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Full text of "Manual of operative surgery"

MEOK 



Columbia Slniticr^ft|> 

College of 3^\)vsikian9i anb burgeons; 
ilibrarp 




i 




Dr. Clay Ray Murray 



Digitized by tine Internet Arciiive 

in 2010 witii funding from 

Open Knowledge Commons (for the Medical Heritage Library project) 



http://www.archive.org/details/manualofoperativ1921binn 



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 



BY 

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. 






Copyright, 1921, by P. Blakiston's Son & Co. 



TBE MAPX.K FKR8S VORK PA 



CD 

O 



o PREFACE TO EIGHTH EDITION 

CD 

CO 

^ 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. 



XI 



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 

XV 



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// 



ID 



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. 




V? 


ifpMH 


p ' 


-'"'■'"^f^H 


1 


' 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 



lO 



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. 



I 




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 



II 



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 



13 



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. 



15 



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. 



i6 



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 



21 




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. 



22 



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." 





9 



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 




26 



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 



27 




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 



29 



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- 



30 



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 



31 



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." 







11 



{' 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 



32 



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 



35 



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 



41 



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 



44 



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 



47 



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 



49 



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 



50 



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 



SI 



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 



54 



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 



55 



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. 



56 



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; 



6o 



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 



62 



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 



67 



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 



68 



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 



72 



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 



73 



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. 



74 



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. 



76 



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 



77 



(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 



78 



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 



79 



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. 



8o 



EXTERNAL EAR 





Fig. Ts.—{Payr.) 



Fig. -je—iPayr.) 




Fig. 77. — (Payr.) 



PROMINENT EAR 



8l 




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, 



84 



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 




86 



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 



88 



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 



89 



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. 



90 



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. 



92 



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. 



96 



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 



97 



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 



98 



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 



99 



(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 ' 



V, 



, 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. 



no 



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.) 






I 



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 


25 

126 

18 

25 

12 

s 
18 


2 

126 

18 

25 
12 

5 

18 


6 

99 
18 
20 
12 

5 

15 


19 2 
27 83 

9 

S 14 
4 

1 
1 2 
3 II 


23 
16 

9 

6 
8 

3 

6 


17 







,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 



D^ 




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 



^m 



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. 



A 


^^■i 


B 


^1^1 


c m 


fm 


E 


/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 

13 



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. 




J 


^m JT "** v^^^B^t> 


5 


^^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. 

(c) Tendon lengthening. 

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. 

(c) No more cutting should be done than is absolutely necessary. Blunt 
dissection is most meritorious. 

(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- 

15 



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. 

16 



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. 



MC 




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), 






a 

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 

17 



^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 

18 




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- 

19 



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 

22 



$$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. 

23 




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 



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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 



4 



(.\ 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 




,f 






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 

IS 

2 


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. 

25 



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/ 




r^ 



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. 



a. 




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- 

26 



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^ 




M 





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. 

27 



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 




V^ 




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. 



I 





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 

28 



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, from extensive 
adhesions or from other causes, it seems impossible or improper to excise a 
certain segment of gut, good results may be obtained by protecting it from the 
irritations incident to the performance of its physiological functions. In this 
way faecal fistulae may be induced to close and some neoplasms may develop less 
rapidly. The operation which is used for this purpose may be named ^^ex- 
clusion oj Ike intestine.''^ Tuberculous lesions of the intestine, unless fairly easy 
of excision, may well be treated by exclusion. 

Ileo-colostomy.— Ileo-sigmoidostomy. — ^Lane's Method.^ — Step i . — During 
the administration of the anesthetic begin the hypodermic administration of salt 
solution in both axillae and keep it up during the operation. Six or more pints 
may be given. 

Step 2. — Open the abdomen by a suitable vertical incision to the left of the 
middle line so as to divide the sheath of the rectus twice and thus obtain a 
secure abdominal scar. 

Step 3. — Pick up the ileum and apply two Ochsner (crushing) clamps to it, 
close together, about 6 inches from its termination. Divide the gut between 
the forceps by means of a cautery thus completely sterilizing the stumps of 
the gut. Close the distal aperture by means of a running suture applied before 
and tightened during removal of the clamp. Invaginate the closed stump by 
means of a purse-string suture exactly as an appendix stump is invaginated. 



440 OPERATIONS ON THE INTESTINES 

Step 4. — At a convenient distance from the crushing clamp apply an in- 
testinal clamp to the proximal segment of ileum and anastomose its end to the 
side of the upper part of the pelvic colon using the usual two rows of suture. 
Should the junction appear insecure at any point, owing to tenuity of the ileal 
wall, to inflammatory changes in the pelvic colon or to the abundant deposit of 
fat in the colonic peritoneum, reinforce with extra stitches. 

Step 5. — Draw the intestines out of the pelvis. Very carefully sew the ad- 
jacent surface of the pelvic colon to the divided margin of the mesentery of the 
ileum. This is so important that it is wise to suture not merely the upper but 
also the lower aspect of the junction, otherwise internal hernia may result or the 
constant pressure of the small intestines may cause separation of the mesenteries 
and lead to trouble or disaster. 

Step 6. — Examine the fixation of the sigmoid to the pelvis. If what Lane 
calls the "last kink" is tightly fixed at the brim of the pelvis nothing need be 
done to it; but if it is not so fixed, sew the bowel and mesentery very securely to 
the brim so as to reduce the tendency to the regurgitation of faeces up into the 
iliac colon. 

Step 7. — Have an assistant pass an oesophageal tube through the anus into 
the pelvic colon and guided by the fingers of the surgeon, through the anasto- 
mosis into the ileum for a distance of about 8 inches. (The tube should be 
secured to the anus by a stitch.) " If any difficulty is experienced in passing the 
tube, a quantity of paraffin is injected through it which materially facilitates its 
introduction. This tube prevents the accumulati