The operation is not dangerous and has given

some strikingly brilliant results. ("Archiv f. klin.

Chir.," Ix, 816.) Rovsing reports the following

results: Complete cure, 63.2 per cent.; great im-

FiG. 482 — Rovsing's provement, 12.8 per cent.; improvement, 7 per

gas ropexy. cent.; slight improvement or no change, 12.8 per

cent.; deaths, 4.6 per cent. None of the deaths could be fairly attributed to

the operation (Trans. Surg. Section A. M. A., 191 2);

Gastropexy {Beyea's operation) has been accomplished by means of shorten-
ing the supports of the stomach. The lesser omentum is thrown into trans-
verse folds, which are rendered permanent by a few sutures. In introducing
the sutures be careful not to include any blood-vessels in their bite. Sir Frederic
Eve ("Brit. Med. Journ.," May 7, 1910) is a thorough advocate of a slight
modification of Beyea's operation. The Hver is well raised by an assistant
and the lesser omentum fully exposed. The stomach is suspended by four
or five interrupted silk sutures passed above through the upper part of the
gastro-hepatic omentum and below through the lesser curvature in front
of the vessels. The lesser omentum is much thicker close to the liver than it
is lower down but if the whole membrane is equally thin then the sutures
are passed through the liver substance itself, just anterior to the transverse
fissure. Of seven cases operated on as above and observed for a sufficient time
afterwards, six were cured.

Grouse ["Archives of Surg.," I, 550, 1920] reinforces the plication of the
gastro-hepatic omentum by detaching the falsiform and round ligaments of
the liver from their attachments to the umbilicus and abdominal wall, leaving
the diaphragmatic and liver fixation points intact and then splitting the falci-
form ligament and sewing its raw surface along with the round ligament to the
plicated gastrohepatic omentum.

in-CKR STOMACH 363

Operation for Ulceration of the Stomach. — It is tempting to advise opera-
tion in cases of acute ulceration where there is a copious hemorrhage, but
recovery generally ensues under medical treatment and operation is proper
only when the hemorrhage is not merely copious, but recurrent. Ulcers of the
stomach not producing stenosis ought to l)e buried by invagination with sutures,
or better, they ought to be excised. Unless the invagination or the excision
gives rise to stenosis, gastro-enterostomy ought not to be performed. Every
chronic gastric ulcer with hemorrhage demands operation. For those who be-
lieve that carcinoma of the stomach commonly arises on the basis of a chronic
ulcer it is wise to excise or destroy all chronic or indurated ulcers whenever this
is technically feasible. Balfour's cauterization is excellent for this purpose.
Duodenal ulcers require excision, cauterization or invagination to produce per-
manent stasis, plus gastro-enterostomy, otherwise the relief afforded by the
gastro-enterostomy permits partial healing of the ulcer, a return of the pyloric
function and a return of the symptoms. This rule does not apply when nature
has herself produced the stasis by contraction of scar tissue and the ulcer has
healed. Excision of duodenal ulcers is rarely necessary as a prophylactic
against malignancy but the cautery excision is of great value in preventing
subsequent hemorrhage.

Donald Balfour (Sur., Gyn., Obst., xix, 528) has had very good results from
the use of the cautery. If the ulcer is on the lesser curvature he carefully
dissects free the adjacent lesser omentum and then burns the ulcer completely
with a Paquelin cautery kept at a dull heat. This of course perforates the
stomach. The wound is closed by a few through-and-through chromicized cat-
gut stitches and these are buried by interrupted sutures of chromicized catgut.
The reflected lesser omentum is replaced and fixed to the site of ulceration. In
suitable cases the peritoneum and muscularis may be reflected as a flap from
over the ulcer; the ulcer slowly burned; the perforation closed with catgut
sutures and the flap replaced. (Mayo, Journ. A. M. A., Sept. 25, 1915.)

Moynihan writes (Brit. Med. Jour., July 12, 1919).— "Nowadays I perform,
as a rule, only two operations for cases of chronic gastric ulcer. If the ulcer is
not near the oesophagus, and is of average or small size, I perform partial
gastrectomy. If the ulcer is very large, burrowing deeply into the liver or
the pancreas, and near the cardiac end of the stomach I perform gastro-enter-
ostomy in Y, and into the proximal limb of the jejunum, below the duodeno-
jejunal flexure, I introduce a tube, performing jejunostomy. Through this
tube the patient is exclusively fed, for few or many months, until an X-ray
examination suggests that the ulcer is healed."

One must always bear in mind that in pure neurasthenia many of the
symptoms of gastric ulcer may be present, the stomach may be dilated, etc.,
and the patient may be in such a frame of mind as to tempt the surgeon to
perform gastro-enterostomy. If the abdomen is opened and no scar of ulcer
is found and there is no enlargement of the gastric lymph nodes indicating
ulcer, do not perform gastro-enterostomy, as the latter state of such a patient
is very liable to be worse than the first. The most experienced surgeons are
completely skeptical as to the existence of the so-called "mucous ulcers" which
cause bleeding but cannot be seen either on the operating or postmortem table.

364 THE STOMACH

Whenever there is acute perforation of the gastric wall from ulceration,
operation is imperative. Excision of the ulcer is unnecessary. All that is
necessary is to close the ulcer with a single stitch of catgut and to infold the
ulcer and a portion of healthy stomach with two rows of continuous Lembert
sutures (Moynihan) or to use Balfour's operation. If there has been much
soiling, flush the cavity; "if the operation is done within ten or twelve hours, a
gentle wiping of the surrounding area with wet swabs will suffice. Drainage,
as a rule, is not necessary except in the late cases. When adopted it should be
free, a split tube and a gauze wick being placed in the original incision and in
a second suprapubic opening." Do not be content with finding and closing
one perforation: look for more.

When operating for perforating ulcer, if the patient is in very poor con-
dition, it is often wise to follow W. G. Richardson's advice (Northumberland
and Durham Med. J., Nov. 12, 1903) and pass a rubber tube through the
perforation into the stomach. By stitching the stomach surrounding the tube
to the parietes a fistula is established through which the stomach may be
washed and food administered. After a few days the tube may be removed
and usually the opening closes spontaneously.

In the preceding remarks no account has been taken of the presence of
adhesions, or of scars and stenoses resulting from ulceration. Adhesions
are Nature's means of protecting the peritoneal cavity from general infection,
but while immediately life-saving, they are very liable to occasion much gastric
disturbance, and certainly make operative interference much more difficult.
The mere breaking-down of gastric adhesions (gastrolysis) often suffices to
cure apparently inveterate cases of dyspepsia. Mayo Robson ("Trans-
actions Am. Surg. Association," xix) has carried out this treatment fifty-six times
with complete success. Before closing any perforation or before uniting
bowel to stomach, if adhesions exist, they must be so broken down or divided
that the parts to be united tend to lie together, and the sutures when inserted
keep the parts together •without any tension. Tension on sutures is fatal.
The technical difficulties occasioned by adhesions may dominate the choice
of operation for the relief of ulcer or its sequelae. More
than 90 per cent, of gastric ulcers are situated along the
lesser curvature, often constituting the so-called saddle
ulcer where the disease extends on to both the anterior
and posterior walls of the stomach. Ulcers not along the
lesser curvature are more frequent on the posterior than the
anterior wall of the stomach. Less than 6 per cent, of the
' ^ ^' ulcers seen are multiple (Mayo). It is very commonly

accepted that chronic gastric ulcers may and do act as the starting-point of
malignant disease. Influenced by the above consideration, Rodman has sug-
gested the advisabihty of excising the pylorus and that portion of the stomach
most commonly the seat of ulceration. The lines of incision advised by this
surgeon are shown in Fig. 483. Operations for the excision of gastric ulcers
are described in the sections devoted to partial gastrectomy and to pylorectomy .
Gastro-enterostomy, or anastomosis between the stomach and intestine,
is indicated in cases of pyloric obstruction, and of ulceration. According to

ANTERIOR GASTRO-ENTEROSTOMY

365

the portion of intestine selected for anastomosis, the name "gastro-duodenos-
tomy" or "gastro-jcjunostomy" may be used.

According to whether the gut is united to the anterior or to the posterior
wall of the stomach, the operation is designated "anterior" or "posterior
gastro-enterostomy . "

Woljler's Operation. — Anterior Gastro-enterostomy. — The preparation of the
patient is the same as in exploratory gastrotomy.

Step I. — Open the abdomen by an incision in or near the middle line, be-
tween the umbilicus and the ensiform cartilage. The cut is about four inches
long.

Fig. 484. — Anterior gastro-enterostomy. (Mayo.)

Step 2. — Expose the small intestine by pulling the omentum upwards and
to the left. Find the jejunum by the method described on page 366. Empty
the loop of gut and apply clamps to keep it empty.

Step 3. — On the lowest possible point of the anterior wall of the stomach
select a spot for the stomach opening (Fig. 484). Pull this portion of stomach
and the loop of jejunum out of the belly and protect the cavity with gauze pads.
Make an anastomosis between the stomach and the jejunum, using either
sutures or the Murphy button. The method of making the anastomosis is
identical with that employed in posterior gastro-enterostomy, page 368.

Step 4. — Cleanse the field of operation. Put aside all instruments which

366

THE STOMACH

have touched the mucosa. Inspect the line of union, and if necessary rein-
force it with a few Lembcrt sutures. If the point of union causes the intestine
to kink sharply, this may be remedied by a few stitches uniting to the stomach
a little more of the afferent or efferent portions of gut or of both.

Step 5. — Close the abdominal wound. The after-treatment is the same as
for exploratory gastrotomy. Anterior gastro-enterostomy is practically obsolete.
Occasionally it may be of use in j)yloric obstruction when the patient is so weak
that the simplest possible method must be chosen and under such circumstances
possibly a jejunostomy might be preferable.

Posterior Gastro-enterostomy. Step i. — Expose the stomach through an
incision 'j'i inch to the right of the median line. Examine the whole anterior
surface of the stomach and duodenum. No matter what condition is apparent
at the first glance, there may be something else present, e.g., a trifid stomach,
which it is necessary to recognize. Remember that enlarged lymph nodes may
give information as to the site of an ulcer.

Fig. 485. — Exposure of beginning of jejunum.

Step 2. — -Lift the transverse colon out of the abdomen and by pulling up-
wards and to the right, bring so much of the mesocolon with it that the jejunum
becomes visible (Fig. 485). The jejunum from its point of origin at the trans-
verse mesocolon passes downwards, to the left and backwards, i.e., it goes into
the left kidney pouch below the splenic flexure of the colon. The duodeno-
jejunal junction (the origin of the jejunum) is well fixed or immobile, lies about
i>^ to 2 inches above the umbilicus and its level is only about 2 inches lower
than that of the pylorus. To avoid kinking, any anastomosis between the
stomach and jejunum should be made along the natural line of relationship
between these two viscera, i.e., along a line on the posterior gastric wall running
from above downwards and towards the left. The origin of the jejunum being
a fixed point, if the anastomosis is made at too high a level the jejunum will
pull the stomach upwards and trouble may result. If the anastomosis is too
low there will be a loop of jejunum above it and if, as has often happened, this
loop becomes filled with bile, etc., the weight of its contents can pull it down and
cause angulation at the anastomosis. This is the principal cause of the 'vicious
circle' which was the chief danger in the early days of gastro-enterostomy.

POSTERIOR GASTRO-ENTEROSTOMY

367

Pick up a i)ropcr loop of jejunum, usually about three inches from the duo-
deno-jejunal junction. Note the fold of peritoneum passing from the jejunal
origin to the transverse meso-colon; near where this fold joins the mesocolon
is the best place to tear a hole in the mesocolon and expose the posterior surface
of the stomach (Fig. 486). Sometimes this fold of peritoneum (ligament of
Trcitz) extends so far down the jejunum that an anastomosis between the
stomach and the jejunum distal to the fold leaves sufficient gut above the anas-
tomosis to form a dangerous loop. When such is the case divide the fold of

Fig. 4S6. — Colon and transverse mesocolon pulled upwards exposing jejunum.
Exposure stomach through rent in mesocolon. Limited separation of gastro-colic omentum and gastro-
epiploic vessels from lowest point of greater curvature of stomach permits exposure of small portion of
anterior wall stomach. Fold of stomach in clamp consists of a small portion of the anterior and large por-
tion of the posterior wall.

peritoneum as the avoidance of any loop of gut above the anastomosis is of
prime importance. Division of the fold is not always innocuous. J. H. Nicoll
(Brit. Med. Journ., Oct. 21, 1916) found in one case, that the resultant raw
surface on the intestine became adherent to the under surface of the transverse
meso-colon causing occlusion of the loop of gut leading to the neostoma. There
was reflux of duodenal contents through the pylorus into the stomach with
inveterate vomiting. If the raw surface on the jejunum is utilized in the
gastro-enterostomy, i.e., if the opening into the gut is made in this area then
the accident reported by Nicoll could hardly arise.

368

THE STOMACH

Step 3. — Tear a hole through a non-vascular area of mesocolon. Pull a
portion of the posterior wall of the stomach through this hole. By separating
the gastro-colic omentum, and with it the gastro-epiploic artery from the
greater curvature of the stomach for a short distance it is easy to pull a portion
of the anterior as well as of the posterior wall of the stomach through the rent
in the mesocolon (Fig. 486). It is important to do this in order to drain the
very lowest point of the stomach. Apply a gastro-enterostomy clamp to a
fold of stomach, including about one inch of the anterior wall. The direction
of the clamp and of the contained fold must be from right to left, and from
above downwards (Fig. 486).

Step 4. — Apply a similar gastro-enterostomy clamp to the jejunum along
its long axis. The highest point of the gut grasped in the clamp must be i3^
to 33-^ inches from the duodeno-jejunal junction (Fig. 487).

Fig. 487. — Posterior gastro-enterostomy.

Step 5.— Lay the two clamps side by side. Place a narrow gauze pad imme-
diately behind the clamps, between the stomach and the jejunum. With other
pads placed beneath the clamps and around the segregated portions of stomach
and jejunum thoroughly shut off from contamination the abdominal cavity
and the abdominal wound.

Sinclair White and some others have given up the use of clamps because of
fatal hemorrhage having taken place from the suture line after their removal.
If the following method is used there is little if any danger of bleeding, certainly
the danger from this source is less than the danger to be apprehended from
soiling of the field of operation and from loss of blood during the operation in
weak patients when the clamps are not used. When hemorrhage takes place it
is from the posterior suture line of the gastro-jejunostomy.

Unite the stomach to the jejunum for a distance of about 2^^ inches by a
row of mattress sutures exactly as in intestinal lateral anastomosis (posterior
serous suture). Make an incision parallel to and shorter than the posterior
serous suture, through all the coats of the stomach except the mucosa. The

POSTERIOR GASTRO-ENTEROSTOMY

369

mucosa now pouts up into the wound. Make a corresponding incision in the
jejunum. Introduce a button-hole or locking continuous suture of chro-
micized or formalinized catgut, including in each stitch (a) a bite of the unopened
gastric mucosa, (b) the other coats of the stomach, (c) the serous and muscular
coats of the jejunum, (d) a bite of the unopened jejunal mucosa. This line
of suture unites the posterior edges of the stomach wound to the corresponding
wound in the jejunum (Fig. 488). Incise the mucosa of the stomach and

Fig. 488. — Gastro-jejunostomy made with three lines of sutures on posterior line because
of occasional hemorrhage into the gastro-intestinal tract after clamps are removed. Drawing
shows catgut button-hole (second line of sutures) suture applied posteriorly without opening
mucous membrane. (Mayo.)

jejunum and with the same needle and catgut suture used in the preceding line
of suture unite by a whip stitch the mucous coats of the stomach and jejunum
(Fig. 489). With the same suture unite the anterior edges of the stomach
and intestinal wounds by means of a Connel stitch (through all the coats of the
organs) or of a through-and-through buttonhole (or locking stitch) exactly as
in lateral anastomosis. Remove the intestinal clamps. Complete the serous
suture as in lateral anastomosis. Discard all instruments used in making the
anastomosis; they are soiled. Cleanse the operative field. Remove the gauze
pads. By taking hold of both ends of the narrow gauze pad or strip placed be-
hind the site of anastomosis and manipulating it properly it is easy to bring
into view the whole posterior surface of the anastomosis for inspection. //

370

THE STOMACH

necessary introduce one or more Lembert or Gould sutures to assure safe union.
The gastro-enterostomy is complete.

Step 6. — Unless the opening in the gastro-colic omentum is rendered secure
hernia of the small intestine or omentum through it into the lesser peritoneal
cavity can take place and cause disaster.

With three or four sutures unite the lower peritoneal surface of the meso-
colon, a quarter of an inch away from the rent, to the suture line and tuck in
the torn edges of the rent so as to avoid adhesions. If the mesocolon is fat

^^**™ '^^^SHUfc^ ^^^J^^Wi

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A sk m ^fl|' A ^\ "^^fiL*»5ol

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Fig. 489. — Gastro-jejunostomy made with three sutures on posterior line because of
occasional hemorrhage into the gastro-intestinal tract after clamps are removed. Drawing
shows mucous membrane opened. Running suture of catgut to bring mucous coats of stomach
and jejunum together. {Mayo.)

attach the torn margins of the opening to the stomach (instead of to the suture
line) so as to avoid the formation of a coUar-Hke band at the anastomosis
(Mayo).

In order to give nourishment early after gastro-enterostomy and to avoid
irritating the stomach with food, A Hammestahr (Cent, fiir Chir., Jan. 6, 1903)
uses Rutkowsky's method of combining a gastro-enterostomy with a gastros-
tomy. A catheter is introduced through the gastric fistula into the jejunum
and is kept in place until the stomach is in condition to take care of food.
Feeding is carried on through the catheter. On removal of thf catheter the

MAURY S OPERATION

37^

fistula quickly closes. The method seems entirely unnecessary and objection-
able.

Maury's Method. — Maury's operation is essentially a modification of Mc-
Graw's, but is accomplished with materials always at hand (strong cord in-
stead of elastic ligatures).

Steps 1,2,3 ^re the same as in the preceding operation, except that no clamps
are used.

Step 4. — Lay the chosen segment of jejunum against the lower portion of
the stomach. Insert a row of Lembert sutures, 90 degrees distant from the
mesentery, and so unite the intestine, to the stomach. Leave the ends of this
the posterior line of Lembert sutures, long.

Fig. 490. — Maury's method of gastro-enterostomy.

Step 5. — Thread a straight, round needle (darning-needle), 3 inches long,
with very strong twine. Introduce the needle into the stomach at the point
A (Fig. 490). Be sure the mucosa is penetrated. The point A should be
near the vessels of the greater curvature, and the distance between A and
X (the mid-point of the line of Lembert sutures) should be less than the diameter
of the gut. Bring the needle out from the stomach at the point B, ^ inch from
the beginning of the Lembert suture. Make the needle traverse the intestine
from C to D and the stomach from E to F. The points D and E must be 3^
inch from the ends of the Lembert suture.

Make the same needle and thread traverse the gut from G to H, the stomach
from I to J, and lastly the gut from K to L.

This apparently comphcated but really simple series of stitches forms two
equal triangles the apices of which (A F, L G) are equidistant from the middle
of the base (X).

Step 6. — Pull firmly on the ends of the twine (S, S') and tie very tightly.
This is of great importance, as necrosis of the included tissues is essential.

372

THE STOMACH

Step 7. — Continue the line of Lembert sutures already in place completely
around the site of the twine. The tying of the twine will have thrown the sur-
face of the gut into a number of radiating folds, therefore to obliterate these
while completing the Lembert sutures insert the stitches as much as possible at
the bottom of these sulci.

Wire

Edges of split in transverse
mesocolon sutured to
stomach.

Gaslro-enter ostomy .

Entero-enterostomy .

Fig. 491.

Fig. 492.

Roux's Operation; Operation en Y. — Steps i, 2, and 3, as in posterior gastro-
enterostomy.

Step 4. — Having chosen the appropriate portion of jejunum, empty it of
its contents, apply two clamps, and completely divide the gut between them.
Anastomose w'ith suture or button the open end of the lower segment of gut
to the posterior wall of the stomach (Fig. 493). Anastomose the open end of

the proximal or duodenal segment of the gut to
the side of the lower segment of gut, a few
inches below the site of the gastro-enterostomy.
Many surgeons, to avoid the possibility of
the formation of a "vicious circle" (page 375),
complete the gastro-enterostomy by forming an
anastomosis between the afferent and efferent
loops of jejunum at a point 6 inches lower
down the gut (Fig. 491). Fowler, to make
assurance doubly sure, encircled the afferent
loop, between the two points of anastomosis,
with a silver wire thread to obliterate its
lumen; the same object may be attained by a
purse-string suture of silk around the gut at
the same place, Fig. 492.
Pyloric Exclusion. — The above methods endeavoring to obliterate the gut
lumen have proven unreliable, at least in the case of the pylorus, as the sutures
or ligatures become extruded into the gut which soon assumes its former size.
Lambotte finds that if the ligature is tied tightly enough to obstruct but not
tightly enough to strangulate or cause pressure, then the desired occlusion is
attained and maintained. Brewer uses strips of aluminum instead of threads.
For the same purpose and also to prevent the passage of food into the
duodenum after gastro-enterostomy for duodenal ulcer various methods of

Fig. 493.
tomv.

— Roux's gastro-enteros-

{Monod and Vanverts.)

PYLORIC EXCLUSION

373

pyloric exclusion have been practised. Operative closure of the stomach or
duodenum above the ulcer is not indicated when there is sufficient stenosis due
to the ulceration.

Bier writes: "pyloric occlusion ought never to be omitted in cases of gastro-
jejunostomy when well-marked stenosis is absent and when the operation has
been performed for very painful or bleeding ulcers of the pylorus or particularly
of the duodenum."

1. Doyen and v. Eiselsberg's Method. — -Choose a place to the oral side of the
ulcer and in healthy tissue. Make an opening, close to the lesser curvature,
through the lesser omentum and a corresponding opening close to the greater
curvature, through the gastro-colic omentum. Apply two clamps to the stom-
ach. Place a strip of gauze behind the clamped portion of the stomach.
Divide the stomach between the clamps with a thermo-cautery. Close each
stump by a row of through-and-through sutures buried by a row of serous
sutures.

2. BartleWs Method (Journ. A. M. A., Aug. 15, 1914). — Choose a place on the
oral side of the ulcer (whether of the duodenum, pylorus or pyloric antrum).
Make an opening through the great omentum close to the greater curvature.
Apply two crushing clamps to two-thirds of the diameter of the stomach and cut
between them. Close the wound with through-and-through sutures. Bury
this line of sutures by serous sutures (Fig. 494).

Fig. 494. — Bartlett's method.

Fig. 495. — Bier's method.

3. Bier's Method. — Well to the oral side of the ulcer and on healthy tissue
apply a crushing clamp, e.g., Payr's, to the stomach. Remove the clamp and
replace it by a strong ligature. Bury the ligature with a row of serous sutures
(Fig. 495).

4. Author^ s Method. — ^Ligate and cut away a sufficient tag of great omentum.
Apply this tag like a ligature tightly around the pylorus. Bury the implant
by a row of serous sutures. A strip of fascia may be used in the same fashion
(Wilms).

5. C. H. Mayo's Method. — Introduce a closed hemostat through the great
omentum close to the greater curvature, pass it upwards behind the stomach
and make its point seize the lesser omentum some distance above the lesser
curvature. Pull the lesser omentum behind the stomach out through the per-

;74

THE STOMACH

forated great omentum and then upwards in front of the stomach to be sutured
to the rest of the lesser omentum.

6. Brewer (Surg., Gyn., Obst., Feb. 1914). — Pass a band of aluminum about
5 cm. long by i cm. wide around the pylorus and compress it sufficiently to
obliterate the lumen without interfering with nutrition.

Fig. 498. — {Porta, J. de Chir.)

Fig. 499. — {Porta, J. de Chir.)

Fig. 500. — {Porta, J. de Chir.)

Fig. 501. — {Porta, J. de Chir.)

7. Biondi's Method (Figs. 496 to 501). — In the middle of the anterior sur-
face of the antrum pylori make an incision about 6-10 cm. long in the long axis
of the stomach and duodenum. Most of this incision should be on the gas-
tric side of the pylorus. Cut through the peritoneum and the muscular and
submucous tunics but leave the mucosa intact. Shell a segment of the mucosa

JEJUNAL ULCER 375

as a tube out of its submucous bed and doubly ligate and divide this tube
at each end. Close the wound in the serous and muscular tunics. Of these
methods, section of the pylorus (Doyen, v. Eiselsberg, Bartlett) is the most
efficacious and least safe.

Biondi's operation seems good. Probably the methods devised by the
author and Bier are the simplest and least efficacious.

Instead of using these methods of pyloric occlusion, some surgeons having
supplemented the gastro-enterostomy by making a lateral anastomosis be-
tween the afferent and efferent loops of jejunum completely divide the afferent
loop between the two points of anastomosis and close the open ends of the gut
by purse-string sutures (Fig. 491). This method has all the advantages of
Roux's operation, but does not interfere to the same extent with the mesentery.
It is certain that in the hands of most surgeons, the dangers of the vicious
circle are less than those incident to the complicated methods devised for its
avoidance.

Occlusion of the duodenum must never be practised if the McGraw elastic
ligature or Murphy's triangular string method have been employed in making the
gastro-enterostomy. By these methods it takes about seventy-two hours to
establish gastric drainage. Maury's experiments ("Surg., Gyn. and Obstet-
rics," May, 1906) clearly show that if, in dogs, the gut is divided and both ends
closed at any point nearer to the pylorus than 14 inches (35 cm.) and the distal
segment is united to the stomach by the ligature method, the dog will promptly
die with symptoms of tetany. The death in these cases seems to be from some
form of auto-intoxication due to the want of gastric drainage, because when a
fistula is established between the stomach and the distal portion of gut at the
time of the operation, no such catastrophe arises.

The Vicious Circle.^ — When the afferent portion of gut is so placed that
stomach contents pass into it instead of into the efferent loop, grave conse-
quences are liable to ensue, and to the condition the name "vicious circle" has
been given. The accident seems to be very rare after posterior gastro-enter-
ostomy. Roux's operation, "en Y," almost precludes its possibility, and the
various methods of adding an enterostomy to the gastro-enterostomy give safety
in regard to the vicious circle, but of course add distinctly to the gravity of
the operative procedure. No symptoms of the vicious circle seem to have
followed the performance of the no-loop operation.

Peptic, Gastro-jejunal or Jejunal Ulcer.^ — Braun and Mikulicz have shown
that the duodenum and upper segments of the jejunum are more resistant to
the corrosive action of the gastric juices than are the lower segments of gut.
In posterior gastro-enterostomy the portion of gut opened is 9 inches below
the duodeno-jejunal fold, while in the anterior operation it is 16 to 20 inches
below that point. Several cases of fatal peptic ulcer have been noted after the
anterior operation — hence this constitutes an argument in favor of the posterior
and especially of the no-loop method. The ulcers occur at the point of anasto-
mosis or within 4 inches of it.

Mayo finds that the employment of continuous non-absorbable sutures (even
in the serous coats) in gastro-enterostomy occasionally causes ulceration at the
site of anastomosis.

376

THE STOMACH

If jejunal ulcer is diagnosed some time after the operation of gastro-enter-
ostomy and general treatment has proved useless the abdomen must be opened
again and the anastomosis and neighboring jejunum examined.

Mayo-Robson ("Brit. Med. Journ.," Jan. 6, 191 2) advises as follows:

1. There is ulceration at the anastomosis or in the jejunum. The original
pyloric or duodenal ulcer has healed (without stenosis). Detach the jejunum
from the stomach. Excise the ulcer. Close the openings in the stomach and
jejunum. If the gastro- jejunal ulcer is extensive excise that segment of gut.
Restore the continuity of the gut by end-to-end anastomosis. Close the opening
in the stomach.

2. The pyloric or duodenal ulcer in healing has caused stenosis. Either
choose a new site for posterior anastomosis or perform Roux's gastro-enteros-
tomy, after excising the ulcer or the ulcerated segment of jejunum.

3. The anastomotic opening is healthy; the jejunum alone is affected.
Excise the ulcer, repair the bowel, do not interfere with the anastomosis.

4. If the patient is profoundly ill and unable to bear a prolonged operation
perform jejunostomy, so that he may be fed and the ulcer, whether in the jeju-
num, stomach or duodenum, can be given complete rest until healing is effected.

Choice of Method by Which to Efifect the Anastomosis. — Unless under very
exceptional circumstances the anastomosis by suture is the method of choice.
Where haste is the prime consideration Murphy's button has its place of useful-
ness as a time saver.

Fig. 502.

Fig. 503.

Fig. 504.

Fig. 505

Fig. 506

Fig. 507.

0- X 10. «,uu r

Figs. 502 to 507. — Hour-glass stomach. (Moynihan.)

Operation for "Hour-glass" Stomach. — The figures (502 to 507*) suffi-
ciently explain the older methods of operating on hour-glass contraction of the
stomach. In Fig. 502 an anastomosis is made between the two gastric pouches
at the points X and Y. In Fig. 505 the cardiac pouch, being large and depend-
ent, is united to the jejunum. In Figs. 503 and 504 and incision is made through
the lowest part of the constriction and when the edges of the cardiac side are

* Figs. 502 to 507 are taken from Moynihan's work, but Figs. 503 and 504 have been
modified.

CONGENITAL PYLORIC STENOSIS 377

united to those of the pyloric side, the normal shape of the stomach is more or
less restored. The principle of this operation is identical with that of Mikulicz's
pyloroplasty.

Note that pyloric stenosis may accompany hour-glass stomach. When this
is so, the condition must be corrected or a gastro-enterostomy established.

Hour-glass stomach is the result of ulceration and as carcinoma is often
grafted on to an old ulcer it is wise to excise the affected portion of the stomach
(see Partial Gastrectomy, Segmental Excision of Ulcer, etc). The operations
of gastro-gastrostomy (Fig. 502) and double gastro-enterostomy (Fig. 506)
have not given great satisfaction.

OPERATION UPON THE PYLORUS.

Congenital Pyloric Obstruction. — Cases of congenital pyloric obstruction
which do not promptly yield to medical treatment must be subjected to
operation.

Operation may either avoid or remove the obstruction. Gastro-enterostomy
gives excellent ultimate results, but in this class of case it's death rate is high.
(Scudder, Annals of Surg.,lix, 257, 1914, 23.5 per cent. Downes,Surg. Gyn. and
Obstetrics," xxii 251, 1916, 35 per cent.) The Fredet-Rammstedt operation and
it's modification by A. Strauss seeks to remove the obstruction. Downes re-
ported (Jour. A. M. A., Ixxv, 228) 165 operations by the Fredet-Rammstedt
method with 30 deaths (17 per cent.) while Strauss (Surg. Clinics of Chicago,
ix, 93, 1920) reported 103 operations by his own method with but 3 deaths.

Fredet-Rammstedt Operation. — From beside the umbilicus make a i)-^ inch
incision upwards through the right rectus muscle. Deliver the pylorus and ro-
tate its superior surface forwards. Incise the tumor longitudinally, from end to
to end, through the bloodless area above the limits of the pyloric vein. Carry
the incision down to, but not into, the submucosa which shows a white
glistening membrane. With blunt scissors separate the musculosa from the
submucosa for about 3^ inch on each side of the wound. Gas now escapes from
the stomach through the pylorus to the duodenum and the distended stomach
collapses. (If there is any doubt as to the patency of the pylorus open the
stomach and pass dilating forceps through the constriction. Close the wound
in the stomach.)

Replace the pylorus in the abdomen. Do not suture the wound in the
pylorus. Close the abdomen.

Strauss' Operation. — Open the abdomen and deliver the tumor as in the
Fredet-Rammstedt operation. With a knife make an incision over the most
bloodless part of the tumor throughout its whole extent. Only cut the super-
ficial layers of the musculosa. With the handle of the scalpel split the rest of
the musculosa at the stomach end of the tumor, until the submucosa is
reached. From this point continue the splitting of the muscle down to the
duodenal end of the tumor. Should the mucosa be accidentally opened close
it's wound by a few catgut stitches. Seize the edges of the split tumor with
fingers and thumb and spread them apart like opening a book (Fig. 508).
Be sure that every muscle fiber of the tumor is separated down to the
duodenum. With a blunt instrument separate the mucosa from the musculosa
until the former is entirely free. Make a flap of musculosa with its hinge at

378

THE STOMACH

/ch' r//f

(.\ JnHfi ~; ° f ' ^^f ^^''"u stenosis. The abdomen is opened by a right rectus incision
(I) and the pyloric tumor brought out by means of a blunt hook (2). The superficial lavers of
pentoneum and muscle are incised with the blade of the knife {t, and xa), but the further dis-
section to the mucosa is made with the handle. The flaps of muscle are turned out with the
hngers, exposing the mucosa (4) and the mucosa shelled out. {Aljrcd A. Shauss, in Surgical
Clinics of Chicago, I-ebruary, 1920.) e "

CONGENITAL PYLORIC OBSTRUCTION

379

Buicrcn\i mucosa
heiddsiS'i. Knife
mukiri.-- i'Lfxp-

Fig qoQ —Congenital pyloric stenosis. A flap of muscle is made by sphttmg one of the
leaves of the incision (5) and is stitched over the bulging mucosa (6); this m turn is covered
by omentum (7). A cross-section of the condition as pictured m 6 is shown in b. K^Alited
A. Straitss, in Surgical Clinics of Chicago, February, 1920.)

38o

THE STOMACH

the edge of the longitudinal split through the tumor. Sew this flap over the
bulging muscosa. Pull a piece of omentum over the site of the oi)eration and
fix it there with a few stitches (Fig. 509). Close the abdomen. The opera-
tion is not difficult and has been very successful. The author has used both
gastro-enterostomy and Strauss' operation with satisfaction.

Pylorodiosis. — When pyloric stenosis is due to spasm or hypertrophy of
the sphincter this operation may be indicated, but as it has proved to be by
no means safe and recurrence of the trouble is frequent after its performance,
and as other methods give more certain results, the operation is not much in
favor.

Hahns Method of Performing Pylorodiosis. — Expose the stomach by an
incision to the right of the middle line. With the finger invaginate a portion
of the anterior wall of the stomach and push it, along with the finger, through
the pylorus. When the pylorus is sufiiciently dilated, close the abdominal
wound.

Loreta's Method. — Expose the pylorus. Incise the stomach near the pylorus.
Through the stomach-wound pass the forefinger of each hand into the pylorus
and forcibly dilate it. Instead of the fingers bougies may be used.

Fig. icio.

Fig. 511.

Pyloroplasty. Wrong method.

Fig. 512. — Pyloroplasty. Correct method.

Pyloroplasty (Heineke-Mikulicz operation) is indicated in cases of spasmodic
or cicatricial pyloric stenosis.

Step I. — Expose the stomach near the pylorus by a vertical incision. Ex-
plore the whole stomach lest coexistent disease be overlooked. Separate ad-
hesions which may exist around the pylorus. If possible, pull the pylorus out
of the abdomen. Protect the peritoneal cavity with gauze pads. Clamp the
stomach and duodenum with appropriate instruments {e.g., Doyen's clamps).

PYLOROPLASTY 38 I

Step 2. — Make a small opening into the stomach near the stenosis. Pass a
finger or an instrument through the pylorus as a guide. If is generally advised
to make a longitudinal incision through the anterior wall of the pylorus, com-
pletely dividing the stricture, and then to convert the longitudinal into a trans-
verse wound and close it by sutures (Figs. 510, 511). But, as Mikulicz re-
marked "that is not the way we do it." According to him, the longitudinal
incision is made on the under surface of the stenosed pylorus (Fig. 512, A, B,
C). Having made this inferior incision, unite the posterior edges of the wound
first by a continuous or interrupted row of Lembert sutures, and then by a row
of sutures embracing the whole thickness of the walls. Continue the latter row
so as to close the anterior edges of the wound, and complete the union by in-
serting an anterior row of Lembert sutures. It is very evident that this method
possesses all the good qualities of that usually described, and has the great
advantage, in addition, that it lowers the level of the exit of the stomach.

Finney s Operation. — Finney's operation is a most valuable contribution to
surgery and in many cases it is a desirable substitute for gastro-enterostomy.
When as a result of ulceration there is a spastic condition of the pylorus the rest
secured through gastro-enterostomy gives a very brilliant immediate result,
but as spasm abates food once more resumes its normal route through the py-
lorus, the artificial opening is liable to contract, and recurrence of the trouble
is frequent. In such cases Finney's method is of great service. The presence
of many adhesions is stated to be a contra-indication to the operation but it
was exactly in such a case, where adhesions impeded gastro-enterostomy,
that Finney noticed how closely and conveniently the duodenum and stomach
lay together and at once proceeded to unite them. Many variations in tech-
nique have been devised but the principles of all are the same and the author
will take the liberty of describing the operation as he has done it himself.*
Clamps may or may not be used.

The Operation. — The abdomen having been opened and the pylorus with
the adjacent portions of the stomach and duodenum, if possible, pulled out of
the abdominal wound, protect the peritoneum thoroughly with gauze packs.

Step I. — Unite the adjacent surfaces of stomach and duodenum by a con-
tinuous Lembert suture (A, B. Fig. 514). (Posterior line of serous suture.)

Step 2. — Make the fl-shaped incision XYZ (Figs. 513 and 514), opening
both the stomach and duodenum and dividing the pylorus.

Step 3. — Unite the two posterior edges of the fl incision by means of Connell
sutures or by a through-and-through whipping-stitch (Figs. 514 and 515).
At this stage scar tissue or active ulcers present in the anterior wall of the
stomach or duodenum may be excised through the incision. Ulcers in the
posterior wall may have their overhanging mucous edges trimmed and their
dense fibrous base incised, care being taken to avoid perforation and to stop
all bleeding by ligature or suture. With the same suture unite the two anterior
edges of the fl incision (Fig. 515).

Step 4. — Continue the Lembert suture introduced in Step i, around the
anterior surface of the anastomosis (anterior line of serous suture) and bury
from sight the stitches introduced in Step 3.

* This account of the operation was submitted to Finney and met his approval.

382

THE STOMACH

Fig. 516 shows in section the result of the operation. An examination of
78 cases seen from one to twelve years after operation showed an average of
93.8 per cent, satisfactory results. (Finney, Surg., Gyn., Obst., March, 1914.)

If it is difficult to lay the duodenum along side of the stomach without
tension it is easy to make a vertical incision through the parietal peritoneum
two finger-breadths to the right of and parallel to the descending portion of

Fig. 513. Fig. su-

Figs. 513 and 514. — Finney's operation.

Fig. 515.

Figs. 515 and 516. — Finney's operation

Stomach/.

the duodenum (Kocher). The fingers introduced through the wound in the
peritoneum easily separate the duodenum (and with it, if necessary, the head
of the pancreas) from the vertebral column, vena cava and aorta and so mobilize
the gut that Finney's operation becomes easy.

How extensive ought one to make the new opening between the stomach
and duodenum? Finney makes a very extensive opening and finds it satis-

codmAiN's operation 383

factory. The Mayos think the lower end of the new opening ought not to
reach as low as the ampulla of Vater.

Excision of Gastric Ulcers. — Codman jwints out that ulcers of the stomach
are practically always confined to the lesser curvature; when they are ap-
parently posterior, it is because adhesions to the pancreas, etc., so twist the
stomach as to make the lesser curvature appear to be the posterior wall of
the viscus. Excision of the ulcer-bearing area, when done in the classical
fashion, sacrifices unnecessarily the greater curvature, renders diflScult the
closure of the gastric wound near the oesophagus and does not permit of
thorough exploration of the interior of the stomach.

Codman operates as follows (personal communication) : *

Step I. — Open the abdomen and explore.

Step 2. — Divide the gastro-hepatic omentum. Divide the gastro-colic
omentum leaving intact the left gastro-epiploic vessels. Doubly clamp and
divide the duodenum near the pylorus. Treat the duodenal stump secundum
artem and let it drop back into the abdomen.

Step 3. — At this point the jejunum should be sought and pulled upward
through a slit in the transverse mesocolon. A clamp is applied to it in the
usual manner and it is left ready to take part in the gastro-enterostomy.

Step 4.— Pull the mobilized stomach out of the abdomen. Apply an in-
testinal clamp to the stomach close to the oesophagus and permit the clamp
(well protected by gauze) to go inside
the abdomen. This clamp should
have short handles. It should be
applied to the stomach at right
angles to the direction in which
clamps are usually placed — that is,
it should clamp the stomach trans-
versely. Cut an appropriate slit in
a large sheet of rubber dam. Pull
the mobilized stomach through this
hole and spread the rubber dam as a

protection over the whole territory P^^ .

of operation so that no stomach con-
tents can soil the abdomen. The clamped jejunum can be palpated through
this rubber sheet and when it is needed the rubber can be incised.

Step 5. — Make a free cut across the greater curvature at a point chosen so
that the tip of the greater curvature flap will easily extend to the point of
division on the lesser curvature (Fig. 517). The gastro-epiploic vessels are of
course ligated at the point of section.

It is the fact that both curvatures are sutured transversely that makes
them so much easier to suture and turn in than when one is dealing with a
corner or a point. By this method the corners come in the free part of the
stomach where there is no tension.

When the cut in the greater curvature is made, the latter is held up so
that when it is divided nothing but gas will escape. Beginning on the greater
curvature near the pylorus cut through both the anterior and posterior walls

384

THE STOMACH

on a line directed towards the oesophagus and so excise the whole lesser curva-
ture. At this point all of the stomach can be carefully cleaned out and in-
spected as far as the oesophageal clamp. If necessary the clamp can also be
removed and still more of the lesser curvature excised. If the two main vessels
are tied, the hemorrhage from the free edge may be ignored for a few minutes.
Before completing the section it is well to apply forceps or a stout stitch to the
stomach near the oesophagus and proximal to the line of section in order to
insure against the stump slipping through the intestinal clamp. Ligate the
coronary vessels.

Step 6. — Incise the rubber dam and secure the clamped loop of jejunum.
Lay the greater curvature of the stomach at a suitable place over it having made
a button hole in the posterior wall. Through this pull the loop of jejunum
(the clamp remaining outside the stomach). Working inside the stomach,
open the loop of jejunum and complete the gastro-enterostomy (exactly as in
Maunsell's end-to-end enterorrhaphy) in the simplest possible manner. (Cod-
man says that any method of suture suffices as long as the edges of the sutured
wound project into the stomach; he believes that a single row of ordinary

close sewing is enough.) Remove the
clamp from the jejunum. If there is
any bleeding from the gastro-enteros-
tomy wound it is easily stopped by a
stitch or two.

Step 7. — The greater curvature and
adjacent stomach wall form a large
flap, well nourished by the left gastro-
epiploic vessels. With a mattress
suture unite the end of the above flap
to the upper end of the stomach wound
in such a fashion that the coronary
vessels and the distal divided end of
the left gastro-epiploic vessels are en-
circled by the stitch and the edges of
the wound are everted (Fig. 518). Com-
plete the closure of the stomach by
means of sutures so introduced that the
wound is everted, that is, mucosa to
mucosa. Remove the clamp controlling the gastric circulation. If any bleed-
ing occurs it must be visible and so easily controlled because the edge of the
wound is slightly everted. The preferable suture material is chromicized catgut.
Bury the everted line of sutures by a continuous layer of chromicized catgut
sutures.

Step 8. — Remove the rubber dam and gauze protection. Restore the organs
to the abdomen. Close the abdomen.

Codman claims for this operation that the lesser curvature can be re-
moved up to the very edge of the oesophageal opening. By the use of a double-
headed suture the flap made by the greater curvature is readily drawn up.
The completion of the gastro-enterostomy has been made with ease and the

Fig. siS.

GASTRECTOMY

38s

usual difficulty of attaching the jejunum to the stump is avoided. But the
main point is that unsuspected soft ulcers may be detected when the stomach
is open.

The presence of ulcers or of their sequelae is the most common occasion
for operations on the stomach. When ulcers are present, the lymph nodes
corresponding to the diseased area are generally enlarged and form a good
guide to the location of the disease.

Gastrectomy. Partial gastrectomy. — i. It is imperative to bury by suture
or better to excise by knife or cautery every duodenal ulcer which bleeds easily
or threatens to perforate. Hemorrhage is more common before operation in
gastric than in duodenal ulcer, but hemorrhage subsequent to operation is more
common in the case of duodenal ulcer. One cause of this pecuharity is undoubt-
edly that the fear of malignancy has 'led more frequently to excision of the
gastric ulcer by knife or cautery. The following tables from the Mayo Clinic
are striking.

TiVBLE I. — HeMATEMESIS IN CaSES OF DuODENAL UlCER IN WhICH OPERATION WAS DONE

Jan. I, 1906, to Jan. i, 1918

Total number 2,875

Patients having hemorrhage before operation 583

Patients having hemorrhage before operation heard from. . . 494

Patients reporting hemorrhage after operation 63

Patients reporting hemorrhage after operation but none

before 20

20+
86.0
12. 7"

0.9

Operative
mortality

from all
causes,

per cent.

1.6

1 +

* Or 2 per cent, of the total number.

Table 2. — Hematemesis in Cases of Ulcer of the Stomach in Which Operation was

Done

Cases. Percent.

Operative
mortality
from all
causes,
per cent.

Total number

863

222

180

81 +
8.0*

0-3

3 +
4.8

Patients having hemorrliage before operation

Patients having hemorrhage before operation heard from. . .

Patients reporting hemorrhage after operation

Patients reporting hemorrhage after operation but none
before

Or 1+ per cent, of the total number.

2. It is hardly necessary to say that in cases of well-limited tumors of the
stomach wall as well as in some cases of ulcer the diseased area may be removed
and the wound closed by two layers of suture.

386

THE STOMACH

Balfour's cautery excision of duodenal ulcer is sufficienlly explained by
Figs. 51Q and 520, Journ. A. M. A., Aug. 2;^, 1919). The line of suture may
be reinforced by covering it by adjacent omenlum. Of course this operation
must be combined with gastro-enterostomy.

Excision of Saddle Ulcer. — When a saddle-shaped ulcer or any disease
situated on the lesser curvature is excised, the manner of closing the wound
is very important. If the resulting wound is closed in the long axis of the

Fig. 519. — {Balfour, Jour. A. M. A.)

Stomach, a certain amount of necessary contraction gives rise to an hour-glass
stomach (Fig. 521), the wound must be closed transversely. A good way to
operate is as follows:

Step I. — On each side of the ulcer apply a ligature to the coronary vessels.
Make a longitudinal slit in the gastro-hepatic omentum above the ulcer.
Through this slit apply a volsella to the posterior wall of the stomach about
^^ inch beyond the posterior limits of the ulcer. At a corresponding point
on the anterior surface of the stomach apply a second volsella. By lifting
the volsellae, at ransverse fold of stomach is brought forwards (and lies anterior
to the gastro-hepatic omentum) consisting of the ulcer and portions of the
anterior and posterior gastric walls.

Step 2. — Apply an intestinal clamp to the fold. The blades of the clamps
are at right angles to the long axis of the stomach (Fig. 522).

BALFOUR S OPERATION

387

Ga.stroh.epatLc
OTTven-taTTb

Mattress .■i\xturr

Fig. 520. — {Baljour, Jour. A. M. A.)

Fig. 521. — E.xcision saddle ulcer. Wrong method.

388

THE STOMACH

Step 3. — Excise the ulcer. Payr dries the mucosa with gauze and paints
it with tincture of iodine so as to lessen infection. Close the wound with
catgut sutures applied in the Connel fashion. Remove the clamps. Apply a

Fig. 522. — Excision saddle ulcer.

second row of sutures (fine chromicized catgut) in the Lembert fashion. The
wound is so closed that its scar is transverse to the long axis of the stomach.
Step 4. — Close the wound in the gastro-hepatic omentum.
4. Segmental or Slevee Resection. — Instead of this triangular excision of the

ulcer a segmental or "sleeve" resection of
the stomach may be adopted as it is be-
heved to give a better result as regards
gastric motility. (Stewart and Barber,
Annals of Surg., Nov., 191 6.

Segmental Resection. Step i. — Having
exposed the stomach and the ulcer on its
lesser curvature Ugate the coronary vessels
on each side of the ulcer and divide the
gastro-hepatic omentum close to the ulcer.
At corresponding points on the greater curva-
ture ligate the gastro-epiploic vessels and
divide the gastro-cohc omentum between
those points close to the stomach.

Step 2. — Apply intestinal clamps to the
stomach on each side of the segment to be removed. Cut away the segment
including the ulcer (Fig. 523).

Step 3. — Unite the proximal and distal segments of stomach as in any end-
to-end anastomosis using fine chromicized catgut sutures. If the end of one

Fig. 523. — Segmental Resection.

PYLORECTOMY

389

segment is longer than that of the other, place the sutures farther apart in the
longer than in the shorter segment. Remove the clamps and repair any open-
ings in the omenta.

Transgastric Partial Gastrectomy. — If an ulcer exists on the posterior wall
of the stomach and is adherent to the pancreas it may be possible to gain access
to it by penetrating both the gastro-hepatic omentum and the transverse
meso-colon and then to divide the adhesions, excise the ulcer and close the
wound in the stomach, W. J. Mayo has found it much easier in several cases
to perform a transgastric operation as follows: Incise the anterior wall of the
stomach by a vertical incision; note the extent of the ulcer and its adhesions;
incise the posterior wall of the stomach from the inside around and close to
the ulcer. Remove the ulcer, if necessary shaving off a thin surface of pan-
creas. This shaving of the pancreas is not so formidable as might be im-
agined, because the inflammation which has made it adherent to the stomach

Fig. 524. — Transgastric excision of ulcer on posterior wall of stomach.

has converted the adherent portion, to a large degree at least, into scar tissue.
Close the posterior gastric wound by a row of serous sutures, then by a row of
through-and- through chromicized catgut sutures (Fig. 524). Close the anterior
wound in the stomach.

Pylorectomy and partial Gastrectomy. — Pylorectomy is almost always
supplemented by a partial gastrectomy. The indications for its performance
are usually malignant disease or pyloric ulcer and its sequelae. Before opera-
ting on the stomach especially for cancer, it is of great importance to have a
good working knowledge of the anatomy of the region, a knowledge which the
standard textbooks on anatomy are careful not to give.

The gastro-hepatic or lesser omentum may be divided into three parts:
{a) a thick, strong portion running from the liver to the cardiac end of the
lesser curvature and part of the oesophagus (gastro-hepatic ligament), {b) a
central or thin, often translucent portion, and (c) a thick, strong portion at and
near the right end of the omentum and often named the hepato-duodenal
ligament as it run's from the liver to the duodenum (Fig. 525). The hepato-

390

THE STOMACH

duodenal ligament 's subject to variations which may be understood by the
descriptive names given to it, e.g., cystico-colic ligament; cystico-duodenal

Fh...

I. ft triangular lig. of live

Gall-bladder

Hepa to-duo-
denal lig.

Superior portion
of duodenum

Diaphragm

Transverse colon I'ostirior layer of great omentum

Fig. 525. (Sohotta.)

Right
Gastro- Epiploic
Vessels

esentcric
Vein

Vfssels

Fig. ,26.

ligament; cystico-hepato-duodeno-colo-epiploic ligament (Tuffier and Jeanne,
"Revue de Gyn. et Chir. Abdom.," Jan., iQia).* If a hole is torn through the
thin or median portion of the gastro-hepatic omentum, the lesser peritoneal

ANATOMY

391

cavity (antrum bursae omentalis) is entered. Behind the peritoneum forming
the posterior wall of the lesser cavity lies the caliac axis which divides into
three branches all of which are, to begin with, retro-peritoneal (Fig. 526). These
branches are (a) the splenic which passes to the left to reach the spleen.
During much of its course the splenic artery remains retroperitoneal lying above
and behind the pancreas. Before reaching the spleen the vessel gives off the left
gastro-epiploic artery which runs along the greater curvature of the stomach in
the gastro-colic or great omentum to anastomose with the gastro-duodenal artery.
(b) The hepatic artery which passes retro-peritoneally to the right along the
upper border of the pancreas for a short distance when it enters a fold of per-
itoneum (hepatic fold) through which it reaches the lesser omentum (hepato-
duodenal ligament). In its course the hepatic artery gives off (i) the pyloric

Coronary Art.

IN FalX CORONARIA

Gastro
Duodenal
Ar

Coronary Art.
IN Gastro-Hepatic
Omentum

Splenic Art.

Peritoneum Removed
ExposiNs Pancreas

Fig. 527.

artery which enters the lesser omentum and runs to the left along the lesser
curvature of the stomach to anastomose with the coronary artery, (2) the
gastro-duodenal which runs downwards between the pancreas and the duodenum
and after giving off a duodenal branch, passes in the gastro-colic omentum
along the greater curvature of the stomach to anastomose with the left
gastro-epiploic. ^^

(c) The coronary or gastric artery which passes into the falx coronaria or
gastro-pancreatic fold (Fig. 527) and through it reaches the lesser omentum
near the cardiac orifice of the stomach where, after sending a branch towards the
oesophagus, it runs along the lesser curvature of the stomach to anastomose with
the pyloric artery.

The folds of peritoneum which have been mentioned (gastro-hepatic fold,
etc.) bear to the arteries a relation more or less similar to that of the mesentery
to an intestine.

In the right portion of the lesser omentum i.hepa to-duodenal ligament) lie
from left to right the hepatic artery, the portal vein and the bile ducts. If an

392 THE STOMACH

incision is made through the anterior layer of peritoneum forming the lesser
omentum close to the pylorus it is easy to mobilize the pylorus and the gastric
end of the duodenum without injuring the gastro-duodenal vessels or the
common bile duct.

The lymphatics of the stomach have their ultimate roots in two systems:

1. Under the epithelium and surrounding the gland tubules there is a very
rich plexus of lymphatic capillaries. From this plexus short vessels penetrate
the muscularis mucosae and join another rich plexus in the submucosa. In turn,
the submucosal plexus drains through vessels penetrating perpendicularly the
muscular tunics, into the subserous plexus.

2. Among the fibres of the musculature of the stomach another set of
lymphatics arises and drains into the subserous plexus. There is free anasto-
mosis between the lymphatics perforating the musculosa and those originating
in the musculosa. The lymphatics of the mucosa and submucosa are truly
capillaries — i.e., they are endothelial tubes, are innocent of fibrous and muscular
tunics and are not provided with valves. It is only in the large collectors of
the subserous plexus that valves make their appearance.

The richness of the submucosal lymphatic plexus and its freedom from valves
make it easy for infective or cancerous material to spread along the submucosal
plane. There is such free communication between the lymphatics (submucosal
and subserosal) of all areas of the stomach that, given obstruction to the flow
through one set of collecting vessels, material injected into the subserous or
submucous plexuses can readily travel in any direction from which the outflow
is easiest. Thus, if the primary lymph nodes, through which a certain cancerous
area of the stomach usually drains, become diseased and obstruct drainage
then the drainage will take place by another route and the original disease
spread in the submucosa. While the duodenal submucosa is very similar to
that of the stomach, viz., a layer of loose connective tissue rich in lymphatics
and blood-vessels, yet at the pylorus itself the connective tissue constituting it
becomes condensed and poor in lymphatics, thus there is comparatively little
direct lymphatic communication between the stomach and duodenum. The
duodenal and gastric lymphatics, however, drain into the same lymph nodes
and on their way to these nodes may anastomose, and so there may, on occasion,
take place a retrograde flow of lymph from the gastric into the duodenal vessels.
While this exchange of lymph may not be extensive yet it rnust be remembered.
Clinically we know that cancer can spread from the stomach to the duodenum,
but that this spread is not usually extensive and may be explained in part at
least by the above anatomic facts.

From a practical point of view the surgeon is interested in knowing, first,
how and in what directions gastric cancer spreads in the stomach walls so that
he may make his lines of incision beyond those regions which may be reasonably
considered affected, although no macroscopic evidence of disease may be present;
second, in what directions the disease may have spread through the lymphatics
so that he may excise all those lymphatic territories which may reasonably
be considered involved.

The first of these questions has been fairly answered by the remarks already
made regarding the lymphatic plexuses of the stomach and duodenum. For-

LYMPHATICS

393

tunately the drainage from the pyloric and pre-pyloric portions of the stomach
is so free that it is comparatively rare to find obstruction to it sufficiently
extensive to dam back the infected lymph into the cardiac area, and it is cancer
of the pyloric portion of the stomach which is of particular interest to the
surgeon.

Mesenteric

Fig. 528.

Fig. 529. — Lymphatic drainage areas of stomach. (Cuneo.)

The second practical question is much more difficult to answer. Practically
all of the stomach drains ultimately into the glands near the celiac axis. The
areas adjacent to the lesser curvature drain directly into glands along the
coronary artery; the areas adjacent to the greater curvature drain into the gastro-
colic glands which in turn pass into the subpyloric glands. The pylorus itself
drains both upwards to the suprapyloric and downwards to the subpyloric

^94 THE STOMACH

glands (Figs. 528, 520 and 530). Thus the subpyloric glands (Jamieson and
Dobson, "Lancet," April 20, 1907) are a secondary group for the prepyloric
region, but primary for the pylorus and duodenum. One or two vessels form
the suprapyloric group pass behind the duodenum to low-situated nodes on
the biliary chain.

The subpyloric group drain in two directions, (i) along the gastro-duodenal
artery anterior to the pancreas to the middle superior pancreatic glands which
accompany the hepatic artery before its division; (2) downwards in front of the
pancreas to glands lying beside the superior mesenteric artery.

GanJIion

Pneumoga5iric fti^i

Coronary Artery _
Coronary Vein _

Ganglion

Fig. 530.— (J/ajyo, after Cuneo.)

Remember that the celiac axis is retroperitoneal, that the coronary artery
in its course along the lesser curvature of the stomach lies in the gastro-hepatic
or lesser omentum, but that that portion of the coronary artery between its
origin in the celiac axis and its inclusion in the lesser omentum lies in the falx
coronaria or gastro-pancreatic fold of peritoneum. A number of glands are
present in this fold and through them drains the lymph from the glands in the
lesser omentum. It must be remembered that certain of the lymph vessels aris-
ing near or at the pylorus pass along the lesser omentum, dodge the glands there
present and pass directly into those of the falx coronaria. In operating for
gastric cancer it is usuaUy easy enough to remove with the disease the suspected
lymphatics in the greater and lesser omenta and the subpyloric group, but the
relation of the subpyloric vessels to the superior mesenteric group, the supra-

PYLORECTOMY

395

pyloric to the retro-duodenal biliary group and the direct route of drainage from
the pyloric region to the glands in the falx coronaria are all elements threatening
success in the radical operation for gastric cancer.

Malignant disease of the pylorus usually spreads towards the cardiac end
of the stomach, especially along the lesser curvature; hence in operating in
malignancy it is wise to excise along with the pylorus the whole lesser curva-
ture of the stomach and all suspected lymph-glands. "In cutting across the
stomach the incisions should be i}4 to 2 inches wide of the disease at least"
(Mayo Robson). As malignant disease does not, as a rule, iniiltrate towards
the duodenum, the division of the duodenum may be made at a point about
^^ to I inch away from the disease. "In excising glands from the great

Fig. 531. — Lj^mphatics of stomach.

omentum there is great danger of wounding the middle colic artery and thereby
causing gangrene of the transverse colon. The glands along the greater curva-
ture are most numerous near the pylorus." (Mayo Robson, "Surg. Treatment
Diseases of the Stomach.") This danger is avoided in the method described
below.

In view of the facts stated in the preceding paragraphs, it follows that the
original operations of pylorectomy were defective in extent. When a sufficiency
of the viscus is removed, it will rarely, if ever, be possible to unite the open end
of the duodenum to the open end of the stomach (partially closed by sutvures),
and when possible it will be much more difficult, time-consuming, and risky
than the methods to be described.

Pylorectomy or Partial Gastrectomy. — Step- i. — Open the abdomen,
usually by a longitudinal incision between the ensiform cartilage and the
umbiHcus. Explore the abdomen.

Step 2. — Tear a hole in the thin portion of the lesser omentum and through
this hole feel the coronary artery as it passes in the falx coronaria (gastro-

396

THE STOMACH

pancreatic fold) into the lesser omentum near the oesophageal end of the
lesser curvature of the stomach. With a full curved needle pass two ligatures
round the coronary vessels (Fig. 532) and divide the vessels between them.
Divide the lesser omentum except that thick portion of it called the hepato-
duodenal ligament in which He the bile ducts, the portal vein, etc. (N.B.
The lesser omentum is usually sufficiently divided by the tear made in it
during exposure of the coronary vessels. The portion of the omentum torn is
avascular and innocent of lymph nodes.)

%«li

y
J/

Fig. 532. — Ligation of coronary vessels in the falx coronaria. (Guibt.)

Step 3. — Divide the anterior layer of peritoneum forming the hepato-
duodenal Hgament and pass the finger round the duodenum from above down-
wards between the gut and the portal vein, bile ducts, pancreas, etc. Expose
and tie the pyloric artery.

Step 4. — Pass the left hand from above downwards behind the pylorus
and stomach and lift the great omentum forward. Ligate the right gastro-
epiploic vessels. Ligate, in three or four segments, the great omentum. The
hand behind the omentum protects the vessels of the transverse mesocolon
from being included accidentally in the ligatures. Should this accident happen
the devascularized transverse colon must of course be removed (enterectomy).
Ligate the left gastro-epiploic artery well to the left of the disease and of the
last of the glands in the great omentum if the disease is cancer. Divide the
great omentum leaving attached to the stomach that portion containing lymph

PYLORECTOMY

397

nodes. As the gastro-colic omentum is being divided "it will sometimes be
found that the avascular area which lies in the circle of the middle colic vessels
and the posterior layer of the mesocolic peritoneum is attached to the growth.
If this is the case the attached peritoneum can be cut out and removed with
the growth. The opening thus made in the transverse mesocolon can be
used later through which to make the gastro-jejunostomy" (Mayo).

Step 5. — Continue the division of the gastro-colic omentum towards the
right so as to get below and to the right of the inferior gastro-duodenal lymph
nodes situated below and to the right of the pylorus about the head of the
pancreas (Figs. 527, 528, 531). Lift up the fat and glands from over the head of

Fig. 533. — Blood vessels tied, glands separated, crushing forceps in place, and also clamps
to prevent leakage from part to bt removed. Upper left drawing shows stump of duodenum
in crushing clamp with suture placed for closing. {Mayc.)

the pancreas separating them from the curve of the duodenum but leaving them
attached to the stomach and pylorus. During the above dissection the vessels
anastomosing with the branches of the superior pancreato-duodenal artery are
exposed and tied. Continue the dissection until at least 2 inches of the in-
ferior border of the duodenum is cleared and the gastro-duodenal artery is
exposed in the groove between the head of the pancreas and the duodenum.
Ligate and divide the gastro-duodenal vessels. This permits thorough re-
moval of the glands.

Step 6. — If the gastric growth is adherent to the pancreas, shave oflF a
portion of the pancreas leaving the shaved-oflF portion attached to the stomach.

398

THE STOMACH

If the involvement of the pancreas is extensive "it is better to leave this part
of the operation until the stomach is either cut across and separated from
the (luodinuiii or stomach section on the cardiac side is llnished and the
stomach turned over in order that this portion of the dissection may be
completed under inspection. If such injuries to the pancreas are properly
cared for, we have not found that they give rise to serious consequences. . . .
The best manner of treating such an injury to the pancreas is to cover it as
far as practicable with the sheath and posterior peritoneum, and after com-
pletely closing the end of the duodenum, if possible the stump of the duodenum
should be buried in the injured surface of the pancreas" (Mayo).

KiG. 534. — Crush clamp on stomach. Cautery used to sterilize and prevent carcinomatous
implantation. Stump of duodenum closed. Sutures placed to turn the duodenal stump
into the denuded head of the pancreas. (Mayo.)

Apply two clamps to the duodenum distal to the disease and about 3^
inch apart. The distal clamp should be a very powerful crushing one like
Payr's; for the proximal segment of gut any efficient clamp, such as Ochsner's,
will serve. Cut between the clamps with a cautery and burn the stumps
protruding from the clamps even to such an extent that the Payr's clamp is
heated sufficiently to char the tissues crushed between its jaws. Insert a
continuous fine chromic catgut suture, in the Gushing fashion, the bites being
alternately on each side of the clamp and the threads crossing it (Fig. 533).

Remove the Payr's clamp, pulling its blades out from under the threads.
The divided duodenum is so crushed and charred that it remains closed. Pull

PYLORECTOMY

399

on the ends of the suture. As tension is put on the suture the wound becomes
inverted as by a continuous Lembert suture. Fasten the ends of the suture.
Put in an extra line of mattress sutures to reinforce the closure. Suture the
duodenal stump to the area of pancreas denuded during the mobilization of
the duodenum or to the edge of the fascia which covered the pancreas.

Fif"' 535- — Thierry de Mattel's Clamp.

Thierry de Martel (La Pr. Med., July 7, 1910) uses a powerful clamp which
crushes evenly. Figs. 535 and 536 sufficiently explain it. Two of the clamps
are applied to the duodenum and two to the stomach, section of the viscera
being made between each pair of instruments; de Martel applies an ordinary
intestinal clamp to the intestine before removing the crushing clamp and closes
the viscus with two lavers of suture.*

Fig. 536. — Forceps for closing de Mattel's clamp.

Step 7. — Choose the line of section on the stomach to the left of the lym-
phatic glands into which the diseased area drains (Figs. 529, 530, 531). To
the cardiac side of this line apply Payr's large crushing clamp; to the pyloric
side apply any efficient clamp. Divide the stomach between the forceps
with the cautery and remove the diseased segment. Insert a chromicized
catgut suture in the stomach stump exactly as was done in the duodenal stump,
tightening the suture as the Payr's clamp is removed. Reinforce the line of
suture by a few mattress or Gould sutures of chromicized catgut and bury these
by a line of interrupted sutures.

Step 8. — Perform a posterior gastro-jejunostomy.

If the portion of the stomach left after excision of the disease is very small

* Since this was written de Martel has devised a double clamp which seems convenient
though not essential. (L. Pr. Med., June 30, 1920.)

400

THE STOMACH

it might be technically difficult to perform gastro-jejunostomy and the second
operation might well jeopardize the nutrition of the gastric stump. To avoid
these evils the latter part of Step 7 may be modified by using a method of
anastomosis credited by Mayo to Polya and by Bier to Kronlein. Instead of
closing the gastric stump as described above, anastomose it to the side of the
jejunum as follows: Make an opening in an avascular portion of the transverse

Fig. 537. — Upper jejunum, 6 to 12 inches from origin, brought through an opening which
has been made in the transverse mesocolon and united by outer row of sero-muscular
chromicized catgut sutures to posterior wall of stomach. (Mayo.)

mesocolon; pull the upper jejunum through this opening and lay it along side
the stomach stump without tension. Balfour (Surg., Gyn. Obst., Nov., 1917)
prefers to select a loop of jejunum 14 to 18 inches below the duodenojejunal
junction and bring this loop anterior to the transverse colon so as to reach the
stomach stump without perforating the mesocolon. Apply an intestinal clamp
to the loop of jejunum exactly as in gastro-jejunostomy. Unite the jejunum
to the posterior wall of the stomach behind the Payr's clamp by a row of
chromicized catgut sutures (Lembert or Gould sutures) (Fig. 537).

Apply an intestinal clamp to the stomach proximal to the line of serous
sutures. Remove the Payr's clamp. Unite the open end of the stomach to a

PYLORECTOMY

401

corresponding opening now made in the jejunum, by a row of through-and-
through sutures of chromicized catgut, exactly as in gastro-jejunostomy (Figs.
538 and 539). Remove the intestinal clamps and introduce the anterior row of
chromocized catgut Lembert sutures. Draw the entire anastomosed end of the

l^:in'i><.,ctch

^^■J'

'0 '

Fig. 538.

-Crushing clamp removed from the stomach and holding clamps applied to jejunum
and stomach to prevent soiling. (Mayo.)

Stomach down through the opening in the transverse mesocolon. Unite the
edges of the opening in the mesocolon to the stomach wall (Fig. 540). Some-
times it is not easy to pull the jejunum up to the upper end of the opening in the
stomach or to keep it there without tension. Under these circumstances it is
easy to apply an intestinal clamp well back of the Payr's clamp and after re-

402

THE STOMACH

moving the latter to close the upper end of thr gastric opening by two rows of
suture and then to anastomose the side of the jejunum to the low part of the
stomach opening. When this is done it is well to suture the jejunum to the

JF!y*T^

Fig. 539. — Inner row of catgut through-and-through sutures applied to the posterior
walls, uniting jejunum to cut end of the stomach and continuing part way down the anterior
wall. {Mayo.)

stomach for a short distance alcove the site of anastomosis so that'the unopened
jejunum acts as a patch applied to a part of the line of suture closing the
stomach (Fig. 541).

PYLORECTOMY

403

Moynihan's Technic. — The sequence of steps in the operation as per-
formed by Moynihan is as follows:

The belly having been opened and parts exposed.

(a) Divide the duodenum between crushing clamps. Catch and ligate
vessels individually. Find and remove the subpyloric (subduodenal) lymph
nodes which lie near the second part of the duodenum.

Fig. 540. — Anastomosis completed by an anterior row of scro-muscular sutures. Anas-
tomosed end brought through the opening in transverse mesocolon, and margins of opening
sutured to the stomach. (Mayo.)

(b) Divide, between ligatures, the gastro-colic omentum.

(c) Divide, between ligatures, the gastro-hepatic omentum as high up as
possible. Ligate the coronary artery late; this permits access to it at a high
level and gives access to some high lymph nodes into which lymphatics drain
directly from the pyloric region. Remove the nodes.

(rf) Tear a hole in the mesocolon and pull a loop of jejunum through it.
Perform posterior gastro-enterostomy using the cardiac portion of the stomach.

404 THE STOMACH

The anastomosis is more easily performed before rather than after excising the
portion of stomach to be removed.

■(e) Choose the line of section on stomach. Put in a stay or traction suture
on the lesser curvature well proximal to the line of section. Apply a clamp to
the stomach ^4 inch proximal to the line of section and distal to the stay suture
which forms a great safety if the clamp slips.

(/) Divide the stomach with the cautery.

(g) Suture the mucosa with catgut. Apply two layers of continuous
Lembert (Gushing) sutures, after removing the clamp.

(h) Fix the cut edge of the gastro-colic omentum to the lower end of the
stomach.

v^ilk

•

Fig. 541. — The stomach has been closed from the lesser curvature to the point A. A.B. is
the site of anastomosis. A.C., a portion of jejunum acting as a patch over Billroth's fatal
angle.

[i) Attend to the duodenal stump in the usual fashion and then attach it
by a stitch to the anterior surface of the pancreas.

(/) Pull the great omentum up in front of the transverse colon and tuck it
into the cavity now existing above the colon.

Pauchet's Gastrectomy. — Pauchet (La Pr. Med., Oct., 9, 19 16 Sherwood
Dunn, Am. J. of Surg., Oct., 1916) is a great advocate of the intercoloepiploic
route for exploring the posterior gastric and duodenal walls, for operating upon
lesions of these walls as well as upon ulcers of the lesser curvature.

Step I. — Open the abdomen. Pull the great omentum and the transverse
colon out of the abdomen and reflect them upwards. If slight traction is
made upwards on the omentum and downwards on the colon numerous delicate
peritoneal folds will be seen passing from omentum to colon. Divide some of
these folds carefully close to the gut and begin separating the omentum from
the colon by scissors guided by the finger introduced through the original cut.
As soon as possible enter the lesser peritoneal cavity. Turn the stomach with
the attached omentum upwards, thus exposing the whole posterior surface of
the stomach and doudenum as well as the pancreas (Fig. 542, 543, 544, 545).

In case of a bullet wound of the stomach the anterior wound may be sutured, the posterior
wound found by inter-colo-epiploic separation and sutured. The great omentum may now
be packed into the lesser peritoneal cavity and the. inferior border of the stomach sutured
directly to the colon along the line of its separation from the great omentum.

PAUCHET S GASTRECTOMY

405

Step 2. — (There is extensive ulcer" of the lesser curvature, or hour glass
stomach is present.) Ligate the coronary and gastro-epiploic vessels proxi-
mally and distally to the segment of stomach to be removed.

Step 3. — Choose the lines of section necessary for removal of the affected
portion of the stomach. Apply a crushing clamp to the stomach on each side
of the distal line of section and divide the stomach between them with the cau-

FiG. 542. — Separation of omentum from transverse colon. {Lardennois, Journ. de Chir.)

tery. Burn the pyloric stump protruding from the clamp until the clamp is
heated sufficiently to char the tissues crushed between its jaws (p. 398). Insert
a continuous fine chromic gut suture in the Gushing fashion, the bites being
alternately on each side of the clamp and the threads crossing it. Remove the
clamp. Pull on the ends of the suture until the wound becomes neatly inverted
as by a continuous Lembert suture. Fasten the ends of the suture and rein-
force by a number of mattress sutures. Similarly apply crushing clamps to
each side of the proximal line of section and proceed exactly as described on
page 399, steps 7 and 8. If the disease is cancer, after carrying out step i

4o6

THE STOMACH

m0''y'''^'

Fig. 543. — {Paiichet of Dunn.)

Fig. 544. — {Pauchei & Dunn.)

GASTRECTOMY

407

proceed as follows: Working from below upwards by sharp dissection, separate
the cancerous pylorus from the ])ancreas and mesocolon (Fig. 544). 'There
may or may not be oozing of blood during this step but there will not be real
hemorrhage.'

Slcp 3. — Mobilize the duodenum down to the pancreas. Ligate the vessels
following the u])])er and lower borders of the duodenum. Crush, divide and
close the duodenum as described on ]). 398. As a precaution cover the duodenal
stump with a cap made from remnants of the gastro-hepatic omentum or of
great omentum. This may be done at a later stage of the operation but should
not be omitted.

Step 4. — ^Complete the operation as described on p. 399.

Fig. 545. — {Pauchel er Dunn.)

After-treatment.- — ^The special rules for the after-treatment of stomach opera-
tions are, shortly, as follows:

(a) If the patient is much dehydrated, give intravenous or subcutaneous
infusions of saline solutions. These may be repeated during a few days if
necessary. If not dehydrated and if stimulation is necessary, administer sub-
cutaneously a 20 per cent, solution of camphor in sterile olive oil. As the
patient leaves the operating-table 8 ounces of warm coffee should be given
per rectum. Murphy's proctoclysis is excellent. Transfusion of blood is
often of life-saving value. Morphine in an efficient dose may be administered
if required.

{b) As soon as the effects of the anesthetic wear off (within a.few hours)
raise the patient into a sitting or rather semi-sitting posture. This tends to
obviate pulmonary disturbances and is important.

408 THE STOMACH

(c) Small doses of hot water or tea may be given as soon as nausea is over-
come. Water, if well born by the stomach, is of great value.

(d) It is usually safe to give liquid food twelve hours after operation. If
the stomach is troublesome rectal feeding must be practiced.

(e) These rules are possibly too conservative. Roux permits his patients
to eat almost anything they desire as soon as they desire after gastroenterostomy.

Ultimate results of resection of the stomach for cancer.

Out of ninety-four cases which survived three years or longer and which
were without recurrence at the beginning of the third year only five suffered
from later recurrence. Of the remaining eighty-nine cases the cures had
persisted sixteen years in one, ten years in five, and from five to ten years in
thirty-four. The hope of permanent cure, according to Leriche's figures,
is about 20 per cent. [Leriche, "Rev. de. Med.," Feb., 1906. Ref. "Zentral-
blatt flir Chir.," 1907, No. 29.]

The Mayos' statistics of partial gastrectomies and pylorectomies per-
formed between April, 1897, and January, 19 10, are as follows:

Number of operations 266 with thirty-four deaths (12.4 per cent.). Forty-
two of the operations were nofior cancer. During 1909 there were forty-six
operations w-ith four deaths (8.6 per cent.).

Operations for carcinoma involving the pyloric end of the stomach:
Total number, 224. Average age, 53.

Patients operated on over five years ago: Total number, 50. Present con-
dition known, 39. Alive and well: one 8 years, 2^^ months; one 8 years;
one 7 years 2 months (has since died of recurrence); one 6 years; one 6
years, 11 months; one 5 years, 3)^ months; one 5 years. Total, 8.

Patients operated on over four years ago: Total number, 85. Present con-
dition known, 64. Alive and well, 13.

Patients operated on over three years ago: Total number, 117. Present
condition known, 88. Alive and well, 18.

Patients operated on less than three years ago: Total number, 107.

In one case of gastric carcinoma operated on by the author the stomach was
inseparably adherent to the abdominal wall at the umbilicus and also adherent
to the pancreas. The umbilicus was excised along with most of the stomach.
Three years after the operation the patient was well.

(B) Complete gastrectomy is indicated when the whole stomach is affected
by malignant disease; or if only one part is evidently affected, the rest is in
a suspicious condition. It is useless to attempt a complete gastrectomy if
neighboring structures are involved. Connor first performed this opera-
tion in 1889. The patient lived forty-eight hours. Schlatter subsequently
and independently operated; his patient died one year afterwards from
recurrence.

The Operation. — Open the belly in the middle line by an incision extending
from near the ensiform cartilage to the umbilicus. Divide the greater and
lesser omenta after securing their vessels by chain ligatures. The stomach
remains attached to the body by the oesophagus and duodenum. Pull the
oesophagus downwards as far as possible and apply a clamp to it at as high
a point as can be reached; Clamp the cardiac orifice of the stomach. Divide

DUODENUM 409

the oesophagus between the clamps. Apply two clamps to the pyloric end
of the stomach or to the duodenum and divide between them. Remove the
stomach. Close the open end of the duodenum by a continuous through-
and-through suture covered by a row of Lembert sutures, interrupted or con-
tinuous. Approximate a loop of jejunum to the open end of the oesophagus.
Anastomose the oesophagus and the portion of gut selected by suture or by
the Murphy button. Of course, if the open end of the duodenum can be
approximated to the oesophagus without undue tension, then these structures
ought to be united. (Harvie, "Annals of Surg.," 1900, p. 344.)

Excision of Cardia and Abdominal (Esophagus. — H. Boit (Zent. fiir Chir., xvi, May,
1914) has frequently successfully operated on dogs and once unsuccessfully on man, in the
following manner:

Anesthesia by the Sauerbruch or Meltzer-Auer method.

"Left dorsal flap incision with base near spine. Temporary division of the ribs from
the eighth to twelfth near the longitudinal muscles of the back. Longitudinal opening of
the pleura and peritoneum. Intercostal incision in the seventh interspace with retraction
of the wound in chest. Division of the tendinous diaphragm up to the cardia. Separation
of the cardiac end of the stomach and of the affected oesophagus. -Division of both vagi
immediately above the diaphragm. ■ The stomach and oesophagus can now be pulled out
of the wound and the operation carried on outside of the body. Completely protect the
chest cavity, mediastinum and abdomen with pads. Resect a segment of stomach and
oesophagus. To avoid subsequent stenosis divide the oesophagus obliquely. Close the wound
in the stomach. Make an anastomosis between the fundus of the stomach and the stump
of the oesophagus using two rows of interrupted sutures. Suture both halves of the divided
diaphragm over the line of anastomosis in such a way as to provide the latter with a per-
itoneal covering. Close the diaphragmatic and mediastinal wounds. Close the chest under
hj'perpressure." The great danger apart from shock consists in suture insufficiency. This
is prevented by avoidance of too great dissection of the oesophagus, avoidance of tearing and
crushing of the oesophageal stump and in avoidance of tension on the sutures. Usually the
operation must be preceded by jejunostomy to permit of nourishment being given. During
the laparotomy the abdomen must be explored to determine if the major operation is justifiable.

CHAPTER XXXIV

OPERATIONS ON THE INTESTINES

Apart from operations which are essentially directed against the biliary
passages, or from the operation of gastro-duodenostomy, the only lesion
commonly calling for interference with the duodenum is ulceration. Duo-
denal ulceration is much more common than is usually supposed and has been
largely dealt wdth in the chapter on ulceration of the stomach. The opera-
tive treatment depends on the presence or absence of perforation.

Perforation of the Duodenum. — The ulcer is almost invariably situated
in the first 23>^ inches of the gut, and is, therefore, accessible.

Step I. — Open the abdomen by the right rectus incision. Guided by
evidences of inflammation and by anatomical knowledge, expose the disease.

Step 2. — Cleanse the affected area. Protect the rest of the belly with
gauze. If possible, close the perforations by Lembert sutures. Reinforce

4IO OPERATIONS ON THE INTESTINES

the suture by an omental graft. If possible make the line of suture trans-
verse to the long axis of the bowel; this to avoid stricture. In one case H. S.
Clogg ("Brit. Med. Jour.," Jan. 2, 1905), unable to close the perforation by
sutures, brought up the free edge of the omentum and stitched it around
the perforation with excellent effect. One must remember, however, that this
procedure might form the excuse for the occurrence of an internal hernia. A
free, i.e., non-pedunculated omental graft is entirely preferable. Murphy
writes: "Where the intestinal wall is indurated and adherent to neighboring
tissues it must be sufficiently liberated and freed to admit of an easy apposition
of its convex surfaces with two rows of suture. The failure to free the intestine
from neighboring structures is the most common cause of failure of union."

Step 3. — Provide for drainage through the primary incision; through a special
opening made in the right loin just below the last rib, or when there is much
peritonitis, provide pelvic drainage through an anterior wound and keep the
patient in the Fowler position.

When the patient's general condition is good, it might be wise to follow
Step 3 by performing a gastro-enterostomy so as to give rest to the duodenum
and permit healing" of the ulcer.

Corner has treated duodenal and gastric perforations by mere plugging
with a strip of gauze. This seems a very risky procedure as a duodenal fistula
does not tend to close spontaneously and unclosed is invariably fatal.

A. A. Berg recommends treatment of duodenal fistulae by means of gastro-
enterostomy plus pyloric occlusion. This is thoroughly logical. Pannett
(Lancet, April 18, 1914) in a case of duodenal fistula when the patient was in
extremis from starvation, established a jejunostomy after the Witzel method,
at the same time anastomosing the loop of jejunum going to, with that coming
from the jejunostomy opening. Pannett claims the following advantages for
jejunostomy: "it is technically a simpler operation, because there are few or no
adhesions to be dealt with; a septic area of the abdomen has not to be opened
up; the normal functioning of the pancreas is not interfered with by hindering
the formation of the hormone of the pancreas (secretin), which occluding the
pylorus does.

The disadvantage lies in the fact that a subsequent gastro- jejunostomy,
should it become necessary, would be a very difficult and complicated pro-
cedure. Nevertheless, I think this operation will become the method of choice,
and Mayo has found that \ery few perforated duodenal ulcers subsequently
need a gastro-jejunostomy."

Duodenal Ulceration without Perforation. — The treatment of ulceration
and its sequel, stenosis, has been dealt with in the chapter on gaetric ulcers.

Duodeno-jejunostomy. — Chronic obstruction due to trouble at the duodeno-
jejunal angle may call for an anastomosis between the duodenum and the
jejunum. The distal portions of the duodenum are normally immobile and
thus unless mobilized are inconvenient of access. Kummer ("Bui. et. Mem.
Soc. de Chir. de Paris," xlvi, 1161, Oct., 1920) advises mobilization of the
last (fourth or ascending) portion of the duodenum through Clairmont's inci-
sion ("Beitr. 2 Klin. Chir.," Ixxi, 509). Pull the transverse colon upwards;
retract the small intestines upwards and towards the right. This e.xposes

ENTEROTOMY

411

the duodeno-jejunal junction. Beginning al the inferior duodeno-jejunal fold
make a vertical incision downwards through the posterior parietal peritoneum
and through this mobilize the gut. The rest of the operation requires no special
description.

Enterotomy and Closure of Intestinal Perforations. — Enterotomy is the
operation performed for the extraction of foreign bodies or for the evacuation
of intestinal contents in certain cases of ob-
struction where enterostomy is not indicated.
As the closure of the gut after incision is simi-
lar to the procedure required in perforation,
the two subjects may be treated together.

Step I. — Expose the intestine by an inci-
sion in or near the median line. Exception-
ally some other incision is preferable.

Step 2.— Find and pull out of the belly
the loop of gut to be attacked. (If the case
is one of perforation, empty the loop by strip-
ping it wdth the fingers and apply clamps or
their equivalent.) Protect the belly cavity
with pads.

Step 3. — Make a longitudinal incision
through the intestinal wall on the side opposite to the mesenteric attachment.
Extract the foreign body. Undoubtedly a longitudinal incision when closed
narrows the gut lumen more than does a transverse, but the amount and
danger of this narrowing have been much exaggerated and the longitudinal
cut is the more convenient and practical.

Step 4. — Closure of the intestinal wound.

(A) If the opening is very small, one or two points of Lembert sutures will
suffice, or a purse-string suture may be better (Fig. 546).

Fig. 546. — Purse-string suture.
{Monod and Vanverls.)

Fig. 547. — Intestinal perforation. {Monod and Vanverts.

(B) If the opening, while longer, is linear, insert a row of continuous through-
and-through sutures for hemostasis and occlusion (Connell's Structure is
good), and cover these by a line of Lembert sutures, either continuous or
interrupted. Some surgeons do not use the deep row of sutures, but it is both
a convenient and a safe procedure.

(C) If the opening is large, or so contused or diseased that sutures close
to it will not hold, direct closure, whether transverse or longitudinal, leads
to serious obstruction (Fig. 547). The effects of the resulting stenosis may
be discounted by making an anastomosis between the loop of gut leading

412 OPERATIONS ON THE INTESTINES

to and that going from the stenosis, or the injured segment of intestine may
be excised.

Step 5. — Cleanse the exposed gut. Review the line of suture reinforcing
it, where necessary, by points of Lembert sutures. Remove the protective
pads. Replace the intestines in the belly.

Step 6. — Close the belly.

If there is any fear that the intestinal sutures will fail to do their duty,
many, probably most, surgeons apply a wick of gauze or cigarette drain to
the wounded gut, bringing the free end of the drain out through the parietal
wound. To the writer it appears that such a precaution is liable to lead
to the very state of affairs it is meant to prevent; that the foreign body or drain
close to the line of suture may possibly interfere with the process of repair.

Lateral Anastomosis by Means of Suture. — The following operation is in
all essentials that described by Abbe:

Step I. — Bring outside the abdominal cavity, which is protected by gauze
pads, the loops of gut to be united. Place the loops together in such a manner
that about five inches lie in contact. Squeeze the contents out of the loops and
apply suitable clamps to keep them empty.

Step 2. — Unite the two loops of gut for about four inches by a row of con-
tinuous suture (continuous Lembert), parallel to and not far from the mes-
enteric border. The stitches involve the serous, muscular, and fibrous or
sub-mucous tunics. Fasten the suture with a knot (Fig. 548). The objection
to continuous non-absorbable sutures when used in gastro-enterostomy does
not apply in the case of the intestine where if the suture causes any irritation
it is promptly sloughed into the gut and no harm results.

Step 3. — At a safe distance from the line of suture A, B, make the opening
X, Y, in one of the loops. The opening must be about one inch shorter than
the line of suture A, B. A portion of intestinal wall about one-half inch in
width may be excised along the line of the opening X, Y. This, however,
is optional. Seize any bleeding points with forceps. Payr ("Zent, fiir Chir,,"
March 23, 191 2) wipes the mucosa dry and paints it with tincture of iodine.
This sterilization of the mucosa he finds to be very useful. Repeat Step 3 on
the other loop of gut.

Step 4. — With a continuous catgut suture unite the corresponding edges
of the openings in the two loops of gut (Fig. t;49). This continuous suture
involves all the coats of the intestine and shuts off the intestinal cavity from
the line of Lembert sutures; at the same time it prevents loss of blood. The
suture may be applied in the Connell fashion, v. Schmieden ("Zent. f. Chir.,"
April 15, 1911, No. 15,) advises using the old-fashioned postmortem
suture for the anterior mucosa suture (Fig. 550). This inverts all the coats of
the gut. Rovsing uses a similar stitch.

Step 5. — Continue the line of suture A, B (posterior row of Lembert suture)
completely around the site of the anastomosis (Fig. 549, L, L, L), thus
entirely burying from view the occlusion or hemostatic sutures introduced
in Step 4. Fig. 551 shows the last of these sutures being introduced in the
interrupted fashion. The continuous suture is as good as, or really better
than, the interrupted.

LATERAL ANASTOMOSIS

413

Fig. 548. Fig. 549.

Figs. 548 and 549. — Abbe's operation.

^^^B^H

'' :^' i^

Fig. 550. — {Schmieden.

414

OPERATIONS ON THE INTESTINES

Step 6. — Review the line of suture and if necessary reinforce it by a few
extra stitches. Fig. 552 shows a sectional view of the anastomosis.

Step 7. — Remove the intestinal clamps. Clean the wound. Remove
gauze pads. Return the intestines. Close the abdominal wound.

Fig. 551. — Abbe's operation.

Dr. Charles T. Parkes recommended a smaller opening in the gut than
that described above. After making a longitudinal incision through the

Fig. 552. — Lateral anastomosis.

intestinal wall at a point opposite the mesenteric attachment, he made a short
transverse incision at either end of it and so formed two flaps of gut-wall
which he turned inwards, fastening them in this position by a few sutures

MURPHY BUTTON

415

The turning-in of the flaps prevented contraction of the anastomotic openings.
After making the openings in the opposing loops of gut, Parkes completed the
union by a single row of continuous Lembert sutures, each stitch involving
one-third inch of intestinal wall, the stitches being one-eighth of an inch apart.

"It makes no difference whatever what kind of suture is used, so that
the principle of positively securing the application of two broad surfaces of
peritoneum in contact with each other is certainly carried out." (Parkes.)

Fig. 553 shows how the Abbe operation may be more conveniently per-
formed with the aid of two gastro-enterostomy clamps. The clamps used as
in the diagram simplify the operation amaz-
ingly, hold the segments of gut in convenient
position, prevent bleeding and prevent escape
of intestinal contents.

Lateral Anastomosis by Means of the
Murphy Button. — Step i. — Having opened
the belly, pull the two loops of gut which
it is desired to unite out from the abdominal
cavity and protect the latter with gauze
pads. Empty the segments of intestine and
keep them empty by means of clamps.

Step 2. — Introduce a purse-string suture
of fairly stout silk or catgut into the gut
opposite its mesenteric attachment. The
suture pierces all the coats of the gut.
Make a longitudinal opening into the gut,
large enough to permit the introduction of a
Murphy button of appropriate size. This
cut is in the area surrounded by the purse-
string suture (Fig. 554).

Step 3. — Seize one-half of the Murphy
button with hemostatic forceps and introduce
its head into the gut. Weir has found that
the forceps may so injure the button as to
render it unsafe. Dawbarn plugs the two
segments of the button with corks, thus pro-
viding handles and at the same time preventing escape of intestinal contents.
Cordier has devised ingenious metal handles to plug the button and take
the place of the corks.

Pull the purse-string tight and tie it in such a manner that the opening
in the gut is snugly fastened around the neck of the button (Fig. 555). With
scissors or knife remove any excess of tissue distal to the suture which might
interfere with the proper approximation of the two halves of the button.
Repeat Steps 2 and 3 on the other loop of gut.

Step 4. — Remove the hemostatic forceps or corks from the two halves of
the button. Insert the neck of the male half of the button into that of the
female half and push them together firmly (Figs. 556 and 557). A few points
of Lembert suture may be used to reinforce the union.

Fig. 553. — Lateral anastomosis.

Clamps in place. Posterior row serous
sutures in place. Gut incised; through-
and-through or Connell suture begun.
When the through-and-through suture is
in place completely around the anastomotic
opening, remove the clamps and then
insert the anterior row of serous sutures.
In this diagram it is assumed that a por-
tion of gut has been excised; that both
afferent and efferent loops have been closed.
M. S. indicates the line of union of the
mesentery of the two loops of the gut. No
holes must be left in the mesentery.

4i6

OPERATIONS ON THE INTESTINES

In Step 2 the incision may be made into the gut before the purse-string
suture is introduced. A good method of applying the stitch is shown in Fig. 558.

Fig. 554.

Fig. 555

Figs. 554 and 555. — Use of Murphy's button. {Monod and Vanverts.)

. ,^;v-?<'' fT-'j

Fig. 556. Fig. 557.

Figs. 556 and 557. — Use of Murphy's button. {Monod and Vanverts.)

Fig. 558. — Use of Murphy's button.

Anastomosis by Means of McGraw's Elastic Ligature. — Steps i and 2
are identical with the operation by means of suture.

Step 3. — Thread a piece of well-rounded elastic-cord, about 3 mm. in
diameter, in a straight Hagedorn needle. (The end of the cord is tapered

CIRCULAR ENTERORRHAPHY 417

with a knife to permit of threading.) Pass the needle into the lumen of
the gut and out again at a point about 2)'^ inches distant. The track of
the needle corresponds to the incision made into the gut in the suture
operation. With a sharp jerk pull the needle and with it the elastic cord
through the intestinal walls. The assistant keeps the cord on the stretch
during this manoeuvre. Repeat this in the opposite direction on the other
loop of gut. Tighten the ligature as much as possible; cross its ends and
secure them by a stout silk thread passed underneath and tied on top.

Step 4. — Complete the line of continuous Lembert suture around the site
of anastomosis thus entirely hiding the elastic ligature. This finishes the
intestinal part of the operation.

The elastic cord or ligature establishes a communication between the two
loops of gut in from three to four days. By its use dangers of soiling the
peritoneum by visceral contents escaping during the operation are eliminated.
In the hands of McGraw, Willy Meyer, and others the method has proved
very satisfactory.

End-to-end Anastomosis ; Circular Enterorrhaphy.— In making an end-
to-end anastomosis, whether by means of suture or the Murphy button, it
is of prime importance to understand the anatomy of the mesenteric insertion.
When the mesentery approaches the gut, its two peritoneal surfaces separate
to surround the intestine and leave a A-shaped space loosely filled with fat
and containing the vessels going to or from the gut. Opposite this space the
muscular tunics lie uncovered by peritoneum. The most important stitch
in circular enterorrhaphy is that which closes this space. The author has
frequently operated with satisfaction in the following manner:

Fig. 559. Fig. 560.

Figs. 559 and 560. — Circular enterorrhaphy.

Step I. — Bring the divided ends of the two segments of gut together out-
side the belly cavity. Unite them by a stitch of silk or catgut at a point be-
side the mesenteric attachment, at a point on the free edge, and at a point
midway between these two (Fig. 559). These three stitches insure uniformity
in suturing. The same end may be attained by the use of miniature volsellae.
With a continuous suture, involving all the coats of the gut, complete the
union of the two segments (Fig. 560). This suture stops bleeding and prevents
contamination of the next or essential row of sutures by the intestinal contents.

Step 2. — At the mesenteric attachment introduce a Mitchell-Hunner mes-
enteric mattress suture (Fig. 561), involving the serous, muscular, and sub-
mucous tunics. To secure serous apposition at the mesenteric space there is
no suture comparable to the above. The suture shown in Fig. 562 is less
desirable.

4i8

OPERATIONS ON THE INTESTINES

Step 3. — Introduce a Lembert suture at the free margin of the gut opposite
the mesenteric attachment. Introduce a continuous Lembert suture all
around the gut. Each stitch should pick up about 3.3 inch of the serous
and subjacent muscular tunics. Do not pull the stitches very tight; all
that is required is that serous coat should be kept in touch with serous coat

(Fig- 563)-

Step 4. — Review the wound. Where advisable reinforce the line of union
with Lembert sutures. Beware, however, of causing too much invagination
of the wound and thus producing stenosis.

Fig. 561. — Mitchell-Hunner stitch.

The late Dr. Chas. T. Parkes made use of the continuous Lembert suture
in the manner described, but omitted the provisional suture which penetrates
all the coats of the gut. Parkes writes, apropos of his experimental work:
"The greatest number of mishaps followed drawing the sutures too tightly,
which, if done, leads to death of the applied edges, and, of course, to failure
They must be drawn only sufficiently close to bring the surfaces fairly in con-
tact; the subsequent swelling from obstructed circulation will hold the sur-

FiG. 562. Fig. 563.

Figs. 562 and 563. — -Circular enterorrhaphy.

faces firmly together until glued to each other by the rapidly forming adhesive
material."

End-to-end anastomosis is most easily performed with the aid of clamps.
Any good intestinal clamps, with rubber tubing over the blades, are suitable.

Step I. — Clamp each of the segments of gut about one inch from their
open ends. Place the clamps and contained gut side by side (Fig. 564).

Step 2. — Introduce the posterior row of continuous Lembert sutures
(AB, Fig. 564).

MAUNSETT S OPERATION

419

Step 3. — Beginning at the mesenteric attachment, introduce a Connell
suture (Figs. 564 and 565) completely around the gut, closing it entirely.

Step 4. — -Complete the introduction of the continuous Lembert suture
(AB, Fig. 566).

Fig. 564. Fig. 565.

Figs. 564 and 565. — Connell's suture.

Step 5. — Close the rent in the mesentery.

MaunseWs Operation. — A portion of gut is supposed to have been excised.

Step I. — Unite the severed ends of the gut by two sutures involving the

whole thickness of the intestinal wall. One suture is inserted near the mesen-

.^aii,.

Fig. 566. — Circular cnterorrhaphy.

tery, the other on the opposite side of the intestine. The ends of both sutures
are left long (Fig. 567).

Step 2.- — On the free margm of the larger segment of gut (Fig. 567) make
the longitudinal cut "a" at least one inch from the point of insertion of sutures.

Step 3. — With an eyed probe push the long sutures through the lumen
of the gut and out of the cut "a." Pull upon the threads until the divided

420

OPERATIONS Oy THE IN'TESTINE^S

ends of the gut emerge through the opening "a." Looking at the double
tube of gut protruding through the opening "a" note that their peritoneal
surfaces are in contact (Figs. 568 and 569).

Step 4. — Pass a straight, fine seamstress' needle through the protruded tube
of gut and thus introduce about ten sutures of fine horse-hair or silkworm-gut.
The sutures should be inserted about ^ of an inch from the cut edge of gut.
Pick up the sutures as they pass through the lumen of the gut and divide them,
thus obtaining twenty sutures in position instead of ten. Tie the sutures.

Fig. 567. Fig. 568. . Fig. 569.

Figs. 567, 568, 569 and 570. — Maunsell's operation.

Fig. 570.
(Maylard.)

lodoformize the line of stitches. Cut short the temporary stitches. Pull the
protruded portion of bowel back into its normal position.

Step 5. — Close the wound "a" by appropriate sutures. Repair the mesen-
tery (Fig. 570).

End-to-end Union by Means of the Murphy Button. — This operation is
practically the same as that described for lateral anastomosis. The only
point to be specially noticed is the method of closing the mesenteric space or
insertion with the purse-string suture. Figs. 558, 571, 572, 573 explain them-
selves.

An endless number of contrivances — decalcified bone plates and bobbins,
rawhide plates, catgut rings, segmented rubber rings, vegetable plates, etc. —
have been invented to simplify intestinal anastomosis, but most have been dis-
carded as cumbersome and unnecessary. The same may be said of numerous
devices to support or distend the lumen of the gut while stitches are being
inserted.

Of these, Harrington's segmented metal ring is probably by far the best.
(See "Trans. Am. Surg. Assoc," vol. xxii.)

The operation of lateral implantation, i.e., where the end of one segment
of gut is anastomosed to the side of another, is a combination of end-to-end
and of lateral anastomoses, and is sufficiently explained by Figs. 574 and 575.
Figs. 576 to 580 show a number of varieties of intestinal anastomosis and
implantation.

ConneWs method of enterorrhaphy is similar to Maunsell's in that the sutures
penetrate the whole thickness of the gut- wall, and differs from it in the absence
of the second incision into the gut.

ANASTOMOSIS

421

Fig. 571.

Fig. 572.

V//. , ,■ 1 . , iVVv

Fig. 573.
Figs. 571, 572 axd 573. — Use of Murphy's button. (DaCosla.)

Fig. 574. Fig. 575.

Figs. 574 .axd 575. — Lateral implantation.

422

OPERATIONS ON THE INTESTINES

Fig. 576.

I-'IG. 577-

Fig. 578

Wi-,^

Fig. 570-

Fig. 580.

Fig. 581. Fig. 582.

Figs. 581 and 582. — Connell's suture.

REMARKS ON ANASTOMOSIS

423

Step I. — Place the ends of the gut in apposition, with the mesenteric attach-
ment of one side corresponding to that of the other. Introduce two or more
fixation sutures, F (Fig. 581), to insure accuracy and uniformity in stitching.
Instead of fixation sutures, miniature volsellae may be employed. Introduce
the continuous suture (S) as shown in Fig. 581. In this manner fully two-
thirds or even three-fourths of the circumference of the gut may be united.
The remaining third or fourth of the wound is not so simply united, but if
Fig. 582 is carefully studied, the method will be clearl}'^ understood. When
the two portions of gut are united and the suture pulled sufficiently tight, the
two ends of the suture T, S emerge at the same point (Fig. 583, x).

Step 2. — Introduce through the line of suture at the point Y (Fig. 583) a
threaded needle. Make the eye-end of the needle emerge alongside the sutures
T and S, at the point x. Pass the ends of T and S through the loop of the
thread in the needle and with the needle pull them out through the point Y.

Fig. 583. Fig

Figs. 583 and 584. — Connell's suture.

Step 3.— Slight traction on T and S will bring the mucous surface of the gut
at the point x into contact with the mucous surface at the point Y (Fig. 584).
If now the sutures T and S are tied tightly together and the knot allowed to slip
through the line of union at the point Y, this will sufiiciently fasten the sutures.
The student is strongly advised to familiarize himself thoroughly with this
method before attempting it on the living. An old coat makes a good model
on which to practise this operation. Imagine the wrist ends of the sleeves
to be open ends of gut, and unite them. A few minutes of such practice with
a coarse needle and thread makes easy the comprehension of this rather puzzling
stitch.

Remarks on Anastomosis. — In the preceding pages many methods have
been described by which union between various segments of the gastro-intestinal
canal may be effected for various purposes. The experienced surgeon has
no difficulty in making a selection of the method which will serve his purpose
best; a hint suffices to equip him for the performance of some modified operation
with the details of which he was not previously familiar. With the beginner
in operative surgery it is entirely different. He ought to select a general method

424 OPERATIONS ON THE INTESTINES

of operating suitable for almost all cases, he ought to practise this method ad
nauseam on intestines removed from hogs (vivisection is here unnecessary)
until he almost can carry out the minutest details with his eyes blindfolded.
Having once established for himself a basal or normal method of operating,
excursions into the more refined elegancies of technic become easy and often
desirable.

Lateral anastomosis is the most universally applicable method of uniting
one segment of gut to the other. It is the basal method of operating and must
be mastered in every detail by the surgeon before he presumes to open the ab-
domen for any purpose, as in the course of the simplest of intra-abdominal
operations circumstances may arise which compel interference with the in-
testinal canal.

The following operations are either identical or almost identical with lateral
anastomosis:

A. Gastro-gastr ostomy in Hour-glass Stomach. — (a) Union of the two stomach
pouches by a moderate-sized opening. (Identical with lateral anastomosis.
(b) Union of the two pouches with restoration of the normal shape of the
stomach. This procedure is practically the same as Finney's operation.
(Almost identical with lateral anastomosis.)

B. Finney's Operation. — Gastro-duodenostomy. (Almost identical with lat-
eral anastomosis.)

C. G astro-enter ostomy. — (Identical with lateral anastomosis.)

D. Cholecystenter ostomy. — (Identical with lateral anastomosis.)

E. Enter o-enter ostomy. — ^Lateral anastomosis — indicated after excision of gut

{e.g., in gangrenous hernia, tumor, etc.)
or for purposes of intestinal exclusion.

E. Enter o-colostomy. — ^Lateral anas-
tomosis.

G. Monari's uretero-ureter ostomy is
practically identical with lateral
anastomosis.

Resection of a Portion of Small

c/amp. Intestine. — The indications for this

operation are localized malignant or

benign tumors; localized tuberculous
Fig. 585. — Enterectomy. , . ° ^ . .

lesions; gangrene; trauma extensive

enough to contraindicate local suturing, etc.

The Operation. — Step i. — Open the belly in the middle line.

Step 2.— Pull the affected loop of gut outside the belly and protect the
peritoneal cavity with gauze pads.

Step 3.— Empty the contents from the intestinal loop by "stripping" with
the fingers. Apply clamps.

Step 4.— Note the blood-supply as it passes through the mesentery. Ligate
the vessels supplying the portion of gut to be removed.

Step 5. — Divide the intestine on each side of the disease at a point where
it is well supplied with blood (Fig. 585). Section of the gut should be made
obliquely, more of the free border being removed than of the mesenteric. This

ENTERECTOMY 425

is done: (a) because when obliquely divided the open ends of gut have a greater
circumference than when cut transversely, and hence allow for the loss of
diameter occasioned by suturing; (b) because the gut- wall on the non-attached
border is more liable to be well nourished. If desirable, excise a V-shaped
portion of mesentery corresponding to the segment of gut removed.

Step 6. — Either unite the ends of the gut by an end-to-end anastomosis or
close them by means of suture, preferably purse-string, and provide for
intestinal continuity by a lateral anastomosis.

Step 7. — If a V-shaped portion of mesentery has been removed, unite its
edges by suture. If this has not been done, fold any redundancy upon
itself and secure by a few stitches, being careful not to interfere with the
nutrition of the gut. When several feet of intestine have been
excised and especially when the mesentery is loaded with much fat
it is impossible to suture the mesenteric wound neatly, leaving no raw
surfaces. Even after much has been accomplished by suturing it is certain
that a larger or smaller mass will protrude from the mesentery and if un-
covered by peritoneum will invite adhesion and consequent ileus. When
such a raw stump is present, choose a suitable portion of omentum; ligate
and cut it oflf. Spread the omental sheet, thus obtained, over the raw stump
and fix it by a few sutures.

Step 8. — Review the wound. Cleanse. Remove gauze pads. Return the
gut into the belly. Close the abdomen.

Caecectomy is indicated in cases of malignant or tuberculous disease, in
some cases of intussusception, as well as in some cases of mobile or enlarged
caecum. Moynihan writes (Brit. Med. J., July 12, 1919):

"Many patients who suffer from vague dyspepsias, ascribed perhaps to
intestinal stasis, or to chronic appendicitis, disclose on the operation table this
condition: A membranous band, broad above, where it takes origin from
the posterior abdominal wall, the under surface of the liver, the pelvis of
the gall bladder, the cystic duct, and the duodenum, narrows below as it crosses
the ascending colon to be lost on the peritoneum, to the inner side of the ascend-
ing colon, and on the enteric mesentery. Below this band, which is quite differ-
ent from a "Jackson's membrane," the caecum and the ascending colon are
distended and soggy. Very often the appendix looks turgid, thick, and stiff.
Removal of the appendix, to which the troubles are ascribed, gives little or no
relief. Division of the band allows adhesions to re-form. The only practice
likely to give good results is the removal of the terminal ileum, ceecum, and
ascending colon. The performance of gastro-enterostomy, of course, makes
matters worse."

Step I. — Open the abdomen in right semilunar line; expose and examine the
diseased organs.

Step 2. — Incise the posterior parietal peritoneum at the outer side of the
caecum and ascending colon. Free the caecum from its bed by finger dissection.
Ligate and divide the branches of the ileocolic artery to the necessary extent.
Completely mobilize the diseased segment of gut. The caecum may be so
mobile, i.e., so well provided with mesocaecum, that ligatures or clamps may
be applied directly without preliminary dissection.

426

OPERATIONS ON THE INTESTINES

Step 3. — 'Treat Ihe mobilized gut as in Paul's colectomy or proceed as
follows:

With two crushing forceps applied about i inch apart strongly clamp the
ileum at a point 6 to 8 inches above the Ciccum. Divide the gut between the
forceps. Cleanse the cut surfaces.

Treatment of the proximal segment of the ileum: (a) With a continuous
suture tightly close the open end of the gut {i.e., distal to the clamp); (i) sur-
round the gut about 13-2 inches proximal to the clamp with a purse-string suture;
(c) remove the clamp; invaginate the sutured end of (he gut and tighten the
purse string sutures.

Duodeniim

^ a. Colica dextra

-f—a. Colica
i Ileo-colica

Peritoneum

Ileum

Fig. 586. — Ileum anastomosed
ascending colon.

Peritonealization of wound. Divided ends
of ileum and colon closed.

to Fig. 587. — Lymphatics and vessels of cjecum.

In the same manner with crushing forceps doubly clamp and divide the
ascending colon distal to the disease. Remove the diseased segment of gut.
Treat this distal segment of colon in the same manner as the ileum.

Make a lateral anastomosis betw^cen the ileum and the colon or sigmoid, or,
as is better, unite the end of the ileum to the side of the colon as described in
the following paragraphs.

Repair the wound in the peritoneum (peritonealization) (Fig. 586). To do
this it may be necessary to mobilize the parietal peritoneum on both sides of
the raw surface left by the removal of the caecum. Unless the peritoneum is
mobilized and freed from the ureter when sutures are inserted and tied, the
ureter may be kinked.

Jamison and Dobson ("Lancet," April 27, 1907) have made a very thorough
study of the lymphatic system of the cfficum. The relation of the lymphatics
training the caecum and ascending colon to the ileo-colic vessels is shown in
Fig. 587-

C^CECTOMY

427

Another niethod ol" opcraUug is as follows: —

Step I.— Open the abdomen freely through the right rectus muscle. Apply
an abundant protecting jnick of gauze to the median side of the colon.

Step 2. — Incise the parietal peritoneum along its line of reflection on to the
gut throughout the whole length of the outer side of the ascending colon. By

Fig. 588. — Mobilization of caecum and ascending colon. Note duodenum and ureter

exposed. (Mayo.)

finger and gauze dissection raise the caecum and colon from their bed and con-
tinue the dissection inwards so as similarly to mobilize the ileo-colic vessels,
the lymphatic vessels and nodes along with the peritoneum covering them on
the median side of the mobilized gut (Fig. 588). The ureter and part of the
duodenum are exposed by the dissection. If in case of carcinoma the ureter
is involved it may be removed and the kidney with it. Doubly ligate the ileo-

428 OPERATIONS OX THE INTESTINES

colic vessels high up. Similarly ligate them low down, not far from their
junction with the superior mesenteric vessels supplying the terminal ileum.

Step 3. — Apply two crushing clamps to the ileum about three inches from
the ileocecal valve and divide it between the clamps with the cautery.

Step 4. — From below up divide the mesentery of the caecum and colon.
Ligate and separate the omentum from the right one-third of the transverse
colon. (If the operation is being performed for non-malignant disease it is
unnecessary to remove so much mesentery or to excise the lymphatics.)

Step 5. — Divide the transverse colon with the cautery between crushing
clamps. Remove the mobilized segment of bowel.

Step 6. — By stripping with the fingers push away the contents of the trans-
verse colon for about four inches from the crushing clamp and apply an intes-
tinal forceps there. Before removing the crushing clamps introduce a chromi-
cized catgut suture as shown in Fig. 594 but do not yet tighten it. Remove
the clamp and between the sutures pass the female (spring) part of a Murphy
button into the bowel. Complete the suture of the end of the colon. Leave
the ends of the suture long. Manipulate the button within the bowel so that
its tube is pressed against one of the longitudinal muscular bands about 2}-^
inches from the end of the bowel. Make a crucial incision over the tube of
the button just large enough to permit the tube to emerge and be tightly hugged
by the gut walls. Secure the edge of the button with a hemostat. Similarly
control the contents of the ileum by means of an intestinal clamp, remove the
crushing clamp, surround the open end of the gut with purse-string suture,
insert the other half of the Murphy button and secure it by the purse-string.

Push the two halves of the button together in the usual fashion, if necessary
inserting a few supporting sutures. This gives an end to side anastomosis.
Close the opening in the mesentery beside the anastomosis.

The Mayo's strongly recommend the "button" operation in this locality
but the anastomosis can easily be made by sutures. A side to side anastomosis
is often used but the blind ends may dilate and cause trouble as the author has
found in at least one case.

Step 7. — By judicious suturing cover the raw surfaces with peritoneum.

Step 8. — Bring the blind end of the colon into but not through the muscular
layer of the abdominal wound. Permit the long suture left attached to the
colonic stump to emerge from the wound. Pack the wound down to the intestinal
stump. Suture all the rest of the wound. If there is great distension of the
blind end of the gut between the fourth and sixth days the gas may be let out
by puncturing the gut under guidance of the suture. If there is no need of punc-
ture the suture may be cut short, the small gauze pack removed and the wound
permitted to heal.

Step 6 may be modified so as to secure an end-to-end anastomosis. A
difl&culty to be overcome is the smallness of the circumference of the ileum com-
pared to that of the colon but a small longitudinal incision along the ileum on
the side remote from the mesentery will so increase the extent of free edge that
the end-to-end union becomes easy. Oblique section of the ileum fulfils the
same purpose.

COLECTOMY 429

Partial Colectomy.* — The sigmoid or the transverse colon may be removed
in the same manner as described under the title "Enterectomy" except
when the sigmoid is not sufficiently mobile. The ascending and descending
portions of the colon are usually well fixed to the parietes and require
special treatment. Excision of the ascending colon is practically the same
as caecectomy.

When colectomy is demanded because of practically complete obstruction
due to carcinoma, Desmarest urges a preliminary caecostomy. The opening
into the caecum should be large so as to permit complete evacuation of the bowel
contents and frequent lavage for some days before the colectomy is attempted.
The preliminary treatment has an added value in that it favors the dis-
appearance of oedema from the gut walls near the site of obstruction.

Under local anesthesia open the abdomen over the caecum by the gridiron
incision. The distended caecum immediately pushes into the wound. Punc-
ture the caecum with a small trocar to get rid of gas. Exteriorize a large cone
of caecum and apply an intestinal clamp to the base of the cone. Proximal
to the clamp suture the bowel to the edges of the peritoneal wound. Place
gauze under the clamp to protect the wound. Open the gut widely and clean
the mucosa with tincture of iodine. Suture the wound in the gut to the skin
in such a manner as to make the mucosa overlap the skin wound a little. Be
particularly careful to accurately suture both angles of the wound. To do this,
insert a ' U ' suture through the angle of the wound in the gut and pass both
ends of the suture from within out through the skin. As the intestinal clamp
is being removed tie the U suture.

Excision of Descending Colon. — Step i. — Open the abdomen in the left
semilunar line. Explore. Protect the rest of the abdomen with warm gauze
pads. Desmarest (La Pr. Med. July 3, 1919) strongly recommends a
transverse incision on the left side above the umbilicus. This not only
gives very free exposure but permits of convenient posterior drainage.

Step 2. — Incise the parietal peritoneum immediately external and parallel
to the descending colon. This incision ought to extend well above and below
the level of the disease in the colon. By blunt dissection with finger and gauze
it is easy to raise not only the colon from its bed but the colonic vessels as well,
along with the posterior parietal peritoneum, to the inner side of the colon. An
artificial mesocolon is thus formed containing the blood-vessels but only
covered by peritoneum on one (the inner) side (see Caecectomy). Be careful
to avoid injuring the ureter. Continue mobilizing the colon (if necessary even
its splenic flexure) until all the diseased segment can be delivered through the
abdominal wound without tension. If care has been used in the blunt dis-
section no harm has been inflicted on the blood-vessels. Bring the diseased
segment of gut out through the abdominal wall.

Step 3. — Doubly ligate and divide the vessels going to the diseased segment
of gut, thus leaving that segment completely free except for its continuation
above and below. The ligation should be done high up on the vessels so that
the lymphatic glands may be reached. The vessels may be tied either from

*For Transversectomy, see page 435.

430

OPERATIONS ON THE INTESTINES

behind after the gut has been mobilized or from in front as may be convenient.
Dissect all fat and lymphatic tissue from the site of ligation towards the gut
along with those portions of the vessels attached to the gut. Ligation of the
vessels near their origin is most important, but it necessarily devitalizes a large
extent of bowel and all of the devitalized gut must of course be removed which

Fig. 589. — (C. L. Gibson.)

is really an advantage as ultimate success depends on thorough removal of
the disease. Of course in non-malignant disease, e.^., diverticulitis, such ex-
tensive resection is entirely unnecessary.

Step 4. — At a safe distance above the disease and the devitalized bowel
apply a crushing clamp to the gut, and an inch or an inch and one-half higher
up apply an intestinal clamp to the gut. Divide the gut between the clamps
and sterilize the stumps with the cautery, carbolic acid or tincture of iodine.

COLECTOMY

431

Similarly apply clamps (the crushing clamp nearer the diseased segment) below
the disease and divide the gut. Remove the diseased segment.

Step 5.^ — ^Approximate the divided ends of the intestine. This is usually
possible if mobilization has been sufficiently free. Moynihan urges that thor-
ough mobilization of the splenic flexure, without injury to its vascular supply,
is often necessary to secure approximation of the intestine after resection.

Method A. — Restore the continuity of the gut by means of Murphy's button
or by the ordinary circular enterorrhaphy.

Method B. — C. L. Gibson's method ("Annals Surg.," July, 1910). Seize
the upper cut edge of gut with two Kocher's forceps and push it into the lumen
of the lower end as far down as possible. Rotate "the upper segment about
a quarter circle so that the non-peritoneal surfaces do not entirely approximate
.in the circumference." Introduce a sufficient number of Lembert sutures as
shown in Fig. 589. When tying the sutures tuck in or invaginate the upper
edge of the lower segment as shown in Fig. 5 go.

Fig. 590. — (C. L. Gibson.)

Method C. — The diseased segment of gut has been delivered and its vessels
ligated and divided as in Step 3, but the gut has not been divided. Make
a lateral anastomosis between the afferent and efferent loops of gut. Doubly
clamp the afferent segments between the anastomosis and the disease. Divide
the gut between the forceps. Close with sutures the open end of the gut
next the anastomosis; remove the clamp; invaginate the stump by means of
a purse-string suture or a line of Lembert sutures. Do the same with the
efferent loop. Suture the two stumps to the parietal peritoneum.

432

OPERATIONS ON THE INTESTINES

Method D. — If it has been necessary to remove the splenic flexure along with
the descending colon, close the open ends of the gut and make a lateral anas-
tomosis between the transverse and the remnant of the descending colon or
the sigmoid. If the whole colon and caecum have been excised perform ileo-
sigmoidostomy.

Method E. — Stephen Fenwick (Trans. R. Soc. Med. Surg. Sect., VII, No. 5)
after excising a tumor of the sigmoid along with a V of mesentery found that
an interval of about 3 inches existed between the segments of gut to be united,
even after he had pulled the rectum up as far as possible. To fill the gap he
selected a convenient loop of ileum about 5 inches in length, applied two intes-
tinal clamps at each end of this loop, divided the gut between the clamps and
carried the incisions up the meso-ileum between its vessels. He next united
the proximal and distal segments of ileum by end-to-end anastomosis, and im-
planted the mobilized segment of gut, by means of two medium-sized Murphy
buttons, to fill the defect in the sigmoid. The holes in the mesentery were
carefully sutured. Recovery took place in spite of various compHcations.
The bowel action was satisfactory and in three years there was no recurrence.
Step 6. — Repair the wound in the peritoneum. Close the abdomen.
Partial Colectomy in Two Stages. — Steps i, 2, and 3 as in the preceding
operation.

Step 4. — Method A. — Exactly as in Step 5, method C of preceding operation,
make an anastomosis between the afferent and efferent loops of gut but do not

yet excise the disease. Partially close the abdominal
wound around the protruding intestine. Apply
dressings.

Method B. — Deliver the diseased segment of
gut. Unite with sutures the afferent to the
efferent loops as they pass through the abdominal
wall. Partially close the abdominal wound.

In both methods A and B the diseased segment
of gut is excised after the lapse of from 12 to 48
hours. No anesthetic is usually necessary while
removing the disease but bleeding is usually very
free requiring many ligatures or sutures to be
applied to the mucosa and submucosa. The result
is of course a fecal fistula which maybe closed later.
Method C. — (Paul's Colectomy.) Sew together
the healthy segments of gut as they pass through
the abdominal wound. Make an incision into the prolapsed gut above and
below the disease. Into each intestinal opening pass a glass tube (Paul's,
MLxter's) andligateit there. Fig. 591. Cut away the diseased portion of gut.
Partially close the wound. Apply dressings.

Complete Colectomy. — The transverse colon may be removed in the manner
described under the title "Enterectomy," hemostasis being effected by a chain
of ligatures applied to the transverse mesocolon and the great omentum
between the stomach and colon. This method necessarily sacrifices the great
omentum and leaves clumsy stumps which it is difiicult to peritonealize
satisfactorily.

Fig. 591. — Paul's colectomj-.
{Maylard.)

COLECTOMY

433

The writer has found the following operation devised by Lardennois (Journ.
de Chir., June, 1914) to be unexpectedly easy while by it the omentum is
saved, hemostasis is simplified, clumsy stumps are avoided and if mobilization
of the hepatic and splenic flexures is necessary such is easily accomplished.

Slep I. — After opening the abdomen and making a thorough exploration,
pull the great omentum and transverse colon out of the abdomen and reflect
them upwards. If slight traction is made upwards on the omentum
and downwards on the colon numerous delicate peritoneal folds will be

Fig. 592. — Separation of omentum from transverse colon. {Lardemiois, Journ. de Chir.)

seen passing from the omentum on to the colon (Fig. 592). Divide
some of these folds carefully close to the gut and begin separating the omentum
from the colon with scissors, guided by the finger, introduced through
the original cut. Often during this dissection the operator will think he has
button-holed the omentum but usually his fears prove baseless but if this
accident has occurred it is not of much importance unless a very large hole has
been torn. Continue the separation of the omentum upwards until not only
the colon but the transverse mesocolon as well, lie free from the omentum

434

OPERATIONS ON THE INTESTINES

which is reflected upwards out of the way. When separation of the omentum
from the colon is done to gain access to the lesser peritoneal cavity and to the
posterior wall of the stomach the layer covering the transverse mesocolon is
not elevated but is divided at or near its colonic attachment. Unless mobiliza-
tion of the flexures is necessary or total colectomy is indicated proceed to Step 3.
Step 2. — Mobilization of the ascending and descending colon. Placing the
finger flatly on the mesocolon burrow towards the left under the suspensory
ligament of the splenic flexure and divide this avascular peritoneal band. This

Fig. 593. — {Lardennois, Journ. de Chir.)

detaches the splenic flexure more easily than is possible by any other means.
Retract the descending colon upwards and continue the incision which mobilized
the flexure, downwards through the parietal peritoneum close to its reflexion
on to the descending colon and with the finger separate the colon from its bed.
This mobilization of the descending colon and its vessels may be carried out
freely even to a point not far from the middle line. In a similar manner the
hepatic flexure and the ascending colon may be mobilized, care being taken to
avoid injuring the ureter.

COLECTOMY

435

Step 3. — Return the great omentum into the abdomen. Lift the colon
into the air so as to spread out its meson and make its blood-vessels clearly
visible. If the transverse colon alone is to be excised, doubly clamp the vessels
passing to that part of the gut, divide the meson between the clamps, excise
the desired portion of intestine and restore intestinal continuity by a lateral
or preferably, an end-to-end anastomosis. If a more complete colectomy is
necessary it is easy to assure exact hemostasis by applying ligatures to the
middle and right colic arteries near their origin, and to the left colic vessels at
such points as will not endanger the vitality of the gut which is to be retained.
Divide the mesocolon along the line shown in Fig. 593.

Step 4. — The whole colon is now free except for its continuation into the
caecum and sigmoid.

Place the patient in Trendelenburg's position so that the small intestines
can be kept out of the way.

Choose the point of section on the pelvic colon. Crush the gut with forceps
(Doyen's; Payr's) and apply a silk ligature tightly
in the groove left by the forceps. Apply a strong
clamp to the gut a little above the ligature. Divide
the gut with a cautery between the ligature and the
clamp and place the clamped (upper) end of the gut
away from the field of operation. Insert a purse-
string suture around the distal (ligated) segment of
gut and invert the stump. Instead of removing the
Payr's clamp one may cut between it and the clamp
on the upper segment of gut, with a cautery, being
careful to destroy all the tissue between the two
clamps and to thoroughly sear or desiccate the tissues
crushed between the blades of the Payr's clamp
(distal segment of gut). Keeping the clamp in situ
insert a continuous suture, the alternate stitches
being on opposite sides of the clamp (Fig. 594)
and the loops of the thread passing over the clamp. Remove the clamp.
The crushed and burned edges of the wound adhere together so that there is
no danger of the lumen of the gut opening or of bleeding occurring. Trac-
tion on the two ends of the silk suture causes a neat and thorough invertion
of the wound. Fix the ends of the suture and insert a second row of sutures.

Step 5. — Mobilize the caecum and lower end of the ileum as in caecectomy.
Ligate the ileocolic artery at an appropriate point. Choose the site for dividing
the ileum. Immediately distal to this site apply a crushing forceps (Ochsner's
forceps) to the ileum. Above this line of section apply a reliable intestinal
forceps. Divide the gut close to the crushing forceps. This completes the
excision of the colon.

Step 6. — Implant the end of the ileum into the side of the pelvic colon.

Step 7. — Review the wound left by the removal of the colon and cover all
raw surfaces with peritoneum.

Lane at this stage of the operation has an assistant pass a rubber tube
through the anus and the surgeon guides it through the anastomotic opening.

Fig.

594-

436 OPERATIONS ON THE INTESTINES

Such direct drainage of the small intestine for a few days is distinctly
valuable.

Subcaecal Colectomy.— If it is justifiable to preserve the caecum when
a colectomy is indicated Lardennois thinks it is very advantageous to do so,
as one then saves the very active terminal ileum, the ileocaecal valve and the
caecum itself where valuable digestive processes take place.

The Operation. — Mobilize the colon and divide its mesenteries as in total
colectomy but do not yet interfere with the caecum. Choose the site of section
in the ascending colon. Apply a crushing clamp (Payr's) to the caecal side
of the line of section and a strong Ochsner's clamp to the distal side. Divide
between the clamps with a cautery. Lay aside (well protected) the clamped
distal segment of gut. Apply a continuous silk or chromicized catgut suture
to the clamped caecum by means of which the wound is
closed and inverted when the clamp is removed exactly as
the pelvic colon was treated in complete colectomy.
Choose a portion of the sigmoid which can be brought
without tension into apposition with the blind fundus of
the caecum. At this site apply two clamps to the sigmoid
(a crushing clamp above, an intestinal clamp below) and
divide the gut between these clamps. The resected por-
tion of the colon is now removed. Apply an intestinal
clamp to the fundus of the caecum. Anastomose the end of
the sigmoid to the fundus of the caecum. Fig. 595. The
■TIG. 595. appendix ought, of course, to be removed. ObHterate all

openings through which a loop of small intestine might penetrate and give
rise to obstruction.

Lane's Colectomy. — Lane in performing colectomy makes no endeavor to
save the omentum. After opening the abdomen his first endeavor is to separate
the "evolutionary adhesions" from the mesenteries without injury to the latter
structures. This greatly facilitates the removal of the bowel and as little or
none of the mesentery is denuded of its peritoneal covering the risk of dangerous
adhesions to the small intestine is lessened. In ligating the vessels no large
masses of mesentery should be included. "It is well to remember that one of
the chief immediate risks of the operation is hemorrhage, which may result
either from the escape of a vessel from the ligature in a fat subject, or from the
friability of the ligatured vessels in a thin toxic one." The ileum is divided
as in ileo-colostomy. The pelvic colon is drawn up out of the pelvis and grasped
with two pairs of forceps (Ochsner's) about 2 inches above the pelvic brim.
The end of the ileum is attached directly to the cut end of the pelvic colon by
the usual method of end-to-end anastomosis. When the circumference of the
colon is considerably greater than that of the ileum if the stitches in the wider
gut are inserted more widely apart than in the narrower gut then a secure union
is easily obtained.

The cut edges of the ileal and colonic mesenteries must be carefully united

by suturing both the upper and lower aspects of their junction. Lane finds the

end-to-end anastomosis preferable in every respect to the lateral or end-to-side.

In the treatment of intestinal stasis Lane considers colectomy the opera-

C^COPEXY

437

tion of choice. He also prefers it to any partial operation in obstruction due
to mobile colonic tumors and in megalo-colon.

Caecopexy. — Wilms' Method. Step i. — Open the abdomen by a right rec-
tus incision. As a matter of routine remove the appendix. Select a site in
the iliac fossa against which the caecum can be placed without the production
of any kinking in the colon or ileum.

Step 2. — Reflect a flap of peritoneum from the iliac fossa. Place the caput
coli on the raw surface thus prepared and suture the peritoneal flap over the
caecum, Fig. 596.

Fig. 596. — Caecopexy.

Step 3. — Close the abdomen.

Quenu and Duval's Method (Rev. de Chir., May 10, 1914). — Place the pa-
tient in Trendelenburg's position. Open the abdomen in the ileo-caecal region.
Examine the caecum. If the mobile caecum is too long or dilated, lessen its
size by transverse or longitudinal plication or by both. Introduce a retractor
and expose the whole iliac fossa. Recognize the right iliac artery and make an
incision through the iliac peritoneum external and parallel to the vessel. This
cut extends from the middle of the iliac fossa to the posterior point of fixation
of the caecum in the lumbar region. If the colon is now slightly freed from its
bed by dissection it is advantageous. Through the peritoneal incision expose
the tendon of the psoas parvus muscle, or if this is absent, the internal border
of the psoas, in which case it is necessary to retract the artery inwards to per-
mit suturing. Introduce three or four non-absorbable sutures through the
tendon of the psoas parvus and then through the posterior longitudinal caeco-
colic band. When these sutures are tied the caecum is well anchored in the

438

OPERATIONS ON THE INTESTINES

iliac fossa. Suture the edges of the incision in the iliac peritoneum to the head
of the caecum.

Caecopexy plus Caecoplication.— Roeder ("Journ. A. M. A.," Feb. 25, 1911)
introduces a number of sutures (hemp or silk) into the outer side of the caecum
in the manner shown in Fig. 597. The last bite of the stitch is in the parietal
peritoneum just external to the root of the meso-ca?cum. The number of bites
each stitch takes in the gut is regulated by the amount of dilatation present.
The number of stitches used is of course in proportion to the length of intestine
to be plicated and anchored.

I iG. 597. — [Roeder. )

DIVERTICULITIS

The papers of Cahier ("Rev. de Chir.," September 19, 1906), Brewer
("Amer. Journ. Med. Sc," October, 1907), Mayo ("Surg.,Gyn. and Obstetrics,"
July, 1907) and others have attracted attention to a condition named acquired
diverticulitis. A few words explanatory of the disease may assist the operator.
Acquired or false diverticula are simple hernia? of the mucous and submucous
tunics through the circular muscular coat of the descending colon and sigmoid
at points where the musculosa happens to be weak. Chronic leakage may take
place through the diverticular walls and give rise to large inflammatory de-
posits. The result of the inflammation may be: (i) Abscess. This requires
free drainage. (2) Acute local infection plus acute obstruction. This re-
quires free drainage plus the establishment of an artificial anus. Subsequently,
if necessary, the diseased segment of colon may be excised. (3) Chronic ob-
struction with inflammatory tumor but no abscess. This form is usually

INTESTINAL EXCLUSION 439

mistaken for malignant disease. The treatment is resection of the involved
segment of gut.

Hirschsprung's Disease. (Megalo-colon. Congenital dilatation of colon.)
This disease generally but by no means always occurs in young children, is
characterized by inveterate constipation, the dilated colon being loaded with
hard faeces. The use of purgatives and lavage may give temporary relief, but
sooner or later colitis shows itself by the symptom of diarrhea alternating with
constipation. The mortality in cases treated medically has been reported as
74 per cent, and 66 per cent, in different series, while in those treated surgically
it has been 48, 34 and 25 per cent.

Plastic operations and suspension of the colon have not been useful. Ap-
I)endicostomy and colostomy have been useful as temporary measures. The
ideal treatment seems to be excision of the whole affected segment of intestine.
As a preliminary to colectomy it is often wise to divide the ileum near its ter-
mination and to unite its end to the lowest possible point in the rectum. (End-
to-side anastomosis.) In children the open pelvis makes the low anastomosis
easier than in adults. Later the colon may be removed. After recovery care
should be exercised to prevent any accumulation of scybalas in the rectal pouch.

Finney's article on Hirschsprung's Disease (Trans. Am. Surg. Assoc, 1908,
vol. XXV, 475, or Surg., Gyn. and Obst., VI, 6) gives a very full bibliography.
See also W. I. Terry (Journ. A. M. A., LVII, 731) and Barrington-Ward ("Brit.
Jour, of Surg., I, 345).

INTESTINAL EXCLUSION OR SEGREGATION

Exclusion or Segregation of Intestine. — In some cases where,