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Full text of "Surgical anatomy and operative surgery, for students and practitioners"

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Digitized by the Internet Archive 

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Surgical Anatomy 



Operative Surgery 



For Students and Practitioners 



JOHN J. McGRATH, M.D. 

Professor or Surgical Anatomy and Operative Surgery at the New York Post-graduate Medical 

School, Visiting Surgeon to the Harlem Hospital, and Assistant Visiting 

Surgeon to the Columbus Hospital, New York. 



Olttb 227 Illustrations, including Colors and Balf-tone$ 




Philadelphia 

F. A. DAVIS COMPANY, PUBLISHERS 

1902 



COPYRIGHT, 1902, 

BT 

F. A. DAVIS COMPANY. 

(Registered at Stationers' Hall, London, Eng.] 



Philadelphia, Pa., U. S. A.: 

The Medical Bulletin Printing-house, 

1914-16 Cherry Street. 



PREFACE. 

In this volume an endeavor has "been made to combine, 
in a practical manner, the subjects of surgical anatomy and 
operative surgery, because a knowledge of the one is essential 
to the proper study of the other. 

Diagrammatic drawings have been used largely for the 
purpose of illustration, because these, in my judgment, are 
the most satisfactory for teaching. 

An effort has been made to exclude all those anatomical 
considerations that are purely technical and not of practical 
value in the performance of surgical operations. 

The arrangement of the subject has been made in accord- 
ance with the plan followed in my courses in operative surgery 
at the Post-graduate Medical School. 

John J. McGeath. 



CONTENTS. 



PAET I. PAGa 

General Considerations 1-18 

Anaesthesia: General anaesthesia, 1; incomplete general anesthesia, 1; 
local anaesthesia, Schleich infiltration method, 3; analgesia by subarach- 
noid injection of cocain, 3. Division of Tissues: Division of soft parts, 

4; division of bone, 5. Hemorrhage: Means to arrest hemorrhage, 6; 

natural arrest of hemorrhage, 6; artificial arrest of hemorrhage, 6. 

Suture of the Tissues: Suture of the skin, 13; intracuticular suture, 14; 
suture of muscle, 14; suture of tendons, 15; suture of nerves, 15; suture 
of bone and cartilage, 15; suture of serous surfaces, bowel, etc., 16. 



PAET II. 
Head and Face 19-117 

Head: Surgical anatomy of the head, 19; of the scalp, 19; of the skull, 

20; of the dura mater, 21; of the pia mater, 23. Operations upon the 

Head: Trephining, 23; for depressed fracture of the skull, 23; for intra- 
cranial hemorrhage, 25; craniectomy (linear craniotomy), 29. Middle 

Fossa of the Skull: Anatomy of the middle fossa, 30; extirpation of Cas- 
serian ganglion (Hartley-Krause), 36. Mastoid Region and Ear: Sur- 
gical anatomy of mastoid region, 39 ; anatomy of the ear, 41. Opera- 
tions upon the Mastoid, etc.: Wilde's incision, 46; drilling into antrum, 
46; to open and drain antrum, 46; for thrombosis sigmoid sinus, 48; for 
cerebellar abscess, 50; for extradural abscess in middle fossa, 50; for 

temporo-sphenoidal abscess, 51. Face: Surgical anatomy of face, 51; 

of skeleton of face, 52; of mouth, 54; side of face, 58; pterygo-maxillary 

region, 58. Operations upon Face: Resection of upper jaw, 64; total 

resection of both superior maxillae, 69; to drain antrum of Highmore, 69; 
resection of half of lower jaw, 70; resection of half of body of lower jaw, 
73; resection of entire body of lower jaw, 75; resection of part of body of 
lower jaw (in continuity), 75; resection of part of body of lower jaw (not 
in continuity), 76; extirpation of Casserian ganglion (Rose-Andrews), 76; 
division of second and third branches of trifacial nerve (Kronlein-Liicke), 
79. Congenital Deformities of Face: Development of face, 80; forma- 
tion of palate, 88; teeth, 89; tongue, 89; deformities of face, 89; deformi- 
ties in which frontal plate is concerned, 91; lateral clefts of the upper 
lip, and alveolar process and cleft palate, 91; median clefts and notches 
of the upper lip, 95; oblique facial clefts, 96; deformities in which the 
first visceral arch is concerned, 98; transverse facial clefts, 98; median 

clefts of lower lip, lower jaw, and tongue, 98. Operations for Harelip, 

Cleft Palate, etc.: Operations for harelip, 98; operations for incomplete 
harelip, 100; operations for complete harelip, 102; operation for single 
complete harelip with cleft of alveolar process and advancement of the 
intermaxillary bone, 104; operation for double harelip without a promi- 
nent advanced intermaxillary bone, 104; operation for double harelip with 
prominent advanced intermaxillary bone, 105; operation for cleft palate, 



(V) 



VI CONTENTS. 

PAGE 

107. Operations upon the Lips: Excision of whole lower lip, 111; res- 
toration of lower lip, 112; Dieffenbach-Jaesche, 112; Bruns, 113; Langen- 
beck, 114; Estlander, 115; restoration of upper lip, 116; Estlander, 116; 
Dieffenbach's Wellenschnitt, 116; Bruns, 117. 



PAET III. 
Neck and Tongue 118-165 

Surgical Anatomy of Neck: Deep cervical fascia, 118; back of the neck, 
120; side of the neck, 120; anterior triangle, 122; posterior triangle, 122; 
sterno-mastoid region, 123; inferior carotid triangle, 123; superior carotid 
triangle, 125; submaxillary triangle, 126; lingual triangle, 127; occipital 
triangle, 127; subclavian triangle, 128; front of the neck, 129; hyoid 
bone, 130; suprahyoid region, 130; infrahyoid region, 130; laryngeal re- 
gion, 134; thyroid gland, 134; suprasternal region, 135; blood-vessels of 
the neck, 136; common carotid artery, 136; internal carotid artery, 137; 
external carotid artery, 138; internal jugular vein, 139; subclavian artery, 

140; inferior thyroid artery, 141; vertebral artery, 141. Operations upon 

the Neck: Tracheotomy, 142; tampon of trachea, 142; high tracheotomy, 
143; low tracheotomy, 144; median tracheotomy, 145; transverse laryn- 
gotomy, 146; thyrotomy, 146; laryngectomy, 148; extirpation of half of 
the larynx, 152; external oesophagotomy, 152; ligation of blood-vessels, 
153; common carotid artery, 153; external carotid artery, 155; internal 
carotid artery, 156; subclavian artery, 156; lingual artery, 158. Opera- 
tions upon the Tongue: Amputation of tongue (Kocher), 159; amputation 
of tongue (Regnoli-Billroth), 161; extirpation of tongue through floor of 
mouth with division of lower jaw, 162; Sedillot, 162; Langenbeck, 163; 
Billroth, 164; extirpation of half of the tongue (Whitehead), 164. 



PAET IV. 
Thorax 166-204 

Surgical Anatomy of Thoracic Wall: Skeleton of thorax, 166; muscles of 
chest wall, 169; fasciae of chest, 169; internal mammary artery, 170; 

diaphragm, 171. Regions of Chest: Sternal region, 172; upper anterior 

pectoral region, 172; clavicular region, 173; infraclavicular region, 174; 
mammary regjon (breast), 175; lower anterior pectoral region, 177; lateral 

pectoral region, 177. Mediastinum and Contents: Pericardium, 178 

heart, 179; thymus, 182; arch of aorta, 182; pneumogastric nerves, 183 
phrenic nerves, 184; trachea, 184; oesophagus, 185; thoracic aorta, 187 
vena azygos, 187; vena hemiazygos, 188; thoracic duct, 188; innominate 

artery, 188; left common carotid and subclavian arteries, 188. Pleura: 

Limits of pleura indicated by lines upon chest wall, 189; anterior edge of 

pleura, 189; lower edge of pleura, 190; dome of pleura, 191. Lungs: 

Root of lung, 192; lung, 193. Operations upon the Chest: Incisions for 

abscess of breast, 194; extirpation of tumors (fibroids) from mammary 
gland, 195; amputation of breast, 195; amputation of breast (Halsted- 
Meyer), 197; ligation of intercostal artery, 200; ligation of internal mam- 
mary artery, 200; thoracentesis, 201; thoracotomy, 201; thoracectomy 
(Estlander), 202; pleurectomy (Fowler), 203. 



CONTENTS. vli 

PAET V. PAGE 

Abdomen and Back 205-337 

Abdomen: Diaphragm, 205; posterior wall of the abdomen, 206; antero- 
lateral wall of the abdomen, 207; superficial vessels of abdominal wall, 208; 
muscles of the antero-lateral wall, 208; fascia transversalis, 211; parietal 
peritoneum, 211; deep vessels of abdominal wall, 212; regions of the ab- 
domen, 213. The Back: Muscles of the back, 215; erector spinse muscle, 

216; quadratus lumborum muscle, 217; lumbar fascia, 217; psoas- and 

iliacus muscles, 218; spinal column, etc., 218. The Stomach: Surgical 

anatomy of the stomach, 221. Operations upon the Stomach: Gastropli- 

cation, 226; gastrostomy, 228; Pyloroplasty (Heinecke and Mikulicz), 231; 
gastrostomy, 232; von Hacker, 232; Ssabanajew and Pranck, 233; Witzel, 
235; gastrorrhaphy, 237; pylorectomy, 237; Billroth, 237; Murphy button, 

241; Kocher, 241; gastrectomy, 244. The Small Intestine: Surgical 

anatomy of the small intestine, 247. Operations upon the Small Intes- 
tine: Enterorrhaphy, 252; enterectomy, 254; end-to-end anastomosis, 
257; suture, 257; Mounsell's, 259; Murphy button, 261; Laplace forceps, 
264; O'Hara forceps, 266; side-to-si.de, lateral, approximation, 268; suture, 
268; Murphy button, 271; McGraw rubber suture, 271; Laplace forceps, 
272; O'Hara forceps, 272; gastro-enterostomy, 272; anterior (Woelfler), 
272; posterior (von Hacker), 276; Murphy button, 280; McGraw's rubber 
suture, 281; Laplace forceps, 283; O'Hara forceps, 284. Large Intes- 
tine and Vermiform Appendix: Surgical anatomy of the large intestine, 
etc., 285; caecum, 285; vermiform appendix, 285; ascending colon, 287; 
transverse colon, 287; descending colon, 288; sigmoid flexure, 288; blood- 
supply of large intestine, 288. Operations upon Large Intestine: Co- 
lostomy, 289; Maydl, 292; resection of cascum, 295; end-to-end anasto- 
mosis, 296; lateral anastomosis, 297; end-to-side, lateral, implantation, 

298; ileo-colostomy, 298; resection of sigmoid flexure, 298. Operations 

upon "Vermiform Appendix: Appendicectomy, 299; McBurney incision, 
300; Battle incision, 301; ligature without inversion, 302; inversion and 
purse-string, 304; inversion (Edebohls), 305; for appendicular abscess, 
306; for appendicitis accompanied with general peritoneal infection, 309. 

Liver and Gall-bladder: Surgical anatomy of liver, 310; surgical 

anatomy of gall-bladder, 312. Operations upon Liver: Hepatotomy, 314; 

hepatectomy, 315; injuries of liver, 315. Operations upon Gall-bladder: 

Aspiration of gall-bladder, 315; cholecystotomy, 315; cholecystostomy, 
318; cholecystostomy in one sitting, 318; cholecystostomy in two sittings, 
320; cholecystostomy with adherent gall-bladder, 322; cholecystostomy 
■when unable to draw gall-bladder up into incision, 322; cholecyst-enter- 
ostomy, 324; cholecysto-duodenostomy with Murphy button, 325. Opera- 
tions upon Gall-ducts: Choledochotomy, 326; choledocho-lithectomy, 326; 

choledocho-lithotripsy, 327; duodenotomy for impacted gall-stone, 327. 

The Spleen: Surgical anatomy of spleen, 328. Operations upon Spleen: 

Splenotomy, 329; splenectomy, 330. The Pancreas: Surgical anatomy 

of the pancreas, 331; operations upon the pancreas, 332. Operations 

upon the Spinal Column: Laminectomy, 332; lumbar puncture, 334. 



PART VI. 
The Rectum 338-361 

Surgical anatomy of the rectum, 338; sacrum, 338; coccyx, 339; rectum, 

339. Operations upon the Rectum: Dilatation of the sphincter, 342; 

fistula in ano, 342; for complete fistula, 343; for incomplete fistula, 344; 
hemorrhoids, 344; ligation and excision, 345; clamp and cautery, 346; 



viii CONTENTS. 

PAGE 

excision of part of rectal wall, 346; innocent rectal polypi, 348; extirpa- 
tion of rectum (Volkmann), 348; resection of rectum (Dieffenbach), 351; 
resection and amputation of rectum through sacral route (Kraske), 353; 
for resection of rectum, 353; for amputation of rectum, 361. 



PAET VII. 
Heenta, Spekmatic Coed, Testes, etc 362-402 

Surgical anatomy of groin, 362; superficial layer of superficial fascia, 362; 
lymphatic glands, 363; deep layer of superficial fascia, 363; inguinal re- 
gion, 363; descent of the testes, 369; femoral region, 372; study of in- 
guinal and femoral region from within the abdomen, 375; inguinal region, 

375; femoral region, 378. Operations for Hernia: Herniotomy, 380; for 

inguinal hernia (Bassini), 383; for inguinal hernia (Halsted), 389; for 

femoral hernia, 392. Spermatic Cord, Scrotum, etc. : Spermatic cord, 

393; scrotum, 394; testes, 394; ejaculatory ducts, 395. Operations upon 

Spermatic Cord, Scrotum, etc.: For varicocele, 395; for hydrocele, 397; 
castration, 401. 

PAET VIII. 
Ueinaey System 403-436 

Kidneys: Surgical anatomy of kidney, 403. Operations upon the Kid- 
ney: Nephropexy, 404; nephropexy (Edebohls), 407; nephrotomy, 410; 
nephrolithotomy, 411; nephrectomy, 411; decortication of kidney (Ede- 
bohls), 412. Bladder: Surgical anatomy of bladder, 413. Operations 

upon Bladder: Suprapubic cystotomy, 415; puncture of bladder, 418. 

Penis: Surgical anatomy of the penis, 418. Operations upon the Penis: 

Forcible dilatation of prepuce, 419; dorsal section, 419; circumcision, 421; 

circumcision with clamp, 422; amputation of penis, 422. Perineum and 

Ischio-rectal Region: Floor of pelvis from without, 424; ischio-rectal 

region, 425; perineum, 426; pelvic cavity from within, 428. Operations 

upon Perineum, etc.: Perineal section with a guide, 430; perineal sec- 
tion without a guide, 431; median lithotomy, 432; lateral lithotomy, 433; 
Prostatectomy (McGill-Fuller), 433; prostatectomy (Alexander), 434; 
prostatotomy (Bottini), 435. 



PAET IX. 
The Uppee Exteemity 437-481 

The Axilla: The axilla, 437; the axillary artery, 437. The Arm: Vessels 

of the arm, 440; the brachial artery, 440; the radial artery, 442; the 
ulnar artery, 443; musculo-spiral nerve, 445; median nerve, 445; ulnar 

nerve, 445. The Hand: Nerve-supply of the hand, 446; ligations, 446; 

axillary, 446; brachial, 447; radial, 449; ulnar, 449. Amputations, Re- 
sections, etc.: Surgical anatomy of hand, 449; phalango-phalangeal joints, 
449; metacarpo-phalangeal joints, 450; exarticulation of the finger at the 
phalango-phalangeal joint, 450; exarticulation of finger at the metacarpo- 
phalangeal joint, 452; exarticulation of hand at the carpo-metacarpal 
articulation, 453; surgical anatomy of wrist-joint, 455; exarticulation of 
hand at wrist-joint, 456; amputation through forearm, 457; surgical anat- 
omy of elbow- joint, 458; exarticulation of forearm at elbow-joint, 460; 



CONTENTS. ix 

PAGE 

amputation of arm, 461; surgical anatomy of shoulder-joint, 463; exar- 
ticulation at shoulder-joint (Spence), 465; exarticulation at shoulder- 
joint (Esmarch), 467; exarticulation at shoulder- joint with deltoid flap, 

469. Resections: Wrist-joint, 472; elbow (Langenbeck), 474; shoulder, 

476; tendon suture, 479; nerve suture, 479; intravenous saline infusion, 

PAKT X. 
Loweb Extremity 482-549 

Thigh: Gluteal region, 482; stretching sciatic nerve, 483; anterior femoral 
region, 485; internal saphenous vein, 485; femoral artery, 486; anterior 
crural nerve, 489; ligation of femoral artery, 489; popliteal space, 491. 

Leg: Anterior tibial artery, 492; anterior tibial nerve, 494; ligation 

of anterior tibial artery, 494; posterior tibial artery, 494; posterior tibial 
nerve, 496; ligation of posterior tibial artery, 496; tenotomy, 496; multiple 

ligature of veins of leg, 497. Amputations, Resections, etc. : Surgical 

anatomy of skeleton of foot, 498; exarticulation of big toe, 500; exar- 
ticulation of big toe with removal of first metatarsal, 500; exarticulation 
of little toe, 500; for ingrowing toe-nail, 501; amputation through tarso- 
metatarsal articulation (Lisfranc), 501; amputation through medio-tarsal 
articulation (Chopart), 504; surgical anatomy of ankle-joint, 505; exar- 
ticulation of foot at ankle-joint (Syme), 506; exarticulation of foot, etc. 
(Pirogoff), 507; amputation of leg, 510; amputation of leg with lateral 
hooded flaps, 510; surgical anatomy of knee-joint, 513; exarticulation of 
leg at knee-joint (Stephen Smith), 516; transcondylar amputation (Carden), 
518; amputation of knee (Gritti-Stokes), 520; amputation of thigh, 521; 
surgical anatomy of hip-joint, 523; exarticulation of thigh at hip (Wyeth), 
526; exarticulation of thigh with preliminary ligation of common femoral, 

529. Resections: Ankle (Langenbeck-Hueter), 529; ankle (Koenig), 533; 

ankle (Lauenstein), 535; ankle, osteoplastic (Mikulicz-Wladimirow), 536; 
knee-joint, 538; hip-joint (Langenbeck), 543; osteotomy, 547; suture of 
patella, 548. 



LIST OF ILLUSTRATIONS. 



FIQ. 



PAGE 



1. Division of Skin by Transfixion a 

2. Esmarch Bandage and Constrictor 6 

3. Trendelenburg Position 9 

4. Square Knot 12 

5. Slip Knot 12 

6. Surgeon's Knot 12 

7. Intracuticular Suture 14 

8. Bone-drill 15 

9. 10. Segment of Bowel— Lembert Sutures 16 

11. Cushing Suture 17 

12. Hartley Chisel 26 

13. Temporary Resection of Skull 27 

14. Base of Skull from Within 32 

15. Section through Floor of Middle Fossa 35 

16. Side of Skull 41 

17. ' Pterygo-maxillary Region 61 

18. Pterygo-maxillary Region (deep) 62 

19. Incisions for Resection of Upper Jaw 65 

20. Resection of Upper Jaw 67 

21. Incisions for Resection of Casserian Ganglion 78 

22. Transverse Section of Head End of Embryo Twelve Days Old 81 

23. Sagittal Section of Head End of Embryo Twelve Days Old 81 

24. Face of Embryo, Fifth Week 83 

25. Face of Embryo, Fifth Week 84 

26. Embryo, Fourth Week, Seen from Side 85 

27. Embryo, Eighth Week, Seen from Side 86 

28. Face of Embryo about Eighth Week 88 

29. Diagram of Congenital Facial Clefts 90 

30. Double Complete Harelip 92 

31. Harelip with Advanced Intermaxillary Portion 93 

32. Double Cleft Palate with Advanced Intermaxillary Portion 94 

33. Oblique Facial Cleft 96 

34. Incomplete Oblique Facial Cleft 97 

35. Transverse Facial Cleft 97 

36. 37. Simple Paring for Incomplete Harelip 100 

38, 39. Von Graef e Operation for Incomplete Harelip 100 

40, 41, 42. Nelaton Operation for Incomplete Harelip 101 

43, 44, 45. Malgaigne Operation for Incomplete Harelip 101 

46, 47, 48. Mirault Operation for Incomplete Harelip 102 

49. Wellenschnitt for Complete Harelip 103 

50, 51, 52. Hagedorn Operation for Single Complete Harelip 103 

53, 54, 55. Double Malgaigne Operation for Double Complete Harelip 105 

56, 57, 58. Hagedorn Operation for Complete Double Harelip 105 

59. Whitehead Gag 108 

60. Repair of Cleft Palate Ill 

61. Excision of Entire Lower Lip 112 

62. Triangular Defect in Lower Lip Closed 112 

63. Dieff enbach- Jaesche Operation for Restoring Lower Lip 113 

64. 65. Bruns Method of Restoring Lower Lip 114 

(Xi) 



x ii LIST OF ILLUSTRATIONS. 

FIG. PAGE 

66, 67. Langenbeck Method of Restoring Lower Lip 114 

6S, 69. Estlander Method of Restoring Lower Lip 115 

70, 71. Dieffenbach Wellenschnitt for Restoration of Upper Lip 116 

72, 73. Bruns Method of Restoring Upper Lip 116 

74. Section through Neck 118 

75. Side of Neck to Show Triangles 124 

76. Front of Neck 131 

77. Tracheotomy Tube 142 

78. Trendelenburg Tampon Cannula 142 

79. Incision for Removal of Lower Jaw, etc 154 

80. Transverse Section through Thorax 178 

81. Outline of Heart, etc 181 

82. 83, 84. Outline of Pleura, etc 190 

85. Section through Seventh, Eighth, and Ninth Ribs 191 

86. Amputation of Breast 198 

87. Transverse Section of Abdomen 211 

88. Transverse Section of Abdomen 211 

89. Regions of Abdomen 213 

90. Sagittal Section to Show Arrangement of Greater and Lesser Omenta 223 

91. Incisions to Reach Abdominal Viscera 225 

92. Gastroplication 226 

93. Cross Section of Stomach after Gastroplication 227 

94. Cross Section of Stomach after Gastroplication 227 

95. 96. Pyloroplasty 231 

97, 98. Gastrostomy (Ssabanajew-Franck) 234 

99, 100. Gastrostomy (Witzel) 236 

101. Pylorectomy 238 

102. Pylorectomy (Billroth) 240 

103. Pylorectomy (.Billroth) 241 

104. Pylorectomy (Eocher) 243 

105. Gastrectomy , 246 

106. Intestine Compressor 255 

107. Enterectomy 256 

108. End-to-End Anastomosis , 258 

109. 110, 111. End-to-End Anastomosis (Mounsell) 260 

112. End-to-End Anastomosis (Murphy Button) 263 

113. Murphy Button 263 

114. 115, 116. Laplace Anastomosis Forceps 265 

117, 118, 119. O'Hara Anastomosis Forceps 267 

120. Lateral Anastomosis 269 

121. Cross Section of the Apposed Coils of Gut (Lateral Anastomosis) 270 

122. Gastro-enterostomy ("Vicious Circle") 273 

123. Posterior Gastro-enterostomy 277 

124. Gastro-enterostomy (Jaboulay-Brauri) 278 

125. Lateral Anastomosis (Murphy Button) 279 

126. Gastro-enterostomy (McGraw Rubber Suture) 282 

127. Colostomy 291 

128. Colostomy (Maydl) 293 

129. Colostomy 294 

130. Colostomy (Maydl) 294 

131. Appendix 303 

132. Appendicectomy 303 

133. Appendicectomy 304 

134. Bile-ducts, etc 313 

135. Gall-bladder 319 

136. Cholecystostomy 320 

137. Keen Bone Forceps 333 

138. Lumbar Puncture 336 

139. Complete FistuJa in Ano 343 



LIST OF ILLUSTRATIONS. xiii 

FIG. PAGE 

140. Blind Internal Fistula 343 

141. Blind External Fistula 343 

142. Hemorrhoids 345 

143. Incision for Resection of Rectum (Kraske) 354 

144. Ilium and Sacrum (Kraske) 355 

145. Resection of Rectum (Kraske) 357 

146. Resection ofRectum (Kraske) 357 

147. Resection of Rectum (Kraske) 360 

148. Inguinal and Femoral Regions 364 

149. Inguinal Canal 366 

150. Descent of Testis 369 

151. Inguinal Region 370 

152. Inguinal Region, Congenital Hernia 370 

153. Inguinal Region, Acquired Hernia 370 

154. Superficial Femoral Region 372 

155. Superficial Femoral Region — Femoral Sheath 372 

156. Pelvis and Ligaments of Ilio-pubic (or Femoral ?) Region 374 

157. Femoral Space 374 

158. Deep Femoral Region 375 

159. Inguinal and Femoral Regions from Within Abdomen 376 

160. Irregular Origin of Obturator Artery 381 

161. Irregular Origin of Obturator Artery 382 

162. Operation for Inguinal Hernia 384 

163. Bassini Operation for Inguinal Hernia 386 

164. Bassini Operation 386 

165. Halsted's Operation for Hernia 391 

166. Operation for Femoral Hernia 392 

167. Spermatic Cord 394 

168. Cross Section of Spermatic Cord 394 

169. Exposure of Cord 394 

170. Varicocele 396 

171. Hydrocele, Tapping 398 

172. Volkmann Operation for Hydrocele 398 

173. Hydrocele, Retroversion of Tunica Vaginalis 400 

174. Castration 401 

175. Incision to Expose Kidney 405 

176. Nephropexy (Edebohls) 409 

177. Relations of Peritoneum to Bladder 415 

178. Dorsal Section (Roser) 420 

179. Circumcision 421 

180. 181. Amputation of Penis 423 

182. Perineum and Ischio-rectal Region 426 

183. Axillary Region 438 

184. Section through Middle of Right Arm 441 

185. Section through Middle of Right Forearm 444 

186. Right Arm, Incisions, etc 448 

187. Exarticulation of Finger 451 

188. Exarticulation of Finger 452 

189. Palmar Aspect of Right Hand 454 

190. Dorsal Aspect of Right Hand 454 

191. Stump after Exarticulation of Hand 455 

192. Right Arm, Anterior Aspect 462 

193. Right Shoulder, Anterior View 466 

194. Right Shoulder, Posterior View 468 

195. Left Shoulder, Side View 469 

196. Left Arm, Posterior View 471 

197. Resection of Wrist-joint 472 

198. Tendon Suture 479 

199. Superficial Vein Exposed for Saline Infusion 480 



x i v LIST OF ILLUSTRATIONS. 

FIG. PAGE 

200. Stretching Sciatic Nerve 484 

201. Section through the Middle of the Left Thigh 487 

202. Ligation of Femoral Artery 490 

203. Section through the Middle of the Left Leg 493 

204. Right Foot 498 

205. Operations for Ingrowing Toe-nail 501 

206. Right Foot, Inner Side 503 

207. Right Foot, Outer Side 503 

208. Right Foot, Inner Side (Pirogoff 's Amputation) 508 

209. Right Foot, Inner Side (Giinther's Modification ) 508 

210. Right Foot, Inner Side (le Fort's Modification) 508 

211. Amputation of Leg 511 

212. Right Leg, Outer Side 517 

213. Right Leg (Carden's Amputation) 519 

214. Stump after Carden's Amputation 519 

215. Gritti-Stokes Amputation 521 

216. Exarticulation at Hip-joint 527 

217. Right Foot, Outer Side (Langenbeck-Hueter) 530 

218. Right Foot, Inner Side (Langenbeck-Hueter) 530 

219. Incisions for Resection of Ankle (Koenig) and for Amputation of Big Toe with 

Removal of the First Metatarsal 533 

220. Resection of Ankle-joint (Lauenstein's Incision) 536 

221. Incision for Mikulicz-Wladimirow Osteoplastic Resection of the Ankle-joint 537 

222. Right Leg, Inner Side 539 

223. Resection of Knee-joint 541 

224. Resection of Hip (Langenbeck's Incision) 544 

225. Resection of Hip (Anthony White's Incision) 545 

226. Osteotomy (Macewen) 547 

227. Wiring Patella for Fracture 549 



PART I. 

GENERAL CONSIDERATIONS 



ANAESTHESIA. 

General Anaesthesia. — Of the general anaesthetics, ether and 
chloroform are the ones most commonly employed. Ether is used 
more generally than chloroform, especially in this part of the United 
States. With ether, the stage of excitement and struggling that 
precedes the stage of anaesthesia is more prolonged and more pro- 
nounced than with chloroform; still, this objection may be partially 
eliminated by administering nitrous oxide or chloroform until the 
period of excitement has been passed. The preliminary use of 
nitrous oxide is much in vogue at present. 

Ether stimulates the heart and increases the arterial tension. 
It has a marked congestive influence upon the kidneys, and acts as 
an irritant to the respiratory tract. 

The first stage of chloroform narcosis is shorter than is that 
of ether and is not accompanied by as much excitement and strug- 
gling. Chloroform does not increase the arterial tension and does 
not congest the kidneys, but it has a tendency to interfere with the 
heart-action, especially if the heart-muscle is diseased and in con- 
ditions accompanied by chronic anaemia. Therefore, if it become a 
matter of choice, one should elect ether if the heart-action is un- 
satisfactory or if the patient is markedly anaemic, and chloroform if 
the urine shows defective kidneys or if there is a tendency to cere- 
bral apoplexy or pulmonary disease and in cases of empyema. Chlo- 
roform is also preferable to ether in young children and in very old 
people. Alcoholics, as a rule, take chloroform much more satisfac- 
torily than ether. 

In operations about the mouth where the mask can only be 
applied during intervals, and for administration through a trache- 
otomy tube, chloroform is the preferable anaesthetic. 

Incomplete General Anaesthesia. — This plan consists in admin- 
istering a liberal dose of morphin hypodermically, shortly before 
commencing the operation, and then giving the chloroform only up 

(1) 



2 GENERAL CONSIDERATIONS. 

to the point of deadening the sensation without nullifying the re- 
flexes. In this way the pain is made endurable and at the same 
time, the reflexes being still active, the patient is able to cough, clear 
the throat, and expectorate. This plan may be practiced with satis- 
faction in operations about the upper and lower jaw, nasal passages, 
larynx, etc., where there is danger of blood entering the respiratory 
canal and asphyxiating the patient if not coughed out. 

Local Anaesthesia. — The skin may be anaesthetized sufficiently 
for simple incision or puncture by freezing, either by the application 
of ice, chopped and mixed with salt, in a bag, or by the ethyl- 
chloride spray. 

Ethyl chloride is a very volatile substance, boiling at the body- 
temperature. It is supplied in glass cylinders with a removable 
brass cap. If the cylinder is held in the hand for a few moments 
sufficient heat is imparted to volatilize the fluid in the cylinder, 
which then escapes in the form of a fine spray. The spray is 
directed against the part to be anaesthetized for a few minutes. 

For operations that require a certain amount of dissection cocain 
in a 2-per-cent. solution, introduced into the skin, hypodermically, 
is more satisfactory. The cocain is still more effective if it can be 
confined to the part that is to be operated upon by constricting it 
with a rubber elastic ligature; for example, in operations upon the 
fingers and toes and for circumcision, etc., by placing an elastic 
ligature about the root of the part. The solution should be thrown 
into the deeper layer of the skin proper so as to raise welts, and. 
not into the loose tissue underneath the skin. 

The solution is introduced, a few drops at a time, through 
several punctures along the line of the proposed incision. 

After the first puncture and injection have been made, the 
needle should be introduced each succeeding time through the skin 
that has already been anaesthetized; ordinarily from 20 to 30 minims 
of a 2-per-cent. solution, according to the age, etc., of the patient,, 
may be introduced during the course of a single operation. 

Occasionally disagreeable symptoms of cardiac disturbances due 
to the action of the cocain present themselves, especially if it has 
been introduced into a part where the circulation cannot be inter- 
rupted with a constricting ligature. Mucous surfaces may be anaes- 
thetized by applying a wad of cotton saturated with the cocain 
solution direct to the part for several minutes. 

Eucain is used as a substitute for cocain; it is said to have no 



ANESTHESIA. 3 

depressing influence upon the heart. From 20 to 40 minims of a 
2-per-cent. solution may be used. 

Schleich Infiltration Method. — The solution used contains 
cocain and morphin. It is thrown into the skin with a hypodermic, 
as described "above for cocain, along the course of the intended 
incision. The solutions vary in strength according to the amount 
of cocain that they contain, and are known as Nos. 1, 2, and 3. 

Solution No. 1. 

Cocain muriate gm. 0.2 gr. iij. 

Morphin muriate gm. 0.025 gr. f . 

Sodium chloride gm. 0.2 gr. iij. 

Sterile water c.c. 100.0 Siiif- 

This is the strongest solution. A quantity up to 6 drams may 
be used. 

Solution No. 2. 

Cocain muriate gm. 0.1 gr. iss. 

Morphin muriate gm. 0.025 gr. f. 

Sodium chloride gm. 0.2 gr. iij. 

Sterile water c.c. 100.0 giiif . 

This is the solution that is commonly used, and of this a quan- 
tity up to 3 ounces may be injected. 

Solution No. 3. 

Cocain muriate gm. 

Morphin muriate gm. 

Sodium chloride gm. 

Sterile water c.c. 

No. 3 is the weakest solution, containing only one-tenth as 
much cocain as No. 2. 

One may use a pint of this solution. 

Analgesia by Subarachnoid Injection of Cocain, etc. — A solu- 
tion of cocain, eucain, etc., may be thrown into the subarachnoid 
space with a hypodermic syringe. This method of inducing anal- 
gesia was introduced by Bier and has been recently practiced by 
numerous surgeons with varying degrees of satisfaction, some dis- 
carding it after a few trials and others advocating its usefulness. 
No doubt it will prove of value in certain cases. The method of in- 
troducing the fluid is described elsewhere (see "Lumbar Puncture"). 

A 1- or 2-per-cent. solution of cocain, eucain, or tropacocam 
may be used. 



0.01 


gr- h 


0.025 


gr. h 


0.2 


gr. ii] 


100.0 


giiif. 



4 GENERAL CONSIDERATIONS. 

If the cocain solution is sterilized by boiling, the potency of 
the drug is very much impaired. We may thus account for some 
of the instances where the method has failed to give satisfaction. 
If cocain, for example, is used, 1 / 2 grain or less of the crystals of 
hydrochlorate of cocain is placed in a sterile glass vessel and 1 or 
2 drams of ether poured in; this is stirred with a sterile glass rod 
until the ether evaporates, when the residue is dissolved with steril- 
ized distilled water (Bainbridge). The solution is then ready for 
injection. 

According to the method of Dudley, the cocain may be steril- 
ized by adding a few drops of chloroform to the crystals of the drug. 
After the chloroform evaporates the residue is dissolved in sterile 
water. 

Three to seven minutes usually elapse before the analgesia 
reaches the level of the diaphragm. The lower limbs and the lower 
part of the trunk first show the analgesic effect of the drug, and 
this gradually extends to the chest and upper extremities. 

The analgesic effect lasts from fifteen minutes to several hours. 

The method may be applicable in those cases where extreme 
weakness or cardiac or renal disease renders the use of chloroform 
or ether especially dangerous. 

DIVISION OF THE TISSUES. 

Division of the Soft Parts. Bloody Division of the Soft 
Parts. — The division of the integument may be accomplished with 
the knife or scissors, either by direct incision or by transfixion 
(Fig. 1). The deeper soft parts may be divided with cutting 
instruments or by tearing with the fingers or blunt instruments, 
the handle of the scalpel, thumb forceps, etc. This plan of blunt 
dissection is especially serviceable in enucleating encapsulated tu- 
mors or lymphatic nodes and in separating between different layers 
of tissue along the normal connective-tissue planes. 

The contents of hollow viscera, serous spaces, and cystic tumors 
may be evacuated or withdrawn in part for the purpose of diagnosis 
by means of the trocar and cannula or some form of aspirating 
apparatus. Substances may also be introduced into the body through 
cannula? or with some form of syringe. 

Bloodless Division of the Soft Parts. — This may be accom- 
plished with the thermocautery, galvanocautery, elastic ligature, 
ecraseur, or wire snare and by the action of corroding chemicals. 



HEMORRHAGE. 5 

Division of Bone. — Bones may be divided through an incision 
in the soft parts with the chisel and mallet, bone forceps, or with 
some form of saw, — circular, chain, or wire, or with the flat saw; 
with the drill, dental burr, or bone scoop. 

The bongs are covered with an adherent vascular membrane, 
the periosteum, which should be incised with the knife and sepa- 
rated from the bone with the elevator before applying the cutting 
instruments to the bone. 

The bone may be divided without an incision in the soft parts 
— for the purpose of correcting deformities, etc. — either by manual 
force or by the use of an instrument known as the osteoclast. The 
osteoclast consists of a solid metal bar with two sliding bracelets 




Fig. 1. — Division of the Skin by Transfixion. 

one on either end and between these a brace by which the breaking 
force is applied and which may be raised or lowered by means of a 
screw. 

HEMORRHAGE. 

During the course of an operation the hemorrhage must be 
controlled in order to minimize the loss to the patient and to keep 
the field clear for proper work. 

Hemorrhage may be described as capillary, venous, and arterial. 

Capillary hemorrhage is characterized by a general oozing. 

Venous hemorrhage is characterized by a steady welling of 
blood into the wound, often filling it so as to obscure the bleeding 
point. Venous blood is rather darker in color than arterial blood. 
If a large vein is divided close to the trunk, — i.e., in the neck or 
axilla, — or if one of the intracranial dura mater sinuses is opened, 
the blood may escape in a remittent stream, synchronous with the 
respiratory movements, diminishing or ceasing during inspiration 
and increasing during expiration. During inspiration, under these 



6 GENERAL CONSIDERATIONS. 

circumstances, air may be sucked into the veins, but, if limited in 
quantity, this is said to do no harm; nevertheless it should be 
guarded against. 

Arterial hemorrhage is characterized by the brighter color of 
the blood and by the fact that it escapes in a distinct remittent 
jet of considerable, though varying, force. The jet is synchronous 
with the heart's action, increasing during ventricular systole and 
diminishing during ventricular diastole. 

Means to Arrest Hemorrhage. The Natural Arrest of 
Hemorrhage is effected by the clotting of the blood. If the divided 
vessels are not too large and the blood-pressure not too great, 
nature will thus be able to bring about a cessation of the hemor- 
rhage. Nature is assisted in her efforts to control hemorrhage from 
a severed artery by the fact that when an artery is divided its 
orifice contracts, thus diminishing the size of the opening through 




Fig. 2.— Esmarch Bandage and Constrictor. The constrictor is provided 
with a chain and hook. 

which the blood escapes, and further by the fact that the inner 
elastic coat of the vessel, the intima, retracts, coiling up within the 
artery, thus blocking the lumen of the vessel and offering a con- 
siderable impediment to the flow. 

The natural arrest of hemorrhage from a severed vein is facili- 
tated by the low blood-pressure within the vessel and by the col- 
lapsibility of its thin, flaccid wall. 

Artificial Arrest of Hemorrhage. — Artificial measures are 
resorted to, as a rule, to control hemorrhage. These may be classi- 
fied as indirect means, acting outside at a distance from the wound, 
and direct means, acting locally within the wound. 

Indirect Means. The Elastic Bandage and Constrictor 
(Esmarch). — Operations upon the extremities may be rendered 
practically bloodless by the use of the Esmarch bandage and con- 
strictor. 



HEMORRHAGE. 7 

The extremity being elevated, a rubber bandage about three 
inches broad is applied about the limb, each turn being drawn pretty 
tight. The bandage is applied spirally about the limb, commencing 
below and working upward toward the trunk, each turn somewhat 
overlapping its predecessor; in this way the blood is forced out of 
the limb. B"aving reached a point above the site of the proposed 
operation, a rubber band or thick elastic tube, the constrictor, is 
passed around the limb several times and then made fast. The 
rubber spiral bandage may then be removed. 

In most cases the application of the rubber spiral bandage may 
be dispensed with, it being sufficient to elevate the limb to a per- 
pendicular position for a few minutes, at the same time massaging 
or stripping it from the periphery toward the trunk, in order to 
force the bulk of the blood out of it. "While the limb is thus 
elevated, the rubber constrictor bandage or tube is applied about 
the upper part of the limb. 

In cases of tuberculous disease, malignant disease, and sepsis 
one should certainly omit stripping the limb or applying the rubber 
spiral bandage on account of the likelihood of forcing infectious 
elements onward into the healthy tissues. Under these circum- 
stances one should be content with elevation of the limb for a few 
minutes before applying the constrictor. 

The rubber constrictor that is placed about the limb may be 
secured with a band of gauze which is placed underneath the con- 
strictor so that after the first loop of an ordinary knot has been 
taken in the constrictor the gauze bandage may be tied over this 
to secure it and prevent it from slipping; the second and final loop 
is then taken in the rubber constrictor. The constrictor shown in 
the illustration is provided with a chain and hook. 

The constrictor should be applied sufficiently tight to shut off 
the arterial current, but not tight enough to bruise the nerve-trunks 
against the underlying bone. The constrictor may be left on for 
two or three hours without any untoward results. 

For operations upon the lower extremity, except at the hip-joint, 
the constrictor is placed about the thigh, just above the knee-joint 
or higher up, nearer the hip-joint. For disarticulation at the hip- 
joint the constrictor is placed about the limb as high up, near the 
trunk, as possible, and it is then prevented from slipping down by 
steel pins, or skewers, which are passed through the soft parts 
(Wyeth). 



S GENERAL CONSIDERATIONS. 

For operations upon the upper extremity, except at the shoulder- 
joint, the ligature is placed about the arm, just above the elbow- 
joint or higher up nearer the shoulder- joint. For disarticulation 
at the shoulder-joint the constrictor is applied as high up as pos- 
sible; it may be passed through the axilla and over the shoulder 
and prevented from slipping by a steel pin, or skewer, that is thrust 
through the soft parts, transfixing the upper part of the deltoid 
muscle mass. 

The main arterial and venous trunks, if they have been divided 
during the course of the operation, may be secured and ligated before 
the constrictor is removed. Any additional bleeding branches may 
be secured and ligated after the constrictor has been removed. 

By Digital Compression of the Main Arterial Trunk at a Distance 
from the Site of the Operation. — During amputation of the thigh 
the common femoral artery, as it emerges from under Poupart's 
ligament, may be compressed against the underlying pubic bone. 

During amputation of the forearm or disarticulation at the 
elbow-joint the brachial may be compressed against the humerus, 
and during amputation through the upper arm or at the shoulder- 
joint the hemorrhage may be controlled by digital compression of 
the subclavian artery against the first rib. This plan is rather 
untrustworthy. 

Preliminary Ligation in Continuity. — This is a very satisfactory 
method of controlling hemorrhage in certain bloody operations. For 
example, in disarticulation at the hip-joint preliminary ligation of 
the common femoral may be practiced, the vein being tied at the 
same time through the same incision. In amputation of the tongue 
one or both Unguals may be ligated as a preliminary step to the 
main procedure. In extirpation of the lower jaw, etc., preliminary 
ligation of the external carotid may be practiced with great advan- 
tage. 

Position. — Position of the part has much to do with the severity 
of the hemorrhage during an operation. Elevation of the part is 
often sufficient, of itself, to check capillary and venous hemorrhage. 
The volume of arterial blood sent to the part is diminished and the 
return-flow through the veins is facilitated. These factors, together, 
serve to markedly diminish the pressure in all the vessels of the 
elevated part. This is especially true of the limbs, but also of the 
pelvis and the head. With the pelvis raised as in the Trendelenburg 
position, the hemorrhage during the course of operations upon the 



HEMORRHAGE. 9 

pelvic organs is much diminished. During operations upon the head 
and face, with the patient in the semi-erect position, the hemorrhage, 
especially the venous, will be found to be very much less than it 
would be with the patient in the Kose position, with the head hanging 
low over the end of the table. 

Direct Means of Controlling Hemorrhage are applied 
within the wound itself, and these may be divided into three groups: 
Agents that act locally through the nervous system; chemical agents 
that act directly upon the escaping blood, causing it to coagulate; 
and mechanical agents. 

Agents that Act Locally through the Nervous System. — Application 
of heat or cold, usually in the form of water, hot or cold, or ice, 




Trendelenburg Position. 



tends to diminish and check hemorrhage. If hot water is used it 
should be as hot as the hand can bear, about 120° F.; if cold, it should 
be quite cold. 

Heat and cold both act by causing the small arterioles to con- 
tract and diminish in size. Heat causes albumin to coagulate so that, 
when heat is applied to a wound, the wound surface becomes glazed 
with a thin, albuminous film, and in this way heat possesses an 
additional potency in checking oozing. Heat is a more effective 
agent in controlling hemorrhage than cold, since the latter acts only 
by causing a diminution in caliber of the small arteries. 

Heat in the form of a hot saline irrigation is a very satisfactory 
agent to check oozing from capillaries and small arteries and veins. 



10 GENERAL CONSIDERATIONS. 

Chemical Agents. Styptics. — These agents tend to check hem- 
orrhage by acting directly upon the escaping blood, causing it to 
coagulate, and thus seal the mouths of the severed vessels. They 
are but little used except in operations upon the nose, etc., and are 
of service only to control capillary hemorrhage and oozing from 
small veins and arteries. The common styptics are the persulphate 
of iron, tincture of the chloride of iron, powdered alum, tannic acid, 
extract of suprarenal capsule, etc. 

The styptic cotton is ordinary absorbent cotton impregnated 
with one of these agents. 

Mechanical Means. Digital Compression. — With the finger 
in the wound hemorrhage may be controlled by pressure exerted 
directly upon a severed vessel, thus closing it until it can be secured 
with an artery forceps. In operations upon the neck, for example, 
a large vessel may be divided and then so obscured by the great 
volume of escaping blood that it cannot be located and secured with 
the artery forceps. With the finger thrust into the wound the hem- 
orrhage may be checked temporarily by compressing the injured 
vessel until the wound can be cleared of blood and the vessel located 
and grasped with an artery clamp. This is especially true of large 
veins; when cut, the blood may well into the wound in such volume 
that one is unable to locate the divided vessel. 

Digital compression may be applied to the main vessels in the 
wound before they are divided in order to minimize the loss of 
blood. For example, in exarticulating at the shoulder-joint, after 
the incisions have been made, but before the brachial artery and 
adjoining vessels have been cut, the assistant grasps the mass of 
soft parts which includes the main vascular trunks and compresses 
these between the thumb and fingers until after the limb has been 
amputated and the vessels secured by the operator. 

Tamponade. — This is really one way of applying the principle 
of compression. This method is especially serviceable in controlling 
oozing and bleeding from veins. For example, hemorrhage from an 
injured intracranial sinus may be readily controlled by packing a 
strand of gauze into the wound between the sinus and the skull. 

If a wound is tamponed and a good snug dressing applied so as 
to exert a considerable degree of firm compression, this will usually 
suffice to check all oozing from capillaries and small veins. 

Bleeding from the nutrient artery of a bone may be checked 
by plugging the orifice of the nutrient canal with a piece of catgut 



HEMORRHAGE. 11 

or a wooden peg. Oozing from the end of a long bone, from the 
edges of the bones of the skull in craniectomy, etc., is readily con- 
trolled by a few minutes' firm compression with a hot gauze pad. 

Suture of the Wound controls hemorrhage from capillaries and 
small veins by bringing the contiguous surfaces into apposition, and 
is simply one method of applying the principle of compression. 

Forcipressure consists in crushing the coats of the severed ves- 
sels with haemostatic forceps. It is a well-known fact that even 
large arteries when crushed or torn do not bleed, and it is upon this 
same principle that forcipressure is applied to control hemorrhage. 

The bleeding artery or vein is seized with the forceps, which is 
then closed down upon the vessel with much force, in this way 
crushing the coats of the vessel, especially the inner coat and so 
effectually controlling the hemorrhage. If the vessels are small the 
iorceps may be removed after a few minutes, when it will be found 
that the hemorrhage has ceased. Forcipressure is a very satisfactory 
method of dealing with larger vessels when situated deep in a small 
wound where they are not readily accessible for ligation. Under 
these circumstances, however, it is wise to allow the forceps to re- 
main in place for twenty-four to forty-eight hours, including them 
in the dressing, since the hemorrhage might recur if they were 
removed earlier. By allowing the forceps to remain one gives the 
blood a chance to form a good firm clot to occlude the vessel. ' 

The angiotribe, a bulky crushing instrument, is applied upon 
this principle. It is provided with a screw which enables one to 
•apply great pressure to the parts within the grasp of its blades. 
This instrument has been used for crushing the broad ligament in 
vaginal hysterectomy, but has not, as yet, won for itself a place in 
popular favor. 

Torsion. — This method of occluding a bleeding vessel consists 
in seizing the end and twisting it until the inner coat of the vessel 
is ruptured and the end of the vessel, in the grasp of the forceps, 
is twisted free. This measure may be applied to small arteries and 
veins as an adjunct to forcipressure. Torsion may be more effect- 
ually applied by grasping the free end of the vessel with one forceps 
and the vessel itself a short distance beyond, transversely, with a 
second forceps. While the vessel is steadied with the forceps that 
grasps it transversely, it is twisted repeatedly upon itself with the 
forceps that grasps its extremity. 

Ligature. — The most commonly employed and safest means of 



12 GENERAL CONSIDERATIONS. 

securing severed arteries and veins especially if of large caliber. In 
the day of the non-absorbable, non-aseptic ligature many plans were 
devised to obviate the use of the ligature, since it had to be cast 
off before the wound could heal and thus precluded the possibility 
of union by first intention, and because, as the ligature separated 
and came away, it w T as often accompanied by a dangerous secondary 
hemorrhage. 

With the aseptic, absorbable ligature, an ideal method of con- 
trolling hemorrhage in the wound was instituted. The aseptic, ab- 
sorbable ligature permits the immediate closure of the wound and 
does not in any way interfere with the healing process. Some sur- 





Fig. 4.— Square Knot. Fig. 5.— Slip-knot. 




Fig. 6.— Surgeons' Knot. The first loop is made double to prevent slipping 
while taking the second loop. 

geons still use silk for ligature. Although silk may be rendered 
absolutely aseptic, it has the disadvantage of not being absorbable, 
and may therefore occasionally act as a foreign body, keeping the 
wound open until it separates or until it is removed. The ligatures 
may be applied in the wound before the vessels have been divided 
or afterward, and may be applied to the isolated vessels or may in- 
clude the immediately adjoining soft parts as well. 

Ligature of blood-vessels before they have been severed is ex- 
emplified in the tying of the external jugular in operations upon 
the neck after the vessel has been exposed in the incision, but before 
it is cut; the ligature is applied double and the vessel then divided 



SUTURE OF THE TISSUES. 13 

between these. Again, in disarticulation through the hip-joint the 
main vessels may be exposed during the course of the operation, 
ligated, and then divided. In resecting portions of the alimentary 
canal the mesentery or omentum that carries the blood-supply to 
the parts must be tied off. This is usually done in sections, each 
ligature including from one to one and a half inches of the mesen- 
tery or omentum; in this case not only are the blood-vessels in- 
cluded in the ligatures, but all of the tissue from one ligature to 
the next. 

Ordinarily the ligatures are applied to the vessels after they 
have been severed. The bleeding point is seized with a haemostatic 
forceps and the ligature is then slipped over the end of this and 
tied. 

Occasionally, vessels in dense fibrous tissue, in the dura mater 
and wall of the chest, when cut, retract into the surrounding tissue 
so that their ends cannot be seized with the forceps. Under these 
circumstances it may be necessary to carry the ligature around the 
vessel with a curved needle. 



SUTURE OF THE TISSUES. 

The various suture materials may be grouped in two classes: 
temporary and permanent. 

Temporary sutures are made of simple catgut, which softens 
and becomes absorbed in from five to ten days according to its thick- 
ness, and chromicized catgut, which remains longer, from two to 
four weeks or even six weeks, according to its thickness and the 
manner of its preparation. 

Permanent sutures consist of silk, silk-worm gut, kangaroo ten- 
don, horse-hair and metal, silver wire, etc. (Kangaroo tendon be- 
comes absorbed after sixty days; so that it is not, in the strict sense, 
permanent.) 

Suture of the Skin. — For this purpose one may use a penetrating 
stitch, continuous or interrupted, or a non-penetrating intercuticular 
stitch, which is at present much in favor. 

The stitch should not be drawn too tight, as it constricts the 
parts, and this interferes directly with the blood-supply and the 
healing process. If the stitch is drawn too tight it may cut its way 
through the tissues, and besides may add much to the pain and 
discomfort of the patient. The stitch should be drawn just tight 



1-i 



GENERAL CONSIDERATIONS. 



enough to bring the parts into immediate contact. The knots should' 
he so arranged that they lie to one side or the other of the wound. 

The Lnteacuticular Sutuee. — For this suture simple or 
chromicized catgut or some permanent material — silk-worm gut, silk,. 
etc. — may be used. It may be introduced with a straight needle or 
with a curved needle in a holder. 

In introducing this stitch, one should, with the needle, catch 
the firm under layer of the skin proper, avoiding the loose, sub- 
cutaneous fat and connective tissue, and with each puncture of the 
needle take a good long bite; after crossing from one edge of the 




Fig. 7. — Intracuticular Suture. A, end of suture fixed with a pledget of gauze. 



incision to the other one should take care to enter the needle directly 
opposite the point at which it emerged or even a trifle back of this. 
The suture may be secured at each end with a small pledget of gauze. 
One pad is fixed to the end of the thread before commencing the 
suture, and then, after the needle emerges through the last puncture, 
it is carried through the second pad and the suture secured with one 
or two turns about this. 

Suture of Muscle. — Divided muscle is usually approximated with 
absorbable material, simple or chromicized catgut. If the muscle 
has been cut across, at right angles to the course of its fibers, the 



SUTURE OF THE TISSUES. 15 

part should be placed in a position to relax the muscle and special 
care should be exercised to bring the cut edges securely together. 
This is aceonrplished by introducing a sufficient number of inter- 
rupted sutures or a continuous suture of moderately thick catgut, 
each taking a good secure bite in the muscle, or one may use several 
mattress sutures for this purpose. If the muscle has been divided 
along the course of its fibers, — i.e., between its fibers, — several in- 
terrupted catgut sutures will usually suffice to retain its edges in 
apposition. 

If the sheath of a broad muscle has been divided, — for exam- 
ple, the sheath of the rectus, — care should be taken to unite accu- 
rately, with catgut, simple or chromicized, the edges of the sheath. 

In operations for the cure of hernias the edges of the muscles 
are sometimes joined with a non-absorbable suture material, — silk, 
silk-worm gut, or silver wire, — with the idea of leaving these as 
permanent sutures to retain the parts in close apposition. 




Fig. 8. — Bone Drill with Eye near the Point to carry Suture, etc. 

Suture of Tendons. — Severed tendons are sewed end to end with 
some absorbable suture material. A single mattress suture or one 
or more ordinary interrupted sutures that pass through the tendon 
proper are usually employed for this purpose (see Fig. 198). If a 
part of the tendon has been destroyed so that the ends cannot be 
approximated, a flap may be turned back from one or both ends in 
order to meet this deficiency. 

Suture of Nerves. — The ends of a divided nerve may be joined 
with one or two catgut sutures which secure the sheath of the nerve, 
or, better, these sutures may penetrate the nerve proper. 

Bone and Cartilage. — For the purpose of suturing bone and 
cartilage silver wire is usually employed. Sometimes heavy, chro- 
micized catgut is used. In order to pass the sutures, holes must 
first be made through the bone. This is done with the drill. Before 
withdrawing the drill the suture is introduced through the small 
eye in the point of the drill, and then as the instrument is with- 
drawn it brines the suture after it. If the suture is too thick to 



16 



GENERAL CONSIDERATIONS. 



enter the eye in the point of the drill, one may pass a loop of silk 
through the eye of the drill and with this draw the suture through. 

Bones are sometimes joined with one or more sutures of chro- 
micized catgut which do not go through the bone, but include the 
periosteum and the fibrous tissue that cover the bone; this method 
may be used, for example, to unite a fractured patella so as to avoid 
entering the knee-joint and the handling that would be necessary 
in the making of drill-holes. 

Bones may also be joined by steel nails, ivory pegs, etc., that 
are driven from one fragment of bone into the other. 





Fig. 9.— Segment of Bowel. Interrupted 
Lembert sutures in place. 



Fig. 10.— Segment of Bowel. Lembert 
sutures tied. It will be noted that they 
do not penetrate through the entire 
thickness of the wall of the gut. 



Suture of Serous Surfaces, Bowel, etc. — The essential object is 
to secure rapid adhesion by approximating serous surface to serous 
surface, and this is accomplished by means of the Lembert suture. 

The Lembert suture catches the serous and muscular coats of 
the bowel, but does not penetrate into the mucous membrane layer. 
It should not enter into the cavity of the gut, etc. For this suture 
silk should be employed. It may be introduced interrupted or con- 
tinuous, and is applied in such a manner as to invert the edges and 
join opposite serous surfaces. 

A straight round cambric needle is usually employed to carry 
the Lembert suture, but occasionally, especially in sewing deep 
within the abdominal cavity, a thin curved surgeon's needle in a 
holder may be more convenient. 



SUTURE OF THE TISSUES. 



17 



In applying the Lembert suture the needle is introduced a short 
distance from the edge of the wound, and after passing through the 
wall of the gut, catching up the serous and muscular coats, hut not 
entering the mucous membrane coat, it emerges near the edge of 
the incision; the needle is then carried across the incision and in- 
troduced upon the opposite side at a point directly opposite and in 
a similar manner. 

The suture may also be introduced and carried in the wall of 
the gut along a line parallel with the incision instead of at right 
angles to the line of the incision. 




Fig. 11.— Cushing Suture Applied to Close Opening in the Bowel. It is a 
continuous stitch and passes through the wall of the gut parallel with the 
line of the incision instead of at right angles to it. 



Small wounds of the bowel may be closed with a single row of 
Lembert sutures. Larger wounds of the hollow abdominal viscera 
should be closed, first, with a continuous or interrupted row of silk 
or catgut sutures that penetrate through all the layers of the organ, 
joining the parts accurately edge to edge, and then, after the open- 
ing has been thus closed, the Lembert stitch, which unites the 
opposite serous surfaces to each other, is applied. The Lembert 
stitch buries the penetrating suture and inverts the edges of the 
wound, so that the serous surfaces become apposed to each other. 
The outside Lembert suture that buries the deeper penetrating 
mucous suture is sometimes called the "outside serous" suture. 



18 GENERAL CONSIDERATIONS. 

Suture of Wounds of the Bladder. — Closure of wounds of 
the urinary bladder requires special mention. They may involve 
the serous or the non-serous portion of the organ. 

Wounds of the serous portion should he first closed with a 
continuous catgut stitch, which should include all the coats except 
the mucous membrane. Each loop of this suture should be drawn 
tight. This serves to close the opening. A continuous Lembert 
stitch of silk is then introduced which unites the opposite serous 
surfaces, immediately adjacent to the edges of the incision, to each 
other and buries the first row of sutures. 

Wounds of the non-serous portion of the bladder: i.e., its ante- 
rior wall. Wounds of this part of the bladder should be closed with 
a continuous or interrupted row of catgut sutures that include the 
whole thickness of the bladder wall except its mucous membrane. 
These sutures should close the opening in the wall of the bladder 
very accurately; owing to the absence of the serous coat from this 
part of the bladder, the Lembert suture — "outside serous suture" — 
cannot be applied. Since we cannot look for rapid adhesion in wounds 
of this part of the bladder, it is well to allow the abdominal incision 
to remain open, packing with gauze down to the suture line in the 
wall of the bladder, so that, if there is any leakage, the fluid may 
find its way out of the wound. 



PART II. 

HEAD AND FACE. 



HEAD. 



Surgical Anatomy of the Head. The Scalp. — The head is cov- 
ered by the scalp, which is a dense layer, composed of the skin, 
subcutaneous connective tissue, and the aponeurosis of the occipito- 
frontalis muscle. These three layers together constitute the scalp. 

The subcutaneous connective tissue is dense and serves to unite 
the skin intimately with the underlying aponeurosis of the occipito- 
frontalis muscle. It is continuous behind, in front, and upon the 
sides with the superficial fascia (subcutaneous fatty and connective 
tissue layer) of these parts. In it ramify the blood-vessels and 
nerves. 

The arteries of the scalp are large and numerous. Bleeding 
from these vessels can often be controlled by pressure applied against 
the underlying bony surface. Anteriorly are the frontal and supra- 
orbital arteries; on the sides, branches of the temporal; and, behind, 
the occipital and posterior auricular. These vessels all course from 
below upward toward the crown of the head, their branches anas- 
tomosing freely with each other all around. These arteries are 
found at times to be very tortuous. 

The occipito-frontalis muscle is broad and flat, consisting of 
an anterior and a posterior muscular portion and an intermediate 
aponeurotic portion which covers the top of the skull. This apo- 
neurosis is firmly united with the overlying skin, whereas it is but 
loosely attached to the pericranium beneath. Upon either side the 
aponeurosis is continued into the temporal fascia. In cases where 
the scalp is torn off, the aponeurosis of the occipito-frontalis comes 
away with the skin and subcutaneous connective tissue, thus leaving 
the pericranium exposed. 

In the temporal region the subcutaneous connective tissue layer 
is looser than upon the top of the head, and in it run the branches 
of the temporal artery and vein and the auriculo-temporal nerve. 
Beneath the subcutaneous layer in the temporal region is the tem- 
poral fascia. This is a strong, fibrous layer covering in the temporal 

(19) 



20 HEAD AND FACE. 

muscle, and is attached above, all around, to the temporal ridge, 
and, below, to the upper border of the zygomatic arch, where it splits 
into two layers, between which are included a small arterial and 
nervous branch. The aponeurosis of the occipito-frontalis muscle 
thins out upon each side and is continued into this temporal fascia. 
Beneath the temporal fascia is the temporal muscle. This is a broad, 
fan-shaped muscle which arises from the whole surface of the tem- 
poral fossa and from the under surface of the temporal fascia; it is 
attached by a strong tendon to the tip, anterior border, and inner 
surface of the coracoid process of the inferior maxilla. 

The pericranium is a shining, fibrous layer of periosteum which 
is closely attached to the external surface of the bones of the skull: 
most intimately at the suture lines, through which it is continuous 
with the dura mater lining the inner surface of the bones. 

Collections of pus or blood between the skin and the occipito- 
frontalis aponeurosis give rise to circumscribed tumors because they 
cannot become diffused in the dense subcutaneous connective tissue 
layer. Between the aponeurosis and the pericranium, however, such 
collections may become widely diffused, owing to the looseness of the 
tissue which joins the aponeurosis and the pericranium together, 
and, raising the whole scalp so that it resembles a water-bag, may 
gravitate and point in the frontal or occipital regions. Beneath the 
pericranium, between this layer and the surface of the bone, such 
collections are again limited, owing to the close union between this 
structure and the underlying bone. 

The Skull is a rounded, elastic case made up of a number of 
bones joined, for the most part, edge to edge. The base of the 
skull is irregular and is strengthened along certain lines by ribs of 
bone, the intervening portions being often very thin. It presents 
many openings for the entrance and exit of important structures. 
The vault of the skull is arched, rounded, and smooth. The bones 
entering into the formation of the vault are flat and vary in thick- 
ness in different places. These so-called flat bones that enter into 
the formation of the vault are made up of spongy tissue — diploe — 
inclosed between two plates of hard compact bone: the inner and 
outer tables. The outer table is twice as thick as the inner. The 
external surface of the skull is covered by the periosteum (peri- 
cranium) already mentioned. The internal surface is lined by the 
dura mater, which is very closely applied to the surface of the bones, 
serving the purpose of a periosteum; the large vascular branches 



SURGICAL ANATOMY OF THE HEAD. 21 

that ramify upon the inner surface of the skull are lodged in the 
dura. 

The spongy substance — diploe' — inclosed between the two layers 
of compact bone presents an extensive system of venous canals. 
These communicate with the intracranial venous channels, that are 
found between the layers of the dura mater, and with the veins of 
the scalp. The vault of the skull varies in thickness in different 
places and in different individuals. About the middle it is thin, its 
average thickness in this situation being from 4 to 5 mm.; it be- 
comes thicker toward the front and still more so toward the occiput. 
Along the course of the intracranial venous sinuses, and also corre- 
sponding to the depressions for the Pacchionian bodies, which are 
located upon either side along the middle line, the bone is thinner. 
"Where the skull is thin it is at the expense of the diploe, which in 
certain parts may be entirely absent, the two tables being in direct 
contact with each other. This is the condition in the temporal 
region. 

Corresponding to the frontal region the skull is marked by the 
presence of two large air-spaces, one on either side, the frontal 
sinuses; these are separated from each other by a septum located 
more or less in the middle line. The anterior wall of these spaces 
is thick, and consists of two layers of hard, compact bone with inter- 
vening diploe. The posterior wall is thin. The frontal sinuses vary 
in size in different individuals, are lined with mucous membrane, 
and communicate with the nasal fossa through a large canal, the 
infundibulum, which opens under the middle turbinated bone, 
toward the front. 

In the mastoid region the bone is prolonged downward in the 
form of a teat-like process: the mastoid process. 

Corresponding to the temporal region, the skull is made up of 
the squamous portion of the temporal bone, which is very thin, and 
of part of the parietal bone. Ascending upon the surface of the 
bone, beneath the temporal muscle, are several deep temporal arte- 
rial branches. 

The parietal and the occipital bones and the mastoid portion 
of the temporal bone present openings for the passage of veins from 
the exterior of the skull which empty into the intracranial sinuses, 
and these may be the routes through which infection is carried into 
the cranial cavity. 

The Dura Mater is a strong, non-elastic, fibrous membrane 



22 HEAD AND FACE. 

which lines the inner surface of the skull and is closely attached 
to the hones (periosteum), but may be separated without much force. 
It supports the intracranial arteries and veins (venous sinuses), and 
when separated from the surface of the bones carries these vessels 
with it. Anteriorly, ramifying in the dura mater, is the anterior 
meningeal artery, which is a branch of the ethmoid. Corresponding 
to the middle fossa of the skull and the temporal region, the middle 
meningeal artery is found. This is a branch of considerable size, 
and is of much surgical importance; it is derived from the internal 
maxillary and enters the skull through the foramen spinosum in the 
base of the skull. Behind are the posterior meningeal branches 
which are derived from the occipital and the vertebral. 

There are a number of large venous sinuses which are situated 
between the layers of the dura and which groove the surface of the 
bones along their course. The largest of these are the longitudinal, 
the lateral, and the cavernous. 

The longitudinal sinus runs from before backward along the 
line of the sagittal suture from the foramen caecum in front to the 
occipital protuberance behind. 

The lateral sinus is important surgically. From the center of 
the occipital bone that of either side passes transversely outward, 
grooving the internal surface of the occipital bone upon a line cor- 
responding to the attachment of the trapezius and sterno-mastoid 
muscles and the inner surface of the posterior inferior corner of the 
parietal; here the sinus curves downward, grooving the inner sur- 
face of the mastoid, and from this bone is continued again over on 
to the occipital, crossing the upper surface of the jugular process 
of this bone, to join with the inferior petrosal sinus to form the 
internal jugular vein. The course of the transverse portion of the 
lateral sinus corresponds to a line drawn from the external occipital 
protuberance to the upper margin of the external auditory meatus. 

The cavernous sinus is lodged in the groove upon the side of 
the body of the sphenoid bone. The internal carotid artery passes 
from behind forward, from the orifice of the carotid canal in the 
apex of the petrous portion of the temporal bone, where the artery 
enters the cranium, to the point where it divides into its terminal 
branches. This part of the internal carotid artery is enveloped by 
the cavernous sinus, the wall of the sinus being, as it were, wrapped 
around the artery. The sixth nerve is also inclosed entirely within 
the sinus, lying below and to the outer side of the artery. The third, 



OPERATIONS UPON THE HEAD. 23 

fourth, and the ophthalmic division of the fifth nerve are located 
in the outer wall of the cavernous sinus, but are not contained within 
its lumen as are the internal carotid artery and the sixth nerve. 

The blood-pressure within these sinuses is low, and hemorrhage 
is readily controlled by packing with gauze. 

The Pia Mater. — The skull contains the brain inclosed within 
its own peculiar membrane: the pia mater. This is a connective 
tissue membrane which serves to support the vessels which supply 
the brain, and contains within its meshes the cerebro-spinal fluid. 
The pia mater is not a simple flat membrane, but is really made up 
of two layers joined together by septa which divide it up into a 
mesh-work of cellular spaces within which is contained the cerebro- 
spinal fluid. It has been compared to a water-soaked connective 
tissue. It has no connection with the dura mater; so that between 
the inner surface of the dura and the external surface of the pia 
there is a narrow free space, or crevice, which contains a minute 
quantity of fluid. This is called the subdural space. 

Between the layers of the pia mater there is a great system 
of spaces communicating with each other, and this is sometimes 
called the subarachnoid space; as already stated, the cerebro-spinal 
fluid is contained in this space. This membrane, the pia mater, is 
attached by its deep internal surface directly to the surface of the 
brain, dipping down between its convolutions and lobes. It acts 
like a water cushion, preserving the blood-vessels from pressure, and 
also permits intracranial tumors, etc., to acquire an appreciable 
thickness before they begin to cause pressure symptoms. 

OPERATIONS UPON THE HEAD. 

Trephining. — By trephining we mean making an opening into, 
or resecting a portion of, the skull. This operation is done to relieve 
compression either from depressed bone or from extravasated blood, 
and to treat intracranial conditions, as abscess, tumor, etc. 

The patient is placed upon the back with a thin sand bag under 
the head. The opening in the skull may be made with a trephine, 
chisel, or rongeur or Keen forceps, or with a circular saw or a 
rotary drill. 

Trephining for Depressed Fracture of the Skull. — If a 
wound is already present, this should be utilized, and, if necessary, 
may be enlarged in order to expose the site of fracture. If no wound 



24 HEAD AND FACE. 

is present and the incision is a matter of choice, a crescentic or 
crucial incision may be employed, or a U-shaped flap be reflected. 
In marking out this flap the base should be below, toward the pe- 
riphery, so as to insure good blood-supply to the flap. The incision 
should reach through the periosteum down to the surface of the 
bone, and in reflecting the flap the periosteum should be included. 

After the site of the fracture has been exposed and spurting 
vessels clamped and tied, one may proceed to relieve the compression 
by elevating depressed bone, clearing out blood-clot, etc. A num- 
ber of loose pieces of bone, entirely detached from the periosteum 
(pericranium and dura mater), may be found, and these may be 
removed with a thumb forceps. We may find other fragments loose, 
but still attached, at least in part, to the periosteum or dura mater. 
These may, in some cases, be readily elevated. We may find other 
depressed fragments so firmly impacted, wedged, that they cannot 
be elevated, and in order to get at these fragments it may be neces- 
sary to remove a portion of the adjoining margin of bone, either 
with the trephine or chisel. If the trephine is used for this purpose 
the periosteum is scraped back, laying bare the surface of the bone 
which is to be removed. When the trephine is first applied the 
center pin should be lowered beyond the level of the cutting edge 
of the crown of the trephine, so as to engage in the bone and steady 
the trephine until the crown has cut a groove within which it may 
work without slipping, when the pin may be again raised. The 
trephine should be so placed that its crown will partly overlap the 
edge of the bone, so that only one-half of a button will be removed 
from the margin adjoining the impacted fragment. The trephine 
should be worked with a firm, steady wrist movement, and the groove 
occasionally probed to ascertain if the bone is cut through at any 
point. The use of such force as would result in sudden, abrupt 
penetration of the skull should be avoided. The button may be 
loosened by gently prying with the elevator. Bleeding from the 
edge of the bone ceases after a few moments' pressure with a hot 
gauze pad. 

In many cases the liberation of an impacted fragment is best 
accomplished by using the chisel to cut away the margin of the 
bone that holds it fast; often, with a few strokes of the mallet, the 
fragment is freed or a space is made to allow the use of the elevator. 

Having removed all loose fragments and elevated those which 
are still attached to the pericranium and dura mater and rounded off 



OPERATIONS UPON THE HEAD. 25 

the edges of any defect left in the skull, one should search carefully 
for any loose fragments or spiculge which may he concealed under 
the edge of the opening in the hone. The finger or prohe should 
be used for this purpose. Small pieces may he washed out by irri- 
gation with a weak bichloride solution or they may be picked out 
with a forceps. One should examine carefully as to the condition 
of the internal table, as this is often more extensively fractured 
than is indicated by the appearance of the external table. The 
internal table is at times extensively fractured and depressed when 
the corresponding part of the external table is apparently uninjured. 
Extravasated clotted blood, between the dura and the inner surface 
of the bone, or beneath the dura, between it and the pia mater, 
should be removed with a scoop and by irrigation and any severed 
vessels tied with fine catgut. If the dura mater has been torn the 
edges of the opening may be brought together with a fine catgut 
suture. 

The wound in the scalp may be closed without drainage unless 
the parts have been exposed to the chance of infection. In this case, 
for the purpose of drainage, a narrow strip of gauze may be intro- 
duced through one corner of the wound and reaching down to the 
dura mater. 

Trephining for Intracranial Hemorrhage (Middle Men- 
ingeal). — The middle meningeal artery is the usual source of 
traumatic intracranial hemorrhage. 

The middle meningeal is a vessel of considerable size, and is 
given off from the upper aspect of the first part of the internal 
maxillary a short distance beyond its origin from the external 
carotid, as it (the internal maxillary) lies beneath the neck of the 
condyle of the jaw, between it and the internal lateral ligament. 
The middle meningeal passes directly upward between the two roots 
of the auriculo-temporal nerve, which surround the commencement 
of the artery, toward the base of the skull, and enters the skull 
through the foramen spinosum. This part of the middle meningeal 
artery is concealed beneath the external pterygoid muscle, the ten- 
don of which is attached to the front of the neck of the condyle 
of the jaw. In front and internal to this part of the artery is the 
inferior maxillary division of the fifth nerve and its motor root, these 
nerve branches emerging from the skull through the foramen ovale. 

After entering the skull the middle meningeal runs a short 
distance outward in a groove in the floor of the middle fossa and 



26 HEAD AND FACE. 

then divides into two branches. The anterior, the larger branch, 
passes forward and outward across the floor of the middle fossa of 
the skull and across the anterior inferior angle of the parietal bone 
just behind the outer extremity of the lesser wing of the sphenoid, 
and may be exposed as it ascends upon the side of the skull at a 
point which corresponds to the intersection of two lines (Vogt), 
one vertical, a thumb's breadth behind the external angular process, 
and, the other, horizontal, placed two fingers' breadth above the 
z} r goma. The posterior branch of the middle meningeal passes out- 
ward across the squamous portion of the temporal bone and then 
ascends upward and backward upon the inner surface of the poste- 
rior inferior portion of the parietal bone above and in front of the 
groove seen here for the lateral sinus. The posterior branch may 
be exposed by removing a button of bone whose center is one inch 
above and one-half inch behind the external auditory meatus. 

The middle meningeal and its branches ramify in the dura and 
groove the surface of the bones against which they are applied. The 



.s^v^^^^-^-.^^^^^^ 



^ 



Fig. 12.— Hartley Chisel. This chisel is pointed, V shape en section, and is 
very convenient for cutting the groove in the bone. 

anterior branch, as it approaches the anterior inferior angle of the 
parietal bone, is lodged in a deep groove, which is occasionally con- 
verted into a complete bony canal. 

Temporary Resection of the Skull. — When the skull is intact, 
it is preferable, in order to gain access to the cranial cavity, to do 
a temporary resection of the skull (Wagner), turning back a flap, 
which consists of the soft parts, periosteum, and corresponding 
piece of bone, rather than to remove a button of bone, which leaves 
a permanent defect in the skull. To reach the middle meningeal 
artery or its divisions this is a most satisfactory method. 

A horseshoe-shaped flap is marked out in the temporal region, 
with its arch above and its base below at the zygoma, the anterior 
leg being placed a good finger's breadth behind the external angular 
process and the posterior leg just in front of the tragus. The in- 
cision should reach through the soft parts, including the periosteum, 
down to the bone. The flap thus marked out should measure in its 
vertical diameter about three inches, and about two and one-half 



OPERATIONS UPON THE HEAD. 



27 



inches across its widest part. At its base the flap should be from 
one and one-half to two inches wide. 

The temporal artery and some of its branches are usually 
divided, and must be clamped and tied. 

Betracting the soft parts, but without separating them from 
the surface of the bone, a groove is cut in the bone all around corre- 
sponding to the course of the skin incision. This may be accom- 




Fig. 13. — Temporary Resection of the Skull. Osteo-tegumentary flap 
turned down, exposing dura. MA, anterior branch of middle meningeal ar- 
tery. MP, posterior branch of middle meningeal artery. 



"plished with a chisel (Hartley or ordinary chisel), or one may com- 
mence by marking it out with a revolving saw and complete it with 
the chisel, or a small opening may be made in the skull with a 
trephine and a rotary drill then used. The line of section through 
the bone should not be direct, but rather somewhat oblique, so that 
the segment of bone in the flap may have a beveled edge, thus giving 
a better fit when it is replaced. After the section through the bone 



28 HEAD AND FACE. 

has been made, the periosteum elevator is introduced into the upper 
part of the groove and the piece of bone pried out, breaking it below,, 
through its base, near the zygoma, and then this flap, which consists- 
of all the soft parts with the corresponding segment of bone attached, 
is turned down over the zygoma, leaving a considerable opening in 
the skull through which the dura mater and the branches of the 
middle meningeal artery, which ramify in it, are exposed. 

If the opening in the skull is not sufficiently large, it may be 
further enlarged by cutting away its margins with the bone forceps. 

The extravasated blood is usually located between the dura and 
the bone, so that as soon as the plate of bone has been turned back 
we expose the blood, which is, as a rule, partly clotted. This may 
be cleared out with a scoop and irrigation, after which the ends of 
the divided vessel are sought and tied. Ordinarily they may be 
seized with a clamp and ligated in the usual manner; there may, 
however, be some difficulty in securing the ends of the divided ves- 
sel, as they may have retracted within the canal in the dura in which 
they are situated to such an extent that they cannot be readily seized 
with the artery forceps, and it may then be necessary to carry a 
ligature around the vessel with a curved needle. 

Should the blood have collected beneath the dura mater, be- 
tween it and the surface of the brain (pia mater), in the subdural 
space, it would be necessary to make an opening in the dura in 
order to clear the blood out. 

Usually the anterior branch of the middle meningeal is the 
vessel which is torn, but through the opening made in the skull one 
can also reach the posterior branch or the main trunk if necessary. 

Having entirely removed the blood, tied the ruptured vessel, 
and sutured the dura, if it has been incised or torn, we replace the 
osteo-tegumentary flap and without drainage unite the edges of the 
soft parts all around with interrupted catgut sutures. 

Removal of a Button of Bone with the Trephine. — By removing 
a button of bone with the trephine the anterior and posterior 
branches of the middle meningeal may be exposed and ligated. 

To reach the anterior branch of the middle meningeal, an in- 
cision, vertical, is made through the skin, muscle, and periosteum 
down to the bone, and with the periosteum elevator the surface of 
the bone, corresponding to the intersection of Vogt's lines, is laid 
bare (see Fig. 16). Instead of using the vertical incision this area 
of bone may be exposed by turning down a U-shaped flap with its- 



OPERATIONS UPON THE HEAD. 29 

base below near the zygoma. This flap includes all the tissues of 
the scalp and the periosteum, and is detached from the surface of 
the bone with an elevator. 

The trephine is then used to remove a button of bone, and 
thus the dura is exposed. If the opening is not sufficiently large it 
may be enlarged with the rongeur bone forceps. The clot is usually 
found between the dura and the bone, and is therefore exposed as 
soon as the button has been removed. It may, however, be situated 
beneath the dura, in the subdural space, and it may thus become 
necessary to incise the dura in order to reach it. After clearing out 
the clot, etc., the ends of the vessels are secured and the incision in 
the soft parts closed. This operation may be performed more quickly 
than the temporary resection of the skull, but it does not give as 
much room, and a further disadvantage is that it usually leaves a 
permanent defect in the skull. 

To expose the posterior branch of the middle meningeal a 
button of bone may be removed one inch above and one-half inch 
posterior to the external auditory meatus, as described above. This 
branch is but seldom injured. 

Craniectomy (Lineae Ceaniotomy). — Making linear furrows 
in the skull for the purpose of providing space to permit of the proper 
growth of the brain, in cases of microcephalia and idiocy. 

This operation was first performed by Lannelongue. It may 
be done on one or both sides of the skull at one sitting: one side 
at a time is probably preferable. 

A longitudinal incision is made in the scalp in the middle line 
commencing at a point just above the occipital protuberance and 
carried forward as far as the hair-line of the scalp; from the ante- 
rior end of this a second curved incision may be made reaching 
downward and outward away from the middle line; this latter in- 
cision is also placed within the hair-line of the scalp. The scalp 
is then raised from the skull with the elevator. 

Posteriorly, just above the occipital protuberance, an opening 
is made in the skull with the trephine, about one-half inch in diam- 
eter, and through this opening, with the bone forceps, a furrow is 
cut which is carried forward to within an inch of the supra-orbital 
ridge. This channel should be about one-fourth of an inch wide 
and will vary from five to six and one-half inches in length and 
should be placed about three-fourths of an inch away from the 
middle line, in order to avoid the longitudinal sinus. The dura is 



30 HEAD AND FACE. 

detached from the inner surface of the skull to permit the use of 
the hone forceps, but should not be opened. 

From either end of the longitudinal furrow in the bone an 
additional channel may be cut, reaching downward and outward for 
one or two inches away from the middle line. 

The periosteum is cut away from the margins of the furrows 
in the bone to prevent reproduction of the bone. If any of the 
branches of the meningeal are injured during the course of the 
operation, they may be surrounded by a ligature carried in a curved 
surgeon's needle and tied. It is often difficult to secure these 
branches with the artery forceps, and thus the necessity of carrying 
the ligature around them in the needle. 

The edges of the incision in the scalp are accurately approxi- 
mated without drainage, to insure primary healing. 

The longitudinal furrow in the skull is usually placed to the 
left of the middle line, but may be placed upon the right side in- 
stead, if this appears to be the less developed side. 

THE MIDDLE FOSSA OF THE SKULL. 

The Anatomy of the Middle Fossa. — The middle fossa of the 
skull is narrow in the middle and widens out upon either side. It 
is limited in front by the posterior border of the lesser wing of the 
sphenoid and by the optic groove; behind by the dorsum epiphii 
and the upper border of the petrous portion of the temporal bone. 
The upper border of the petrous portion is marked by a groove for 
the superior petrosal sinus and gives attachment to the tentorium 
cerebelli. The floor of the middle fossa, in the middle line, consists 
of the upper surface of the body of the sphenoid, presenting in 
front the optic groove, at either end of which is the optic foramen; 
behind the optic groove is the sella turcica, a deep depression which 
lodges the pituitary body and which is bounded behind by the 
dorsum epiphii; laterally the floor of this fossa consists of the upper 
surface of the great wing of the sphenoid, the anterior surface of 
the petrous portion of the temporal, and a part of the squamous 
portion of the temporal. The body of the sphenoid is marked upon 
either side by a groove which commences behind at the foramen 
lacerum medium (carotid foramen) and terminates in front at the 
optic foramen. This lodges the cavernous sinus, etc. 

The foramen lacerum medium is formed at the expense of the 



ANATOMY OF THE MIDDLE FOSSA. 31 

anterior superior surface of the apex of the petrous portion of the 
temporal; it is bounded in front by the posterior border of the 
great wing of the sphenoid and behind by the apex of the petrous- 
portion; through this opening the internal carotid artery enters 
the cranium. Behind and external to this foramen the antero- 
superior surface of the petrous portion presents a depression in 
which the Casserian ganglion rests. In front of and external to 
the foramen laeerum medium, in the posterior part of the great 
wing of the sphenoid, there is a large opening, the foramen ovale. 
As its name indicates, this opening is oval in shape, its long diam- 
eter being directed from without inward and a little forward. This 
opening is seen externally upon the base of the skull at the root 
of the pterygoid process, external to the external pterygoid plate. 
Through this opening the inferior maxillary or third division of the 
fifth nerve emerges from the cranial cavity. Just external to the 
foramen ovale and a little behind it, in the apex or angle of the 
great wing of the sphenoid, is the foramen spinosum, through which 
the middle meningeal artery enters the skull. From this opening 
a groove is seen running outward, marking the squamous portion 
of the temporal near its junction with the petrous portion; this 
groove lodges the posterior branch of the middle meningeal artery 
and is continued upward upon the side of the skull across the poste- 
rior inferior part of the parietal bone. Commencing at or near the 
foramen spinosum there is another groove, which runs forward and 
outward across the squamous portion of the temporal and the great 
wing of the sphenoid, ascending upon the side of the skull, across, 
the anterior inferior portion of the parietal bone; in this groove 
rests the anterior division of the middle meningeal artery. About 
one-half inch in front of and a little internal to the foramen ovale 
is the foramen rotundum. This is the commencement of a short 
canal which passes obliquely forward through the great wing of the 
sphenoid and opens into the spheno-maxillary fossa through the 
upper part of its posterior wall; the superior maxillary or second 
division of the fifth nerve passes through this canal. Toward the 
front of the middle fossa we have the sphenoidal fissure opening 
into the orbit; this is a triangular opening between the free border 
of the great wing and the under surface of the lesser wing of the 
sphenoid, its base being inward toward the body of the sphenoid. 
Through this fissure pass the third, fourth, and the ophthalmic or 
third division of the fifth nerve, the ophthalmic vein, etc. 



32 



HEAD AKD FACE. 




Fig. 14.— Base of Skull from Within. C, cavernous sinus; CG, Casserian 
ganglion; IP, inferior petrosal sinus; JF, jugular foramen; L, lateral sinus; 
MA, anterior branch of middle meningeal; MP, posterior branch of middle 
meningeal; SP, superior petrosal sinus; 8, sigmoid (lateral) sinus; 1, first 
(ophthalmic) division of fifth nerve; 2, second (superior maxillary) division; 
3, third (inferior maxillary) division. The first (ophthalmic) division rests 
upon and is blended with the wall of the cavernous sinus. The second divis- 
ion lies alongside of, but is not connected with, the wall of the cavernous 
sinus. 



ANATOMY OF THE MIDDLE FOSSA. 33 

The cavernous sinus is a wide, loose, thin-walled canal, situated 
between the layers of the dura mater. It reaches from the apex of 
the petrous portion of the temporal bone behind to the inner end 
of the sphenoidal fissure in front, being lodged in the cavernous 
groove upon the side of the body of the sphenoid. The lumen of 
the cavernous sinus presents a reticular structure, being broken up 
into numerous cellular spaces by trabeculse and septa which pass in 
various directions. Anteriorly, it receives the ophthalmic vein, and, 
posteriorly, joins both petrosal sinuses and communicates with the 
pterygoid plexus through veins which enter the skull through the 
foramina ovale, spinosum, and lacerum medium. The external bor- 
der of the cavernous sinus corresponds to a line running from before 
backward, which would skirt the inner margin of the foramen 
rotundum (see Fig. 14). 

The internal carotid artery enters the cranium through the 
foramen lacerum medium and passes forward, along the side of the 
body of the sphenoid, enveloped by the cavernous sinus, the sinus 
being, as it were, wrapped entirely around the artery. (One could 
not wound the artery in this situation without first cutting into the 
sinus.) Anteriorly, at the inner side of the anterior clinoid process, 
the internal carotid, after giving off its ophthalmic branch, turns 
upward and, passing through an opening in the dura mater, divides 
into its terminal branches. Along the outer side of the artery, and 
therefore also inclosed within the cavernous sinus, runs the sixth 
nerve. In the outer wall of the cavernous sinus and intimately 
united to it, the third, the fourth, and the ophthalmic or first 
division of the fifth nerve are lodged; these structures cannot be 
separated from the wall of the sinus without tearing it, and their 
relation to each other is in the order given both from within out- 
ward and from above downward. 

The fifth nerve at its origin appears upon the side of the pons 
Varolii, and consists of a thick sensory and a small motor root; 
these pass forward through an oval slit in the dura mater and 
across the upper border of the petrous portion of the temporal 
bone, near its apex, into the middle fossa of the skull. As the 
roots pass over the upper border of the petrous portion, they lie 
beneath the superior petrosal sinus. In its course the nerve lies 
outside the dura mater, extradural: i.e., between the dura mater 
and the base of the skull. Upon reaching the front surface of the 
petrous portion of the temporal bone the sensory root presents a 



34 HEAD AND FACE. 

swelling, the Casserian ganglion. The motor root takes no part in 
the formation of this ganglion, but lies underneath it. The ganglion 
is reddish gray; crescentic or semilunar in shape; its anterior convex 
border looks forward, downward, and outward. It is 14 to 22 mm. 
wide, 4 mm. from before backward, and 1 1 / 2 mm. in thickness. 

Given off from the anterior border of the ganglion are the three 
divisions of the fifth nerve. Of these, the first, or ophthalmic, the 
longest and thinnest of the three, is the most internal and passes 
from behind forward and upward along, or rather in, the outer wall 
of the cavernous sinus, entering the orbit through the sphenoidal 
fissure. On account of its intimate relation to the wall of the sinus, 
any attempt to separate it would tear the wall of the sinus; it is 
in close relation with the third and fourth nerves, the carotid artery, 
and the sixth nerve. The second, or superior maxillary, division lies 
external to the preceding, is 8 to 11 mm. long, and passes forward, 
entering the foramen rotundum, and emerges from this canal in the 
spheno-maxillary fossa. This branch lies close to the outer edge 
of the cavernous sinus, but is not joined to it, and may be readily 
removed without danger to the sinus. The third, or inferior maxil- 
lary, division, the most external of the three, is short and thick, and 
passes forward and outward, leaving the skull through the foramen 
ovale in company with the motor root. The motor root winds 
around the third division to get upon its outer side, the two be- 
coming joined just after their exit through the foramen ovale. The 
ganglion rests in the depression already described upon the front 
surface of the petrous portion of the temporal bone. The motor 
root takes no part in the formation of the ganglion, but lies beneath 
it, between it and the bone. At times the bone is absent in this 
location and in such cases the ganglion is separated from the carotid 
artery only by the fibrous tissue which intervenes. The surface of 
bone upon which the ganglion and its three divisions rest is covered 
by the periosteum. The ganglion and its divisions, as already men- 
tioned, are placed extradural: i.e., between the dura mater and the 
base of the skull; the dura roofs them over, and is attached to the 
margins of the depression in which the ganglion rests and to the 
floor of the middle fossa of the skull, along the inner margin of 
the second division and along the outer margin of the third division; 
so that not only the ganglion, but its second and third divisions as 
well, are thus roofed in. This space, in which the ganglion and its 
second and third divisions are thus inclosed, is called the cavum 



ANATOMY OF THE MIDDLE FOSSA. 35 

Meckelii. Beyond the ganglion and its divisions the dura is, as 
elsewhere, closely applied to the surface of the hone. The ganglion 
and its divisions are but loosely attached to the periosteum which 
covers the surface of the hone upon which they rest (floor of cavum 
Meckelii) and to the dura mater which covers them and forms the 
roof of the cavum Meckelii. 

The cavum Meckelii is really a space in the floor of the middle 
fossa of the skull between the bone and the non-attached dura, 
which lodges the ganglion and its second and third divisions. 

The Casserian ganglion is in relation, internally, with the 
carotid artery and cavernous sinus. Behind the ganglion is the 
superior petrosal sinus underneath which the roots of the nerve 




Fig. 15. — Transverse Section through Floor of Middle Fossa. B, bone that 
forms floor of middle fossa; CA, internal carotid artery inclosed within the 
trabeculated cavernous sinus; CM, cavum Meckelii; D, dura mater lining 
floor of middle fossa and roofing over cavum Meckelii; P, dura lining floor of 
cavum Meckelii — periosteum; 3, 4, 5 1 , third, fourth, and first (ophthalmic) 
divisions of the fifth nerve, lodged in the wall of the cavernous sinus; 5 11 , 
5 m , second (superior maxillary) and third (inferior maxillary) divisions of 
fifth nerve, situated between the dura and base of the skull in the cavum 
Meckelii; 6, sixth nerve inclosed within cavernous sinus close to the outer 
side of the internal carotid. 



must pass in order to join the ganglion as it rests upon the front 
surface of the petrous portion. The superior petrosal sinus is con- 
tained in the edge of the tentorium cerebelli, which is attached to 
the superior border of the petrous portion. 

The middle meningeal artery enters the skull through the 
foramen spinosum just external to and a little behind the foramen 
ovale (through which the third division passes out of the skull) and 
would therefore be met with in approaching these structures through 
an opening in the side of the skull. 



36 HEAD AND FACE. 

Extirpation of the Casserian Ganglion (Hartley-Krause) . — The 

patient is placed in a semirecumbent position with the head turned 
partly to one side. A horeshoe-shaped flap, consisting of the in- 
tegument and the underlying muscle and the corresponding segment 
of bone, is turned back. 

The incision passes through the whole thickness of the soft 
parts, including the periosteum, down to the bone. This incision 
commences anteriorly, just above the zygoma, and a good finger's 
breadth behind the external angular process; it is carried upward 
upon the temporal region, describing an arc, its posterior limb ter- 
minating behind, just in front of the tragus. Hemorrhage should 
be controlled with clamps. The flap thus marked out should meas- 
ure in its vertical diameter three inches, about two inches across its 
widest part, and from one and one-half to two inches at its base, 
which is just above the zygoma. Corresponding to the skin incision 
a groove is now chiseled all around in the bone; this groove may be 
commenced with a circular saw and completed with a chisel. The 
Hartley chisels are probably the best for this purpose, as they cut 
a distinct groove; if an ordinary narrow chisel is used, it should be 
held quite obliquely and only its corner engaged in the bone while 
cutting. This groove should be deepened to the same extent 
throughout its whole length, going over it several times before 
finally penetrating through the entire thickness of the bone. The 
groove should reach entirely through the bone, except perhaps at 
its lowest part, down near the zygoma. Care should be taken not 
to injure the dura with the chisel. 

The elevator is now introduced as a lever into the upper part 
of the groove, and with a prying motion the segment of bone, with 
the soft parts attached, is broken through at its base and turned 
well down over the zygoma; if the opening is not sufficiently large, 
one may cut more bone away from the lower margin of the opening 
with the bone forceps. It is well if the section through the bone 
is so made that its edge presents a somewhat beveled margin, so 
that it may fit better when replaced (see Fig. 13). Through this 
opening in the skull the dura is exposed, the anterior branch of the 
middle meningeal ramifying upon it toward the front; at times this 
branch is torn when the plate of bone is reflected, especially if the 
groove in which it is lodged is unusually deep; if injured, it should 
be clamped and tied. Now, with the fingers, the dura is separated 
from the bone: floor of the middle fossa. This may be done rapidly 



EXTIRPATION OF THE CASSERIAN GANGLION. 37 

until the middle meningeal artery, as it enters the skull through 
the foramen spinosum, is met. One should then stop and secure 
this vessel with a double catgut ligature and divide it; it would prob- 
ably answer to tie singly or without ligating the vessel, to plug the 
foramen spinosum with catgut, and then divide the artery — its distal 
anastomoses are not free. The field of operation should be kept 
clear of blood with pads on holders. After tying the middle menin- 
geal and still working inward, but rather more cautiously, the dura 
is separated from the base of the skull with a blunt elevator or with 
a small gauze pad in a forceps, at the same time lifting the brain 
away from the base of the skull toward the vault. This is best accom- 
plished with the aid of a narrow, polished, right-angle retractor: serves 
as a reflector at the same time. A pad of gauze may be interposed 
between it and the brain; the hemorrhage may be thus somewhat 
diminished. The hemorrhage caused by separating the dura mater 
from the bone is sometimes considerable. It may be controlled by 
a few minutes' pressure or by shifting or withdrawing the retractor 
for a few minutes and allowing the brain to drop back upon the 
surface of the bone. Thus gradually working inward we reach the 
third division of the nerve, which may be seen passing out of the 
skull through the foramen ovale. This trunk may be seized with a 
narrow forceps and isolated as far back as the ganglion; it serves 
as a guide to the ganglion. "Without cutting this trunk, we then 
work a little farther inward, toward the middle line, until we meet 
the second division. This is likewise isolated from the foramen 
rotundum back as far as the ganglion. The upper surface of the 
ganglion is now gradually freed from the dura. While the ganglion 
is being isolated the brain should be well retracted: lifted away from 
the base of the skull. The ganglion can be separated from the over- 
lying dura with a blunt periosteum elevator; one may seize and pull 
upon the third division and use this as a guide to the ganglion. It 
may be necessary to cut a few connective-tissue bands, between the 
ganglion and the dura, with the scissors, and in doing this one may 
accidentally cut into the dura; but this is of no special significance; 
there may escape some cerebro-spinal fluid, but, according to Tiffany, 
this is rather an advantage. There may be hemorrhage occasioned 
in isolating the ganglion, but this may again be controlled by press- 
ure or by shifting the retractor or allowing the brain to drop back 
in place upon the bone temporarily. The ganglion should be freed 
as far back as the superior border of the petrous portion, so that 



38 HEAD AND FACE. 

one may see the white trunk of the nerve beyond the ganglion. Care 
should be exercised in freeing the inner part of the ganglion, on 
account of the proximity of this part to the cavernous sinus and the 
carotid artery. The ganglion may be separated from the surface 
of the bone, upon which it rests, with the periosteum elevator. At 
times this surface of bone is absent, and the ganglion is then sepa- 
rated from the artery, as it lies in the carotid canal, by only a thin, 
cartilaginous or fibrous layer; therefore one should avoid any rough- 
ness during this step of the operation. 

The ganglion, being finally free all around, is seized with a 
long artery clamp, and in doing this one should avoid catching the 
dura, etc., at the same time. The third and second divisions are 
then cut, either with the scissors or with a tenotome close to their 
foramina; in cutting the third division, the motor branch of the 
nerve is usually divided at the same time with it. One should make 
an effort to avoid cutting the motor branch as the third division is 
severed, but this is oftentimes difficult and in many cases its divis- 
ion is excusable. When the third division is cut there may be con- 
siderable venous hemorrhage from the small meningeal branch 
which enters the skull through the foramen ovale; this can be con- 
trolled by packing or by shifting the retractor and by allowing the 
brain to drop back for a few minutes upon the base of the skull. 

No attempt should be made to isolate or cut the first, the oph- 
thalmic, division on account of the danger of doing damage to the 
third and fourth nerves and to the cavernous sinus, and, besides, 
this branch is readily torn away when the ganglion is twisted out. 

After the second and third nerves have been divided the gan- 
glion, in the grasp of a long, narrow forceps, is slowly twisted free, 
tearing it away from the first division and usually bringing away 
with it a portion of the trunk of the nerve for a greater or less 
distance beyond the ganglion. Should the cavernous sinus be torn, 
the hemorrhage is profuse; but this can be controlled by temporarily 
packing and allowing the brain to drop back into place upon the 
base of the skull. 

The bone is finally replaced and the incision in the soft parts 
closed with suture. It is well to introduce a strip of gauze through 
the posterior part of the opening in the skull, especially if there is 
considerable oozing, for the purpose of drainage. 

This operation may be followed by ulcer of the cornea or con- 
junctivitis, due to infection or the entrance of dirt which is not 



SURGICAL ANATOMY OF THE MASTOID REGION. 39 

appreciated on account of the loss of sensation in the eye. This may 
he avoided by. bandaging the eye or sealing it with a "watch-crystal. 
Ptosis, paralysis of the muscles of the eye, etc., may occur as a 
result of injury to the third, fourth, and sixth nerves. One may 
avoid these conditions by keeping away from the first division of the 
fifth nerve and the immediately adjacent third, fourth, and sixth 
nerves during the course of the operation. 



THE MASTOID REGION AND THE EAR. 

The mastoid region and the ear are intimately associated with 
each other clinically. 

The Surgical Anatomy of the Mastoid Region. — The mastoid 
region is that part of the skull which corresponds to the mastoid 
portion of the temporal bone. 

The integument of this region is thin and contains very little 
fat; its blood-supply is derived from the posterior auricular artery, 
which ascends just behind the ear. The occipital artery ascends 
beneath the sterno-mastoid muscle and becomes superficial midway 
between the mastoid process and the external occipital protuberance, 
whence it is continued upward upon the back of the skull. 

The surface of the mastoid is uneven and perforated by a num- 
ber of small vascular openings. At the back part of the mastoid 
portion, at or just in front of the suture line between it and the 
occipital bone, there is an opening, the mastoid foramen. Through 
this a small vein passes into the lateral sinus and a small arterial 
branch from the occipital artery to the dura mater. 

The inner surface of the mastoid portion presents a wide groove, 
curving from above downward with the convexity forward; this 
lodges the sigmoid (lateral) sinus. This groove is located about half 
an inch behind the posterior border of the external auditory meatus, 
and presents the opening of the mastoid foramen. 

The mastoid portion is prolonged below in a teat-like process 
which varies considerably in size. It is said to be larger in muscular 
subjects; it is comparatively small in the child. The structure of 
this process varies. Its cortex may be thin or may be thick and 
very hard like ivory. The interior may be cut up into a number of 
cellular recesses lined with mucous membrane and communicating 
with each other and, through the antrum, with the middle ear, or it 
may be composed of ordinary spongy bone, or it may be very dense 



40 HEAD AND FACE. 

and hard, resembling ivory. There is always present, however, even 
in the newborn, at least one space, the antrum. The mastoid antrum 
is a space, varying in size from a small pea to a small bean, which 
is found in the mastoid process just behind the tympanic cavity; 
these two spaces communicate with each other through an opening 
in the upper part of the posterior wall of the tympanum. The roof 
of the antrum is formed by the same plate of bone that forms the 
roof of the tympanum. The antrum is lined with mucous mem- 
brane, which is continuous with that of the tympanum. The antrum 
is practically a part of the tympanic cavity, and an inflammatory 
process originating in the tympanum may readily extend and involve 
the antrum, etc. Externally the antrum may be located upon a 
level with the upper margin of the external auditory meatus and 
between 5 and 10 mm. (say, one-fourth inch) behind this opening, 
and is usually found at a depth of from 12 to 18 mm. beneath the 
external surface of the bone. In very young children the antrum is 
comparatively large and very close to the surface of the bone, just 
behind the upper margin of the external auditory meatus. 

The outer margin of the bony portion of the auditory canal is 
marked above and behind by a spine, the spina supra meatum; this 
spine is readily recognized after the soft parts have been incised and 
separated, and may be used as a landmark in locating the antrum. 
The antrum lies upon the same level as the spine, but about one- 
fourth inch posterior to it. 

The mastoid process is usually made up of a number of cellular 
spaces, the pneumatic mastoid, all lined with mucous membrane and 
communicating through the antrum with the middle ear (tympanum); 
these reach to the tip of the process and often penetrate beyond the 
limits of the mastoid process into the occipital bone or zygomatic 
process or they may extend backward into the mastoid portion proper, 
pretty close to the groove which lodges the sigmoid sinus, so that 
there may be but a very thin shell of bone separating the mastoid 
cells from the sinus. Mastoids vary in different people and upon 
opposite sides in the same person as to the extent to which these 
cells are developed. They begin to develop early in life, but the 
age differs at which they are found fully developed. From five years 
on they are fairly well marked, and it is said that at the age of 
fifteen years they are all developed down to the tip of the process. 
Some say that they do not reach complete development until a few 
years later. Occasionally the- septa may undergo a process of rare- 



ANATOMY OP THE EAR. 



41 



faction, the septa gradually disappearing and the spaces opening into 
each other until they are all combined in one large space represented 
by the antrum. Instead of as above described, the structure of the 
bone may be spongy or it may be excessively dense and without spaces, 
resembling ivory. 




Fig. 16.— Side of Skull. A, position of opening in skull to expose the ante- 
rior branch of the middle meningeal (Vogt's lines) ; C, position of opening for 
cerebellar abscess; MA, location of mastoid antrum (directly in front of circle 
MA is the spina supra meatum) ; P, opening to expose the posterior branch 
of middle meningeal; R, Reid's base-line continued backward to external 
occipital protuberance; S, dotted lines represent course of lateral (sigmoid) 
sinus; TS, opening in the skull for abscess of the temporo-sphenoidal lobe. 



The Anatomy of the Ear. — Changes that occur in the first 
visceral cleft result in the formation of the external and middle 
ear. The internal ear, labyrinth, etc., are formed within the sub- 
stance of the petrous portion of the temporal bone. The external 
fossa, or cleft, develops into the external auditory canal and auricle; 



42 HEAD AND FACE. 

the internal fossa, or cleft, which opens into the pharynx, "becomes 
the Eustachian tube and tympanum. Where the funduses of these 
clefts, or fossse, meet, their walls coalesce and thus form the drum, 
the partition between the external and the middle ear. The margin 
of the outer opening of the external cleft, or fossa, becomes thick- 
ened and nodulated, and these nodules, coalescing, form the external 
ear. 

The hearing apparatus may be divided into the external ear, 
which includes the auricle, external auditory canal, and drum; the 
middle ear, tympanum, which communicates with the pharynx 
through the Eustachian tube; and the internal ear, labryinth, etc., 
inclosed within the petrous portion of the temporal bone. 

The auricle is made up of a cartilaginous plate considerably 
folded upon itself and covered with skin; it consists of several parts. 
It is attached to the side of the head by ligamentous bands; one 
of these passes forward to the root of the zygoma; the other back- 
ward to the mastoid process. Its blood-supply is derived from 
branches which are given off by the temporal artery in front and 
the posterior auricular behind. The supply is very abundant, and 
therefore wounds of the ear heal kindly. 

The external auditory canal is about one inch (24 mm., Trolsch) 
in length; its outer portion, comprising one-third of its length, is 
cartilaginous and continuous with the auricle; the inner part, com- 
prising two-thirds of its length, is bone. The course of the canal 
is transverse, but it suffers two curves: one, in its cartilaginous part, 
with its convexity forward; the second at the junction of the carti- 
laginous and bony parts, with its convexity backward; this junction 
is the narrowest part of the canal, and is called the isthmus. 

To expose the drum, the auricle is drawn upward, backward, and 
outward away from the side of the head. 

In the newborn child there is no bony portion to the external 
auditory canal, this part being represented only by a ring of bone 
into which the drum is fitted. This bony ring, the auditory process,, 
is incomplete, and is applied against the depressed, hollowed-out 
under surface of the squamous portion of the temporal, which thus 
completes the ring. At this early age the drum is very near the sur- 
face of the body, there being no depth to the bony auditory canal. 
As the child grows, the bony ring, the auditory process, broadens out, 
and in the adult is represented by the external auditory process, 
which corresponds to its outer edge, and by the vaginal process, this 



ANATOMY OF THE EAR. 43 

latter forming the lower and anterior wall of the bony portion of the 
auditory canal and the back part of the floor of the glenoid cavity. 
The upper wall of the auditory canal is formed by the grooved under 
surface of the squamous portion of the temporal bone. The outer 
edge of the auditory process is rough, and to it is attached, by firm 
connective tissue, the cartilaginous part of the auditory canal. 

The skin which lines the interior of the auditory canal is con- 
tinuous with that which covers the surface of the drum. 

The bony part of the external auditory canal is in relation, 
above, with the middle fossa of the skull, from which it is separated 
by a thin, cellular plate of bone, part of the squamous portion of 
the temporal; behind, it is in relation with the mastoid system of 
cells, and, in front, with the condyle of the lower jaw and the parotid 
gland. 

Blows upon the chin may be transmitted through the lower jaw 
to the condyle, and in this way may injure the auditory canal, so that 
there may be an issue of blood from the external auditory meatus. 
Purulent processes involving the auditory canal may present cere- 
bral complications, especially in children, without the middle ear 
being involved, the infection in these cases passing through the roof 
of the auditory canal directly into the cavity of the skull. 

The drum is the septum between the external and the middle 
ears. It is made up of skin externally, and, internally, of the mu- 
cous membrane of the tympanum; interposed between those two is 
a layer of connective tissue. The drum is set in a bony ring, and 
forms the greater part of the external wall of the tympanum. It is 
set obliquely and in such a way that its outer surface looks down- 
ward, forward, and outward; the anterior wall of the external audi- 
tory canal is thus longer than the upper, posterior wall. 

The middle ear consists of the tympanum and adjoining air- 
cells and the Eustachian tube. 

The tympanum is a wedge-shaped cavity separated from the 
external auditory canal by the drum and communicating by an 
opening in its anterior end, through the Eustachian tube, with the 
pharynx. In the anterior part is also seen the Glaserian fissure, 
through which the middle ear communicates with the glenoid cavity 
and through which the chorda tympani leaves the tympanum. 

The carotid artery, surrounded by a venous plexus, traverses a 
canal, in the temporal bone, which is located just in front of the 
tympanum and which is separated from this cavity by a very thin 



44 HEAD AND FACE. 

plate of bone that is, at times, perforated. Behind, the tympanum 
communicates with the mastoid antrum through an opening in the 
upper part of its posterior wall. The inner wall of the tympanum, 
that opposite the drum, presents, toward the front, the promontory; 
behind this, two openings, one above, the foramen ovale, and an- 
other below and a little behind, the foramen rotundum. The laby- 
rinth is located beneath this inner wall, in the petrous portion of 
the temporal bone. This inner wall presents a smooth, curved ridge 
above the foramen ovale which runs backward and downward toward 
the back of the tympanum; it corresponds to the position of the 
Fallopian canal which lodges the facial nerve in its course through 
the petrous portion of the temporal bone. The layer of bone which 
separates the nerve from the cavity of the tympanum is sometimes very 
thin or perforated. The tympanum communicates with the posterior 
fossa of the skull through the labyrinth and the internal auditory 
canal, which is traversed by the facial and auditory nerves. The bulb 
of the jugular vein is lodged in the depression in the temporal bone 
beneath the floor of the tympanum. The layer of bone which forms 
the floor of the tympanum is usually comparatively thick, though it 
may be very thin, perforated, or entirely absent. In the latter case 
the mucous membrane lining the floor of the tympanum and the wall 
of the internal jugular vein would be in direct contact with each other. 
Through small openings in the floor of the tympanum, Jacobson's 
nerve, a branch from the glosso-pharyngeal, and some small arterial 
and venous branches enter the tympanum. 

The roof of the tympanum, the most common link between dis- 
ease of the ear and intracranial complications, is a thin, cellular 
plate of bone; it may be very thin, perforated, or entirely absent. 
This plate of bone reaches from the petrous portion of the temporal 
bone over to the inner surface of the squamous portion, where a 
suture line, petroso-squanious, exists. In the child this suture line 
is open and contains a process of dura mater which joins with the 
mucous membrane lining of the tympanum and carries blood-vessels 
which take part in the supply of both these membranes. This con- 
dition, although not so visible, continues to exist in the adult. This 
same thin layer of bone, which forms the roof of the tympanum, 
reaches backward and forms also the roof of the mastoid antrum. 
The roof of the tympanum and antrum forms part of the floor of 
the middle fossa of the skull, and is in relation with the dura mater, 
etc., and with the temporo-sphenoidal lobe of the brain. 



ANATOMY OF THE EAR. 45 

The course of the facial nerve through the temporal bone and 
its relation tp the tympanum and the mastoid antrum are impor- 
tant. The nerve enters the internal auditory canal in company with 
the auditory nerve, and passes in a direction forward and outward, 
reaching the inner wall of the middle ear, tympanum, just above 
the foramen ovale; here it makes a turn and runs backward and 
downward in the aqueductus Fallopii. The course of this canal is 
indicated by a prominent linear elevation upon the inner wall of 
the tympanum just above the foramen ovale; at the back of the 
tympanum, the nerve, as it curves downward and still contained 
within the aqueductus Fallopii, is situated but a short distance in 
front of the antrum. It continues its course through the substance 
of the petrous portion of the temporal bone, emerging, externally, 
upon the base of the skull, through the stylo-mastoid foramen. This 
foramen is located internal to, and a little in front of, the base of 
the mastoid process. Just before the facial nerve emerges from the 
stylo-mastoid foramen and while still contained within the canal, it 
gives off a branch, the chorda tympani, which passes forward and 
upward through a separate canal in the petrous portion, and enters 
the tympanum through an opening in its posterior wall, near the 
drum; it runs forward through the tympanic cavity, being covered 
by mucous membrane, and escapes through the Glaserian fissure, a slit 
in the anterior part of the floor of the tympanum, into the glenoid 
cavity. 

The stylo-mastoid artery, derived from the posterior auricular, 
enters the stylo-mastoid foramen to supply the facial nerve and also 
the mucous membrane of the tympanum. 

The Eustachian tube reaches from the tympanum to the phar- 
ynx; its outer one-third is bony; its inner two-thirds, cartilaginous. 
Where these join, the tube is narrowest: the isthmus. The tube 
opens into the anterior end of the tympanum, near the drum; its 
inner end opens into the pharynx above the soft palate and just 
behind the posterior border of the inferior turbinated bone. The 
walls of the cartilaginous portion of the tube are usually in contact 
and the tube is thus closed. To ventilate the tympanum, muscular 
action, which will open the pharyngeal end of the tube, is required. 
This is accomplished by the muscles of the soft palate: the tensor 
and the levator palati. 



46 HEAD AND FACE. 

OPERATIONS UPON THE MASTOID, ETC. 

Wilde's Incision. — This consists of a simple incision through 
the soft parts, including the periosteum, down to the hone. It is 
placed 1 cm. hehind and parallel with the auricle, and reaches from 
the hase of the mastoid process to its apex. Usually no vessels are 
cut and it is not necessary to apply any ligatures. It is often suffi- 
cient in very young children. 

Drilling into the Antrum. — An incision is made through the 
soft parts down to the hone, as in the preceding operation, and a 
channel drilled through the hone down into the antrum. The drill 
is placed upon the mastoid, upon a level with the upper margin of 
the external auditory meatus, spina supra meatum, and rather less 
than one-half inch posterior to it, and a canal is then drilled through 
the hone in a direction downward, forward, and inward toward the 
antrum; this canal should not be carried much deeper than one-half 
inch. This operation is not one to be recommended, as it is uncer- 
tain and may be dangerous, especially if one proceeds deeper than 
one-half inch. It is much more satisfactory to make a free opening 
into the antrum with the chisel. 

To Open into and Drain the Antrum. — The patient is placed 
with the head upon the side resting upon a thin sand-bag. 

Eegardless of any condition that may complicate mastoid dis- 
ease, the first step should always consist in opening into the antrum. 
(Bacon, Schwartz.) 

An incision is made 1 cm. (Schwartz) — one-third inch — behind 
the attachment of the auricle, through the soft parts, including the 
periosteum, down to the surface of the bone, and reaching from the 
base of the mastoid to its tip. In this incision we do not meet 
the posterior auricular artery, and, as a rule, no vessels that require 
ligation are divided. With the elevator the soft parts, including the 
periosteum, are then separated from the surface of the bone, expos- 
ing an area as large as a five-cent piece upon a level with and just 
behind the external auditory meatus. The soft parts are retracted 
with broad, sharp retractors. The surface of bone, which is thus 
laid bare, may be soft, discolored, and may further present the 
orifice of a fistula, or it may be firm and apparently healthy or thick- 
ened, sclerosed, and ivory-like. If the first condition exists, — that 
is, if the bone is softened, carious, etc., — one may easily gouge it 
away with a strong, sharp scoop, continuing thus until the antrum 
is reached. With the curette one should remove all the bone that 



OPERATIONS UPON THE MASTOID, ETC. 47 

is apparently diseased, taking away enough of the cortex, especially 
down toward the tip, to allow good drainage. A rongeur forceps 
will often he found useful in thus removing the cortex. One should 
watch for loose pieces of carious bone. In working backward toward 
the sigmoid sinus one should be careful not, inadvertently, to perfo- 
rate the dura and enter this channel. If the sinus is simply exposed, 
this is of no special significance. There may be some hemorrhage 
from emissary veins that pass through the mastoid foramen into the 
sigmoid sinus. Fistulas that are present should be carefully fol- 
lowed, thoroughly curetted, and laid open. They may lead into the 
auditory canal or into the cranial cavity. During the operation one 
should take frequent soundings with a blunt probe. 

If the surface of bone which is exposed is not softened and ap- 
parently healthy and we may select a point at which to commence 
the excavation in the bone, we choose a point upon a level with the 
upper border of the external auditory meatus (spina supra meatum) 
and from 5 to 10 mm. behind it. The antrum is situated about one- 
fourth inch behind the anterior border of the mastoid process upon 
a level with the upper border of the external auditory canal. In 
cutting through the bone into the antrum we commence by using 
a broad chisel, — they vary in width from 2 to 8 mm., — working 
rather with the corner of its edge and chipping the bone out in the 
form of a circle at least three-fourths inch in diameter. This ex- 
cavation is carried deeper into the substance of the bone, in a direc- 
tion forward, inward, and downward. As we progress, narrower 
chisels or gouges may be used and the opening made smaller in 
diameter. We continue thus, occasionally sounding with the probe, 
until the antrum is reached. It may contain only a few drops of 
pus. During this part of the operation the field may be kept clear 
of blood and chips of bone by a stream of salt-water or bichloride 
or by sponging. A funnel-shaped excavation, extending through the 
substance of the mastoid, is thus made, the base of the opening corre- 
sponding to the external surface of the bone and its narrow end to 
the antrum. The base, or external orifice, of this canal should be 
sufficiently large to allow of convenient work in its deeper part. The 
antrum is usually found at a depth of from 12 to 20 mm., but may 
occasionally be nearer the surface. After having opened into the an- 
trum, if a probe introduced feels firm, healthy bone and if no sinuses 
are present, one may then proceed to complete the operation by goug- 
ing away the cortex down to the tip of the process, in order to expose 



48 HEAD AND FACE. 

and drain these most dependent cells. One should also see that the 
communication between the antrum and the tympanum is free. The 
drum is usually already perforated, and fluid introduced into the 
antrum may escape in part from the ear. After irrigating, a thin 
strip of gauze is packed into the opening in the mastoid, reaching 
into the antrum, and the edges of the soft parts drawn together 
in part. This would be the procedure in a simple uncomplicated 
ease of mastoid disease. 

In order to avoid accidental opening into the sigmoid sinus, 
the base, the commencement of the cone-shaped canal which is 
chiseled through the bone into the antrum, is placed anterior to the 
location of the sinus; and as we proceed deeper into the substance 
of the bone we work in a direction forward, downward, and inward, 
so that there is no danger of injuring the sinus, as it lies behind the 
most posterior part, base, of this excavation in the bone; and as we 
proceed deeper into the substance of the bone we get farther away 
from the sinus. It is of but little consequence if the sinus is ex- 
posed, but one should avoid accidentally perforating the dura and 
wounding it. If the sinus is opened, the hemorrhage which results 
may be controlled by the pressure of an aseptic tampon; air may 
be sucked into the sinus, if it is opened, but this is not accompanied 
by any danger (Schwartz). Accidental opening into the middle 
fossa of the skull is avoided by commencing the channel in the bone 
below tbe level of the upper margin of the external auditory meatus, 
below the spina supra meatum, and, as we proceed, working in a 
direction rather downward. The floor of the middle fossa will thus 
lie above the base of the cone-shaped canal which is made in the 
bone. 

If one does not chisel beyond the antrum, there is but little 
danger of injuring the facial nerve or the inner wall of the tym- 
panum (labyrinth). The facial nerve, contained within the Fallo- 
pian tube, lies rather deeper than the antrum and anterior to it, 
in the inner wall of the tympanum. If one penetrates to a depth 
of 2 cm. or more, there is then danger of getting beyond the antrum 
and injuring the facial nerve or the labyrinth. 

For Thrombosis of the Sigmoid Sinus. — The sigmoid sinus is 
encountered about one-half to three-fourths inch posterior to the 
bony auditory canal (spina supra meatum). 

One should always, as a preliminary step, open into the antrum 
as described above and from here start out to investigate the sinus, 



OPERATIONS UPON THE MASTOID, ETC. 49 

etc. After the antrum has been opened an incision is carried back- 
ward, through the soft parts, for a distance of about two inches, 
and with the "chisel or rongeur the bone is removed in a direction 
backward until the region of the sinus is reached and the dura ex- 
posed. The opening in the skull may be still farther enlarged by 
cutting away its margin with the rongeur forceps, so that the sinus 
is freely exposed, and an opening made in the skull which is suffi- 
ciently large to work through. This opening in the skull should 
be at least as large as a silver quarter. Oftentimes pus and granula- 
tion tissue are met with just as soon as the dura is exposed, — extra- 
dural abscess, — and if the sinus is not diseased it will not be neces- 
sary to proceed farther, it being sufficient to curette and drain the 
parts about the sinus without opening into the latter. 

If the sinus is thrombosed, it will appear firm and prominent, 
and in case of doubt an aseptic aspirating needle may be introduced. 
If pus is not present in the sinus and the needle withdraws fluid 
blood it does not necessarily prove that the sinus is unaffected. 
Tenderness along the course of the internal jugular, etc., is an indi- 
cation for opening the sinus. If in doubt it is always wise to incise 
the sinus, as this is not accompanied by any special danger. 

If one decides to open the sinus it should be done by making 
an incision, corresponding to its long diameter, with a sharp, narrow- 
bladed knife. If a clot is found, this should be curetted away first 
from the jugular end down to the bulb, — if necessary, removing more 
bone with the rongeur, — until there is a free flow of blood: good, 
free bleeding tends to wash out any remaining portions of clot. This 
bleeding may be readily controlled by introducing a small wad of 
gauze between the sinus and the adjoining bone. This flow of blood 
does not necessarily prove that there is not a clot in the jugular 
vein beyond the bulb: blood may flow around from the inferior 
petrosal sinus. 

This procedure is repeated in the other direction — i.e., toward 
the torcular — until hemorrhage is established; this may then be 
-controlled in a similar manner. It may be well, after the hemor- 
rhage has been controlled, to remove the packing and freely irrigate 
the sinus with normal salt solution. Before opening the sinus, the 
internal jugular vein, the facial vein, etc., may be exposed in the 
neck and tied, or the internal jugular, in its entirety, and including 
all its branches, may be resected through an incision in the neck 
after first having tied the vessel below, at the clavicle, and above, 



50 HEAD AND FACE. 

at the bulb (avoid the pneumogastric nerve). This procedure is 
indicated especially if tenderness and induration are present along 
the course of the internal jugular vein: along the anterior border 
of the sterno-mastoid muscle (McKernon). If the internal jugular 
vein has not been tied, it may be compressed in the neck, during the 
operation, to prevent the passage of dislodged clots (Dench). 

Besides the condition described, we may find an opening lead- 
ing through the dura mater to a collection of pus beneath the dura 
or within the cerebellum; these purulent collections may also be 
present without thrombosis of the sinus or without a fistulous open- 
ing in the dura. All fistulous openings should be thoroughly explored 
and treated as the condition indicates. 

For Cerebellar Abscess. — The opening in the skull may be made 
with a trephine or chisel. Usually the antrum and sinus have al- 
ready been explored, and the opening in this case may be simply 
extended backward with the rongeur. The center of the opening 
in the skull for cerebellar abscess should be located two inches behind 
the external auditory meatus, and should be placed below a line 
drawn from the upper margin of the external auditory meatus to 
the occipital protuberance (see Fig. 16). The opening in the bone 
is thus placed below the superior curved line of the occipital bone 
and we enter therefore below the attachment of the tentorium cere- 
belli and below the course of the lateral sinus. The bone is here 
very thin, and the opening may be readily enlarged to any necessary 
extent with the rongeur. A good free opening should be made in 
the skull. One may meet pus between the dura mater and the bone 
or there may be a fistulous opening in the dura leading to a deeper 
purulent collection. If there is no opening in the dura an aspirating 
needle may be introduced and search thus made for the pus. When 
the pus is located, without withdrawing the needle, the dura may be 
incised and a director or thin artery forceps introduced along the 
aspirating needle and the opening then enlarged by spreading the 
forceps so as to permit the introduction of the little finger. The 
abscess cavity may be irrigated with a double-current tube and then 
loosely packed. The opening in the dura may be closed in part. 

For Extradural Abscess in the Middle Fossa. — There may be an 
abscess located between the dura mater and the bone. 

If the mastoid antrum has already been explored one may find 
a fistula leading through the roof of the antrum or tympanum into 
the middle fossa. The incision, which is already present and through 



SURGICAL ANATOMY OF THE FACE. 51 

which the mastoid antrum has been opened, is prolonged from the 
base of the mastoid in a direction upward and forward over the ear, 
dividing the temporal vessels and muscle. With the rongeur or 
chisel, the bone is cut away so that one may enter the middle fossa 
just above and in front of the external auditory meatus; here we 
work in between the tegmen tympani and the dura mater, where 
the abscess is usually located. The pus is evacuated and the abscess 
cavity drained as described in the preceding operation. 

For Temporo-sphenoidal Abscess. — Associated with the extra- 
dural abscess we may find an abscess in the temporo-sphenoidal lobe, 
and there may be a fistula leading through the dura and commu- 
nicating with such a collection. In this case the fistula should be 
followed, enlarging the opening in the dura, evacuating and draining 
the abscess. A temporo-sphenoidal abscess may be present without 
an extradural abscess. 

If the mastoid has been already explored, one may extend the 
incision upward and forward over the ear, as described in the pre- 
ceding operation, and remove sufficient bone with the chisel and 
rongeur, proceeding from the opening in the mastoid, or, instead 
of this, a button of bone may be removed with the trephine. This 
opening in the skull should be at least one inch in diameter with 
its center located one and one-fourth inches above the bony meatus, 
and may be farther enlarged with the rongeur forceps to the requisite 
dimensions (see Fig. 16). 

The temporo-sphenoidal lobe may also be exposed by doing 
a temporary resection of the skull (see "Ligation of the Middle 
Meningeal Artery"). 

After the dura has been exposed an aspirator is introduced, and 
when pus is discovered the dura is incised and, without withdrawing 
the needle, a director — or, better, an artery forceps — is introduced 
and the abscess freely opened by spreading the forceps and with- 
drawing them. The finger may be then introduced and the abscess 
cavity irrigated with a double-current tube and packed. The open- 
ing in the dura may be partly closed. 

THE FACE. 

Surgical Anatomy of the Face. — The skin of the face is soft, 
thin, and intimately united to the underlying muscles and connective 
tissue, and cannot be pinched up without including these deeper 



52 HEAD AND FACE. 

layers. The subcutaneous tissue of the face is widely meshed, and 
within these meshes there is contained much fat. Those parts of 
the face where the fat is absent from the subcutaneous layer are 
loose and flaccid, — for example, under the eyes, — and become marked 
early in life by wrinkles. These parts also readily become swollen 
and distended in dropsical conditions. In this layer are contained 
the muscles of expression and the vessels and nerves. 

The facial artery is the chief source of supply to the face. It 
is a large vessel derived from the external carotid. It pursues a 
tortuous course, upward and forward, across the side of the face, 
from the anterior border of the masseter to the angle of the mouth, 
and then, as the angular, continues upward alongside the nose, anas- 
tomosing at the inner canthus with a branch of the ophthalmic. 
Just below 1 he corner of the mouth the facial gives off a branch, the 
inferior labial, for the supply of the lower lip; those from either 
side anastomose. At the corner of the mouth the facial gives off 
the inferior and superior coronary. These branches pass inward, 
lying a little beyond the edge of either lip and situated beneath 
the mucous membrane: between it and the muscular structure of 
the lip. Those from either side anastomose freely with their fellows. 

The facial vein, which accompanies the artery, is not tortuous, 
and lies superficial to the artery. 

The facial nerve supplies the muscles of expression, etc., and 
the buccinator. It emerges from the parotid gland upon the side 
of the face at a point corresponding to the lower border of the lobe 
of the ear, and divides into branches which supply the facial mus- 
cles and the platysma. The sensory supply to the face and teeth 
is derived from the fifth nerve. 

The Skeleton oe the Face. — The upper part consists of the 
superior maxillary and the adjoining bones with which it articulates 
and which serve to join it to the skull; it articulates,, toward the 
middle line, with the nasal bones which form the bridge of the nose 
and laterally with the malar. The malar bone forms the prominent 
part of the cheek and gives off a process which passes backward and 
unites with a similar process from the temporal to form the zygo- 
matic arch. 

The body of the superior maxillary is pyramidal, its base being 
directed inward toward the nasal cavity, forming part of its outer 
wall and presenting the opening into the antrum of Highmore; its 
apex corresponds to its junction with the malar. The upper surface 



SURGICAL ANATOMY OF THE FACE. 53 

of the superior maxillary is thin and forms the floor of the orbit. Its 
anterior or facial surface is very thin in places and easily perforated; it 
is rather concave, and just below the margin of the orbit presents the 
opening of the infra-orbital canal. A canal descends, as an offshoot 
from the infra-orbital canal, through the anterior wall of the bone; it 
transmits a nerve-branch which supplies the upper front teeth. The 
posterior, or zygomatic, surface of the superior maxilla looks backward 
and outward toward the zygomatic fossa; it gives origin, in part, to the 
external pterygoid muscle, and is in close relation with the termina- 
tion of the internal maxillary artery. This surface presents the 
commencement of the superior dental canal for the transmission of 
the superior dental nerve to the upper back teeth. 

The body of the bone is hollowed out. The space within, known 
as the antrum of Highmore, communicates with the nasal cavity 
through an opening into the middle meatus, and is lined with mu- 
cous membrane, which is continuous with that of the nose. The 
walls inclosing the antrum are thin, but strengthened by columns 
of bone which ascend from the tooth sockets and converge toward 
the apex, malar process; in this way the bone is strengthened and 
the shock of blows distributed. The alveolar process is solid and 
presents the sockets for the teeth. The palate process, projecting 
inward, joins with its fellow of the opposite side, and together with 
the horizontal plates of the palate bones forms the hard palate: the 
floor of the nasal, and the roof of the buccal, cavity. 

The periosteum covering the upper jaw is thin and closely at- 
tached to the surface of the bone. It is rather more easily separated 
from the orbital and facial surfaces. 

The lower part of the face is composed of the inferior maxillary, 
which consists of a body and two rami and which is attached to the 
skull through the temporo-maxillary articulations. The body of the 
bone is horseshoe-shaped, presenting an upper border, with sockets 
for the teeth, and a lower rounded border, which may be felt beneath 
the integument. 

To the inner surface of the body of the inferior maxillary are 
attached the muscles which form the floor of the mouth, and in 
front, at the symphysis, are attached the muscles which draw the 
tongue forward and prevent its dropping back into the pharynx. 

The ramus is a perpendicular plate of bone with an upper 
curved border which presents, in front, a thin, pointed process, the 
coracoid, to which is attached the tendon of the temporal muscle, 



54 HEAD AND FACE. 

and, behind, a rather thickened process, the condyle. The upper 
surface of the condyle is rounded and smooth, for articulation with 
the glenoid cavity. Below the articular surface there is a rather 
constricted portion, known as the neck. To the front surface of 
the neck of the condyle is attached the tendon of the external 
pterygoid muscle. The lower posterior corner of the ramus is a 
prominent landmark, and is called the angle of the jaw. The outer 
surface of the ramus is covered by the masseter and gives attach- 
ment to this muscle. The inner surface of the ramus presents, 
about its middle, the orifice of the inferior dental canal, into which 
the nerve of the same name passes to supply the teeth of the lower 
jaw. The anterior margin of this orifice is marked by a small pointed 
process of bone, to which the long internal lateral ligament is at- 
tached. The internal pterygoid muscle is attached to the lower 
posterior part of the inner surface. 

Sixteen teeth are inserted in each jaw, eight on a side: two 
incisors nearest the middle line, and, following these, one canine, 
two bicuspids, and three molars. 

The Mouth. — The mouth is inclosed by the lips and cheeks. 

The lips are composed of fatty connective tissue and muscular 
tissue, and are covered externally by the skin and internally by 
the mucous membrane. The muscular fibers are found in the sub- 
cutaneous connective-tissue layer, coming from all directions and 
interlacing with each other, and with much fatty tissue interspersed 
between them. The mucous membrane, lining the inner surface of 
the lips, is continued over upon the gums. In the middle line, from 
the lip to the gum, there is a thin, delicate fold of mucous mem- 
brane, the fraenum, which is well seen when the lip is drawn away 
from the gum. The vessels to the lips are the labial and the in- 
ferior coronary to the lower lip, and the superior coronary to the 
upper lip. These branches are derived from the facial. 

The cheeks are formed of skin, connective tissue and fat, buc- 
cinator muscle, and mucous membrane. The buccinator muscle is 
attached to the outer surface of the upper and lower jaw-bones just 
beyond the alveolar processes. This muscle is covered, upon its 
external surface, by a layer of fascia, bucco-pharyngeal, which is con- 
tinuous behind with that covering the constrictors of the pharynx. 
The mucous membrane lining the inner surface of the cheeks is 
continuous with that of the gums. The buccal cavity may be divided 
into an outer space, the vestibule, and an inner space, the mouth 



SURGICAL ANATOMY OF THE FACE. 55 

proper. The vestibule is the space between the teeth and the cheeks 
and lips. When the mouth is closed the mucous membrane lining 
the cheeks is thrown into folds, which would be caught between the 
teeth if not prevented by the contraction of the buccinator to which 
the mucous membrane is firmly attached. 

Opposite the second upper molar tooth is the orifice of Stenson's 
duct. At times this orifice is marked by a papilla, which may assist 
one in locating it. 

The mucous membrane, from the lips and cheeks, is reflected 
upon the alveolar process of the upper and lower jaw and extends 
between the teeth. It is intimately united with the periosteum cov- 
ering the bone, and together with it forms the gums. Behind the 
last molar tooth the anterior border of the ramus of the jaw may 
be felt, and upon the outer side of this the masseter muscle may 
also, when contracted, be distinctly recognized. When the teeth are 
tightly closed, the vestibule communicates with the cavity of the 
mouth proper by a small space behind the last molar tooth upon 
either side. 

The cavity of the mouth proper presents a roof and a floor, and 
is bounded in front and upon the sides by the alveolar processes and 
the teeth. Behind, the mouth opens into the pharynx. It is sepa- 
rated from the larynx by the epiglottis, and from the posterior nasal 
space by the soft palate. Where the cavity of the mouth opens into 
the pharynx it is somewhat narrowed and is called the isthmus of 
the fauces. The isthmus is bounded above by the free edge of the 
soft palate; below, by the tongue; and, upon the sides, by the pillars 
of the fauces. 

The roof of the mouth is divided into the hard and soft palate. 
The hard palate is formed by the junction, in the middle line, of 
the palatal processes of the superior maxillaries in front, and of the 
horizontal plates of the palate bones, behind. It is concave, and 
arched from side to side and from before backward. In front, in 
the middle line, just behind the incisor teeth, is a foramen, the 
orifice of the anterior palatine canal, which transmits the anterior 
palatine vessels. Extending from this foramen, forward and out- 
ward, to a point between the lateral incisors and the canine teeth, 
on either side, may be seen, occasionally, a line which marks the 
junction of the intermaxillary bone with the palatal processes of 
the superior maxillaries. 

Near the posterior edge of the hard palate, just to the inner 



56 HEAD AND FACE. 

side of the last molar tooth, is the orifice of the posterior palatine 
canal, and passing forward from this is a groove, close to the alveolar 
process. The posterior palatine vessels descend, through the poste- 
rior palatine canal and then pass forward, upon the hard palate, 
lying in the groove just mentioned. Behind the orifice of the poste- 
rior palatine canal may be seen the hook-like hamUlar process: the 
termination of the internal pterygoid process, around which the 
tendon of the tensor palati is reflected before it spreads out in the 
soft palate. The mucous membrane and periosteum, which cover 
the hard palate, are intimately united with each other and to the 
surface of the bone. There is little or no anastomosis between the 
vessels across the middle line; so that in operating for cleft palate 
it is desirable to retain the arteries in the flaps (Langenbeck). 

The soft palate is a curtain-like structure suspended from the 
posterior border of the hard palate. It is composed of the spread- 
out aponeuroses of the tensor and levator palati. It marks the 
boundary line between the mouth and the pharynx. It presents an 
inferior, or anterior, and a superior, or posterior, surface, each cov- 
ered with mucous membrane. 

The lower, or free, border of the soft palate presents, in the 
middle line, the uvula and upon either side separates into the ante- 
rior and posterior pillars of the fauces. The anterior pillar is con- 
tinued downward into the side of the base of the tongue at a point 
just behind the last molar tooth of the lower jaw, and is made up 
of the palato-glossus muscle. The posterior pillar is continued 
downward and backward into the side of the pharynx, and is com- 
posed of the palato-pharyngeus muscle. Between the two pillars of 
the fauces there is a triangular space in which the tonsil is lodged. 
Just above the soft palate, in the side of the pharynx, is the orifice 
of the Eustachian tube; it is about on a level with the floor of the 
nose. 

In quiet breathing the soft palate hangs passive; but during 
the act of swallowing it becomes tense, owing to the contraction of 
its muscles, and its free border then comes into contact with the 
posterior wall of the pharynx, thus shutting off the posterior nasal 
space from the cavity of the mouth. 

The floor of the mouth is formed of soft parts: chiefly by the 
mylo-hyoid muscle. This muscle extends from the mylo-hyoid 
ridge, upon the inner surface of the body of the inferior maxilla, to 
the body and greater cornu of the hyoid bone, uniting with its fellow 



SURGICAL ANATOMY OF THE FACE. 57 

in the middle line. The upper surface of the muscle, which is 
directed toward the cavity of the mouth, is covered over by the 
mucous membrane, beneath which are found, on either side, the 
sublingual gland, Wharton's duct, the gustatory nerve, etc. The 
external surface of the mylo-hyoid muscle forms part of the floor 
of the submaxillary triangle, and is in relation with the submaxillary 
gland. 

The tongue is a muscular organ which projects upward and 
forward from the floor of the mouth. It is attached by its base 
and through several muscles to the hyoid bone, and is connected 
with the epiglottis through the glosso-epiglottidean folds of mucous 
membrane. The tongue is composed of a mass of muscular and 
connective tissue interspersed with much fat, and is partly divided 
into two symmetrical halves by a fibrous septum. The tongue is 
connected with the hyoid bone by the hyo-glossus muscle on each 
side; with the styloid process by the stylo-glossus; with the soft 
palate by the palato-glossus, and through the genio-hyo-glossus with 
the symphysis of the lower jaw-bone — this muscle serves to draw 
the tongue forward and prevents its dropping back into the pharynx 
and obstructing breathing. 

When the mouth is closed its cavity is almost completely occu- 
pied by the tongue. The anterior part of the upper surface of the 
tongue is in contact with the hard palate; the posterior part, with 
the soft palate and the epiglottis. The tongue is covered by mucous 
membrane, that covering the under surface and sides of the organ 
being similar to that of the rest of the mouth. That covering its 
upper surface, dorsum, is rough, marked by numerous glands, and 
composed of a thick layer of flat epithelium, which gives it rather 
a grayish color. If the tongue is lifted away from the floor of the 
mouth by its tip, the attachment of its under surface to the floor 
of the mouth, in the middle line, through a membranous band, the 
frsenum linguae, is seen. 

The sublingual glands consist each of a number of lobules, and 
are located in the front part of the mouth, upon either side of the 
frsenum, resting upon the mylo-hyoid muscle and covered over by 
the mucous membrane. The location of the glands is indicated by 
a slight swelling in the floor of the mouth, which presents the little 
pin-point orifices of their excretory ducts. 

Upon either side of the frsenum there is a little papilla showing 
the orifice of W T harton's duct. This is the excretory duct of the 



58 HEAD AND FACE. 

submaxillary gland; it passes forward, through the floor of the 
mouth, lying below and to the -inner side of the sublingual gland. 

Each half of the tongue is supplied by the corresponding lingual 
artery; this is a large branch which is given off from the external 
carotid just above the greater cornu of the hyoid bone. It passes for- 
ward beneath the hyo-glossus muscle, and ascends beneath this mus- 
cle to the under surface of the tongue, where it is continued forward 
to its tip. The chief vein of the tongue is the ranine, a large branch, 
which passes backward upon the outer surface of the hyo-glossus 
muscle and terminates in the internal jugular. 

The nerves to the tongue are the hypoglossal, the gustatory, 
and the glosso-pharyngeal. The hypoglossal descends in the neck 
as far as the point where the occipital artery is given off from the 
external carotid; here it passes forward, above and parallel with 
the greater cornu of the hyoid bone, resting upon the hyo-glossus 
muscle. The gustatory is one of the branches derived from the third 
division of the fifth nerve. From its origin it descends in front of 
the inferior maxillary nerve, lying between the internal pterygoid 
muscle and the ramus of the jaw; here it communicates with the 
chorda tympani, from the facial, and passing forward, beneath the 
body of the jaw and above the submaxillary gland, gives off its 
branches to the submaxillary ganglion; continued forward, upon the 
hyo-glossus muscle, it crosses Wharton's duct, and is continued 
alongside the tongue to its apex, lying directly beneath the mucous 
membrane. The glosso-pharyngeal is of but little surgical impor- 
tance. It descends in the neck, in front of the internal jugular vein 
and the internal carotid artery, curving forward upon the outer side 
of the stylo-pharyngeus muscle, to be distributed to the base of the 
tongue, etc. 

The Side of the Face. — Passing transversely from behind for- 
ward beneath the integument, the zygomatic arch may be felt. This 
bony arch is formed by the junction of the zygomatic process of the 
temporal with that of the malar. It is a prominent landmark, and 
serves to separate the side of the head, the temporal region, from 
the side of the face, the pterygo-maxillary region. 

The Pterygo-maxillary Eegion corresponds to that part of 
the side of the face which is situated below the level of the zygoma. 

The skin of this region is intimately connected with the under- 
lying subcutaneous connective tissue, which is thick and only loosely 
attached to the fascia covering the masseter muscle. 



SIDE OF THE FACE. 59 

The masseter muscle is a strong, thick muscle arising by two 
portions from the lower border and inner surface of the zygoma. Its 
fibers pass downward, covering the ramus of the jaw, to the outer 
surface of which and to the angle of the jaw it is attached. It is 
•covered by an expansion of the cervical fascia, which is attached 
above to the lower border of the zygoma. The facial artery crosses 
the lower border of the inferior maxilla just in front of the masse- 
ter muscle, grooving the bone in this situation and passing upward 
and forward across the cheek to the side of the nose. It is accom- 
panied by the facial vein, which joins with a branch from the tem- 
poro-maxillary and thus constitutes a big branch, the temporo-facial, 
which terminates in the internal jugular. 

After the skin and subcutaneous fat have been removed in this 
region the parotid gland is exposed. This gland is situated upon the 
side of the face, reaching from the zygoma, above, to below the angle 
of the jaw. It lies in the space bounded by the angle of the jaw and 
the posterior border of the ramus in front, and the mastoid process 
behind, and extends forward upon the side of the face, lying upon 
the back part of the masseter muscle. The parotid gland is covered 
by a strong layer of fascia, which forms a sort of fibrous envelope 
and sends prolongations into the gland to support it. This fascia is 
continued forward on to the masseter and buccinator muscles, and 
downward upon the side of the neck, where it is continuous with 
the cervical fascia. It is also attached to the angle of the jaw. The 
duct of Stenson (duct of the parotid gland) is about two inches long 
and lies about a finger's breadth below the zygoma, passing forward 
across the masseter, at the anterior border of which it pierces the 
cheek to enter the mouth opposite the second molar tooth of the 
upper jaw. 

The facial nerve, after emerging from the styloid foramen, 
passes forward and downward into the substance of the parotid 
gland. It crosses the external carotid artery and divides in the 
substance of the parotid gland into several branches, which form 
the pes anserinus and which are distributed upon the side of the 
face to supply the muscles, etc. 

The auriculo-temporal nerve emerges upon the face behind the 
neck of the condyle of the jaw after passing through the upper part 
of the parotid gland. It ascends across the root of the zygoma, in 
front of the ear, in company with the temporal artery, to be dis- 
tributed upon the side of the head (temporal region). 



60 HEAD AND FACE. 

Beneath the parotid gland or within its substance the external 
carotid artery divides into its terminal branches: the internal maxil- 
lary and the temporal. The temporal ascends through the substance 
of the gland and across the root of the zygoma, just in front of the 
cartilage of the ear, the auriculo-temporal nerve lying posterior to 
it; and about two inches above the zygoma it divides into the ante- 
rior and posterior temporal. These branches, lodged in the subcu- 
taneous connective-tissue layer of the temporal region, divide and 
supply this part of the scalp, anastomosing anteriorly with branches 
from the frontal and posteriorly with the occipital, etc. The inter- 
nal maxillary artery is not exposed until after the removal of the 
ramus of the jaw, etc. (see later). The temporal artery is accom- 
panied by the temporal vein. The temporal vein does not lie within 
the substance of the parotid gland, but superficial to it; it receives 
many tributaries, and below the angle of the jaw divides into two 
branches; the posterior joins with the posterior auricular to form 
the external jugular vein; the anterior joins with the facial to form 
a large branch, the temporo-facial, which passes obliquely backward 
across the upper part of the superior carotid triangle, to enter the in- 
ternal jugular. This branch is often cut in extirpating glands, etc., 
in this part of the neck, and may give rise to profuse hemorrhage. 

The deeper parts of this region are exposed by dividing the 
zygomatic arch with the chisel or chain-saw at its anterior and poste- 
rior extremities, and then, after cutting the attachment of the tem- 
poral fascia from its upper border, turning the detached segment of 
the arch, with the attached masseter, downward. There is then 
exposed the upper part of the ramus of the jaw, with its coracoid 
process, to which the tendon of the temporal is attached. This 
process is now cut away from the ramus, and, together with the 
attached tendon of the temporal, turned upward, and we then have 
exposed to view the pterygo-maxillary region proper. Occupying 
this space is the external pterygoid muscle. This muscle arises, by 
its broad anterior end, from the under surface of the great wing of 
the sphenoid and from the outer surface of the external pterygoid 
plate; behind, its narrow end is attached to a depression in the 
anterior surface of the neck of the condyle of the lower jaw and to 
the anterior margin of the interarticular fibrocartilage of the tem- 
poro-maxillary joint. Curving around its lower border and passing 
forward and upward upon its outer surface may be seen the internal 
maxillary artery. This vessel gives off branches to the adjoining 



SIDE OF THE FACE. 



61 



muscles and disappears, anteriorly, by passing into the spheno- 
maxillary fossa between the two heads of the external pterygoid 
muscle. This' vessel may now be cut away and the muscle cut short 
at its attachment to the condyle of the jaw and also close to its 
origin, and in this way the parts which lie beneath the external 




Fig 17. — Pterygo-maxillary Region. Ramus of the jaw and the zygomatic 
arch cut away. ID, inferior dental nerve; III, internal maxillary artery; 
L, lingual, or gustatory, nerve; PE, external pterygoid muscle; PI, internal 
pterygoid muscle; SM, superior maxillary (second division of fifth) nerve 
crossing the spheno-maxillary fossa from behind forward. 



pterygoid muscle are exposed, — the zygomatic and spheno-maxillary 
fossae, with their important vascular and nervous structures. 

The zygomatic fossa is that space which is limited above by 
the prominent horizontal ridge called the pterygoid ridge which is 
found upon the under surface of the great wing of the sphenoid 



62 



HEAD AND FACE. 



about opposite the zygoma. The floor of the zygomatic fossa is com- 
posed of the under surface of the great wing of the sphenoid (base 
of the skull) from the pterygoid ridge to the base of the pterygoid 
process, and also of the surface of the external plate of the pterygoid 
process. It presents the foramen ovale and the foramen spinosum. 




Fig. 18.— Pterygo-maxillary Region. External pterygoid muscle cut away, 
exposing external pterygoid plate, etc. AT, auriculotemporal nerve; ID, 
inferior dental nerve; IM, internal maxillary artery; L, lingual, or gustatory, 
nerve; MM, middle meningeal artery; PI, internal pterygoid muscle; BM, 
superior maxillary (second division of the fifth) nerve passing across the 
spheno-maxillary fossa. 



The spheno-maxillary fossa is the narrow perpendicular space 
which is bounded in front by the posterior aspect of the superior 
maxilla and behind by the front of the pterygoid process. Its inner 
wall is formed by the vertical plate of the palate bone and consti- 
tutes a part of the lateral wall of the nasal cavity. Above, this space 



SIDE OF THE FACE. 63 

is bounded by the orbital process of the palate bone and the body 
of the sphenoid. The inner wall presents, above, the spheno-palatine 
foramen, through which it communicates with the nasal cavity and 
below the upper opening or commencement of the posterior palatine 
canal. Into the upper part of this fossa, upon its posterior wall, 
the foramen rotundum opens; above and internal to this is the 
opening of the Vidian canal. The anterior wall of this space pre- 
sents the commencement of the infra-orbital canal. 

Located between the inner surface of the condyle of the lower 
jaw and the internal lateral ligament is the first part of the internal 
maxillary artery; in this situation the vessel gives off the middle 
meningeal branch, which passes directly upward and enters the skull 
through the foramen spinosum. The middle meningeal artery, at 
its origin, is surrounded by the two roots of the auriculo-temporal 
nerve; these two roots join posteriorly to form the auriculo-tem- 
poral, which passes backward, as far as the temporal artery, and, 
after emerging from the upper part of the parotid gland, ascends in 
front of the ear, to be distributed to the integument of the temporal 
region. 

A little in front and to the inner side of the middle meningeal 
artery may be observed the inferior maxillary division of the fifth 
nerve. This trunk consists of a large sensory root and a smaller 
motor root, which emerge from the skull through the foramen ovale 
and join together outside this opening, just below the base of the 
skull, to form the inferior maxillary division. 

The inferior maxillary division gives off two temporal branches, 
which pass upward beneath the temporal muscle, and two large 
branches, which pass downward and forward. One of these, the 
lingual or gustatory, is joined below by the chorda tympani, a branch 
of the facial, and the other, the inferior dental, enters the canal on 
the inner surface of the ramus of the jaw to supply the lower teeth. 
Attached to the inner posterior aspect of the inferior maxillary 
division is the otic ganglion; it is located just below the foramen 
ovale. 

In the upper part of the spheno-maxillary fossa is seen the 
middle, or superior maxillary, division of the fifth nerve. This 
nerve leaves the skull through the foramen rotundum, passes for- 
ward, across the upper part of the spheno-maxillary fossa and, as 
the infra-orbital, and accompanied by the terminal branch of the 
internal maxillary artery, enters the infra-orbital canal, and is finally 



64 HEAD AND FACE. 

distributed to the skin of the front of the face, below the orbit. 
Suspended from the lower border of the middle division, as it passes 
across the upper part of the spheno-maxillary space, is Meckel's 
ganglion, with its descending palatine branches, etc. 

We may now remove rather more of the ramus of the jaw in 
order to expose more completely the internal pterygoid muscle. 
This is seen to arise from the inner surface of the external pterygoid 
plate, and, passing downward, backward, and outward, is attached 
to the inner surface of the angle of the jaw. Between this muscle 
and the inner surface of the ramus of the jaw are the inferior dental 
nerve, which enters the canal on the inner surface of the ramus, and 
the lingual, which is joined by the chorda tympani. The internal 
lateral ligament of the jaw may also be seen in this dissection. 

OPERATIONS UPON THE FACE. 

Resection of the Upper Jaw. — The chief danger in this operation 
is from the entrance of blood into the larynx. This may be avoided 
by previously ligating the external carotid or by a preliminary 
tracheotomy and the use of a Trendelenburg tampon cannula; or an 
ordinary tracheotomy tube may be used, in this latter case packing 
the pharynx, through the mouth, with a gauze pad. The operation 
may be done without a preliminary tracheotomy by operating with 
the patient in the Eose position, the head hanging over the end of 
the table, so that the field of operation is upon a lower level than 
the larynx. It is said that the dependent position of the head, the 
Eose position, favors venous hemorrhage, which would be a dis- 
advantage. The operation may be done with the patient in a half- 
sitting position, using incomplete morphin-chloroform narcosis, the 
patient being but partly ansesthetized, and therefore able to cough 
and keep the larynx clear of blood. 

The incision should be so placed as to avoid Stenson's duct. 

Webee's Incision. — Eeaching from the inner angle of the eye, 
the incision is carried down alongside of the nose and around the 
ala to the middle line, terminating by splitting the upper lip. To 
this is added a second incision reaching from the inner angle of the 
eye, outward, below the lower margin of the orbit. This second 
incision should pass along the lower edge of the orbicularis pal- 
pebrarum in order to avoid cutting into the substance of this muscle. 
These incisions should penetrate to the bone. Branches of the facial 



OPERATIONS UPON THE FACE. 



65 



nerve are not cut in this incision. The flap which is thus marked out 
is reflected outward, and should be raised subperiosteal^ if the char- 
acter of the disease permits. The infra-orbital vessels and nerve are 
cut when the flap is separated from the anterior surface of the supe- 
rior maxilla. 




Fig. 19.— Resection of Upper Jaw. L, Langenbeck incision; V, Velpeau 
incision; W, Weber incision. 



Langenbeck's Incision. — A flap, its lower border curved with 
the convexity downward, is raised. The incision commences at the 
inner angle of the eye, and passes down alongside of the nose to a 
point below the level of the ala, as far as the attachment of the 
upper lip to the alveolar process of the superior maxilla; here it 
curves outward, corresponding to a line drawn from the ala of the 



66 HEAD A:NrD FACE. 

nose to the lower border of the lobe of the ear, and is then carried 
upward to a point over the prominence of the cheek-bone. This 
incision does not divide the lip, but it will be necessary later to 
separate the lip from its attachment to the jaw-bone. It divides some 
branches of the facial nerve, which is a disadvantage. The front 
surface of the bone is exposed by reflecting this flap upward, sub- 
periosteally, if the conditions permit. In raising the flap from the 
bone the infra-orbital vessels and nerve are divided. 

In making either of these incisions the facial artery is divided 
and must be clamped and ligated. 

After the soft parts have been detached from the bone the 
cartilage of the nose is separated from the nasal notch, and the 
soft parts, corresponding to the lower margin of the orbit, raised 
from the bone, and the tarso-orbital fascia cut along the margin 
of the orbit. The floor of the orbit is now exposed, and the con- 
tents of the orbit raised out of the way with a blunt retractor. We 
are then ready to cut through the nasal process of the superior 
maxillary. This division should extend from the margin of the 
nasal notch, across the nasal process, as far as the lacrymal groove 
or fossa. One should avoid injury to the lacrymal sac, the upper 
expanded part of the lacrymal canal, which is lodged in the lacrymal 
depression upon the lacrymal bone. The 'division of this process of 
bone may be accomplished with a chisel, or one may make a hole 
in the lacrymal bone, which is very thin, just in front of the lacrymal 
sac, and introduce through the orbit a Gigli saw, bringing its end 
out through the nasal notch; the Gigli saw is carried around the 
bone with a loop of silk in a curved needle. Probably a chisel is 
more convenient for this part of the operation. 

We next separate the jaw from its attachment to the malar 
bone. This may be done with a chisel or with a chain or G-igli saw. 
The line of division should extend through the maxillary process 
of the malar bone into the anterior end of the spheno-maxillary 
fissure. If this section is made with a chain or Gigli saw, the instru- 
ment may be carried around the bone with a loop of strong silk in 
a large, full-curved needle. The contents of the orbit being well 
retracted, the needle is passed into the orbit, through the spheno- 
maxillary fissure, and then out through the zygomatic fossa, emerg- 
ing upon the face below the malar process; the suture is then pulled 
through, drawing the saw, which thus surrounds the malar bone at 
its junction with the superior maxillary, after it; the division may 



OPERATIONS UPON THE FACE. 67 

then be readily made. If it is desired to take the malar bone away 
in addition to the superior maxillary, the needle, after entering the 
spheno-maxillary fissure, as above described, should be made to 
traverse the temporal fossa, appearing above the upper border of 
the malar bone, thus surrounding its frontal process; after this 
process has been divided the zygomatic arch may be cut through 




Fig. 20.— Resection of Upper Jaw. When it is desired to leave the major 
part of the malar bone, the line cf section through the bone should be as 
indicated upon the right side of the skull. If the malar bone is to be re- 
moved together with the superior maxillary, the section through the bone 
should be as is represented upon the left side of the skull, the line of division 
passing through the frontal process of the malar and the zygoma. 



with the chisel, thus separating the malar bone from its connection 
with the temporal bone. 

We are then ready to make the division through the hard palate; 
this is best done as the last step of the operation, after the other 
connections have been severed, on account of the hemorrhage into 
the mouth. Before dividing the hard palate the muco-periosteal 
layer, which covers it, is detached. An incision is made in the muco- 
periosteal covering of the hard palate, commencing anteriorly just 



68 HEAD AND FACE. 

behind the incisor teeth; this is carried back along the side of the 
hard palate, close to the alveolar process, as far as the attachment of 
the soft palate to the posterior border of the hard palate. "With a 
periosteum elevator, this layer is separated from the surface of the 
hard palate, as far as the middle line; the soft palate is also separated 
from the corresponding half of the posterior border of the hard pal- 
ate. A chisel is then placed in the middle line between the two in- 
cisor teeth, and the hard palate divided down the middle for its 
whole length. It is probably better, in some cases, to accomplish 
this division with a saw. For this purpose we use a narrow saw, 
which is introduced into the nasal cavity, after the first incisor tooth 
of the jaw which is to be excised has been extracted, sawing through 
the floor of the nasal cavity from above downward and from before 
backward. 

The jaw-bone is now free except for its attachment, behind, to 
the palate bone and to the pterygoid plate of the sphenoid. The 
floor of the orbit, which is very thin, may be cut through, just behind 
its anterior margin, with one or two strokes of the chisel, this line 
of section reaching from the lacrymal fossa across the floor of the 
orbit into the spheno-maxillary fissure. One should finally see that 
the soft parts are separated from the facial surface of the bone, well 
beyond the last molar tooth; this may be done with a few sweeps 
of the knife, cutting close to the surface of the bone. 

The body of the jaw is now seized with a strong bone forceps, 
and, with a gradually increasing rocking motion, it is forcibly 
wrenched from its remaining attachment. Usually all of the palate 
bone, except its orbital process, comes away with the superior 
maxilla and there is left remaining a part of the orbital surface of 
the superior maxilla sufficient to support the contents of the orbit. 
If part of the pterygoid process comes away with the superior max- 
illary, the bone will still be held by some of the muscles which arise 
from this process, — the internal and external pterygoids, — and it 
will be necessary to divide these with a sweep of the knife before 
the bone can be removed. 

There is left a large bloody space, but, as a rule, there is little 
or no hemorrhage, owing to the tearing of the blood-vessels in 
wrenching the bone free. The infra-orbital vessels and nerve may 
be seen hanging free in the wound. The vessels, which may bleed 
freely, should be seized at once, clamped, and tied, and the nerve 
cut short. The other branches of the internal maxillary artery also 



OPERATIONS UPON THE FACE. 69 

are exposed, — the descending palatine and spheno-palatine, — and 
these should also be clamped and tied. 

The wound may now be irrigated and tamponed, the ends of 
the gauze emerging through the nostril. The incision upon the 
face is closed with interrupted silk sutures, but, before doing this, 
the edge of the muco-periosteal flap, which was raised from the 
surface of the hard palate, should be sutured, with interrupted silk 
sutures, to the inner side of the cheek, along the line where this was 
separated from the alveolar process of the superior maxilla. The 
ends of these sutures should be left rather long and presenting into 
the mouth, to facilitate their removal later. 

During the operation the back of the mouth and the pharynx 
may be kept clear of blood with gauze pads on long holders. 

Total Resection of Both Superior Maxillae. — This operation is 
analogous to the preceding. 

A curved incision, passing from the angle of the mouth outward 
and upward to the malar bone on each side, or a double Weber in- 
cision, may be used. 

The nasal septum, vomer, is divided with bone scissors, and the 
soft parts, as a whole, including the nose, are then detached and 
reflected upward, or, if a double Weber incision is used, the lateral 
flaps are separated from the bone and reflected outward. 

The attachments of the superior maxillae are then divided as in 
the preceding operation, except that it will not be necessary to split 
or cut through the hard palate, as this is taken away entirely. If 
possible, the muco-periosteal covering of the hard palate should be 
stripped off and preserved; this is done by separating it, with an 
elevator, through a curved incision which penetrates through this 
layer down to the bone and which is placed just inside the line of 
the teeth. The soft palate, at its attachment to the posterior border 
of the hard palate, is also completely separated. Finally, with lion- 
jaw forceps, the bone is forcibly wrenched free, as in the preceding 
operation. 

The soft parts are then brought together with silk sutures, first 
uniting the edge of the muco-periosteal flap, which was raised from 
the hard palate, to the inner side of the cheeks, corresponding to 
the line where they were separated from the alveolar process. 

To Drain the Antrum of Highmore. Thbough the Tooth 
Socket. — Empyema is frequently associated with carious teeth. 
These or their remaining roots may be extracted and an opening 



70 HEAD AND FACE. 

made into the antrum by gouging out the alveolar cavity, which is 
often found to be carious. This may be done, as a rule, with a sharp 
spoon or with a narrow chisel. The chisel should be directed upward 
toward a point corresponding to the middle of the lower margin 
of the orbit. Such an opening, if made sufficiently large, provides 
satisfactory drainage from the antrum. A strip of gauze may be 
introduced to drain the cavity and to prevent the entrance of par- 
ticles of food. The opening should be made through the alveolus 
of the second biscuspid, or, better, the first molar tooth. 

Through the Anterior Wall. — Drainage may be established 
by making an opening through the front wall of the antrum. The 
upper lip is everted and the mucous membrane cut and the soft parts 
separated from the front surface of the bone with the periosteum 
elevator. The front wall of the antrum is perforated through the 
canine fossa just above and to the outer side of the canine tooth. 
The socket of this tooth is marked by a prominent ridge. 

After the periosteum has been stripped off the bone a good- 
sized opening is made into the antrum with the chisel or with a 
strong, sharp-pointed perforator or with a drill. The instrument 
should be directed upward and somewhat backward toward the floor 
of the orbit, but care should be taken to avoid entering the antrum 
abruptly with such force as to endanger the floor of the orbit. A 
drainage tube may be introduced and left in place for several days 
until the drainage opening is well established. It is advisable to 
use a tube with a bulbed end to prevent its slipping out. 

This operation may well be combined with drainage through the 
tooth socket as described above. Both operations may be done with 
the patient in the Eose position or with partial morphin-chloroform 
anaesthesia. 

Through the Lateral Wall of the Nose. — Mikulicz advises 
making an opening in the lateral wall of the nose just below the 
middle of the inferior turbinated. This may be done with a sharp- 
pointed perforator somewhat bent upon itself near the end. The 
bone is thin, and the operation is readily done except when the nasal 
cavity is narrow or the inferior turbinated much hypertrophied. 

Resection of Half of the Lower Jaw. — The incision commences 
at the middle of the chin and follows along the lower border of the 
body of the jaw as far as the angle, whence it is continued upward 
along the posterior border of the ramus as high as the lower border 
of the lobe of the ear (one may cut to this point without danger of 



OPERATIONS UPON THE FACE. 71 

injuring the facial nerve; see Fig. 79). This incision for its whole 
extent should reach to the bone. There may be added in front a 
vertical incision, splitting the lower lip through the middle line, but 
this is usually unnecessary. The facial vessels are severed in making 
the incision along the lower border of the body of the jaw-bone, and 
these should be clamped and tied. 

If the glands, etc., in the submaxillar}' region are diseased, in- 
stead of the above-described incision one may be made which com- 
mences anteriorly, in the middle line, at the lower border of the 
jaw, from which point it passes backward and somewhat downward 
across the submaxillary triangle, deviating from the lower border 
of the jaw as it passes backward, as far as the anterior border of the 
sterno-mastoid muscle, whence it is turned upward toward the apex 
of the mastoid process. This incision passes through the integu- 
ment and the platysma. The flap which is thus outlined is turned 
up over the side of the face, and we are then enabled, as a prelimi- 
nary step, to clear out the submaxillary triangle, and before doing 
this we can, if desired, easily expose and ligate the external carotid 
artery. Some surgeons precede the operation with a preliminary 
tracheotomy, introducing a tampon cannula; or an ordinary tube 
may be introduced and the pharynx tamponed. These measures 
eliminate the danger of blood being inspired into the trachea. 

Having cleaned out the submaxillary triangle, or, if this has 
not been necessary, through the incision along the lower border of 
the body, the soft parts are separated from the external surface of 
the body and ramus of the jaw, back as far as the angle, working 
close to the surface of the bone; the attachment of the masseter 
is thus separated from the ramus. The separation of the masseter 
and, in fact, the soft parts from the body of the bone as well, is 
accomplished with a periosteum elevator, occasionally snipping with 
the knife. It is desirable, if the nature of the condition present 
permits, to make this separation subperiosteally. In the mass of 
soft parts which is raised from the outer surface of the ramus of the 
jaw are included, besides the masseter muscle, the parotid gland and 
Stenson's duct, the facial nerve, and the temporal artery. None of 
these structures are injured if one works close to the surface of the 
bone. ISTow, with a clean cut, the cavity of the mouth is entered, 
incising the mucous membrane close to the anterior border of the 
ramus and along the dental margin of the body of the jaw as far 
as the middle line; in this way the outer surface of the lower jaw, 



72 HEAD AND FACE. 

including the teeth, is laid bare. Anteriorly, where the body of the 
jaw is to be divided, a tooth is extracted and the floor of the mouth, 
close to the bone, incised, so that the chain or Gigli saw may be 
carried around the bone. This is done with a loop of strong silk 
in a large curved needle, and then the body of the jaw is divided. 
This division may also be accomplished with a metacarpal saw. The 
section through the body of the jaw, in front, should, if possible, be 
made a little external to the middle line, toward the side of the 
disease, in order to avoid separating the genio-hyoid and genio-hyo- 
glossus muscles from their attachment to the tubercles on the inner 
aspect of the symphysis mentis. If these muscles are separated from 
their attachment to the jaw, there is a great tendency, both during 
and after the operation, for the tongue to drop back into the pharynx, 
closing down the epiglottis and thus greatly interfere with the pa- 
tient's breathing. 

After the bone has been divided in the middle line its free 
end is seized with a bone forceps and drawn outward, thus putting 
the structures attached to its inner surface (floor of the mouth) on 
the stretch, and they are then divided close to the dental margin 
(teeth) with a scalpel. If the condition of the periosteum permits, 
these parts may be separated from the inner surface of the jaw sub- 
periosteally with an elevator. The body of the bone, still firmly 
grasped with the bone forceps and being now freely movable, is 
dragged forcibly downward and out of the wound so that the operator 
can reach the coracoid process to which the tendon of the temporal 
muscle is attached; this is separated with a knife, cutting close to 
the bone and avoiding the internal maxillary artery and the bone is 
then still further luxated. Behind, attached to the inner surface 
of the ramus of the jaw, at the angle, is the internal pterygoid mus- 
cle; this is also cut away close to the surface of the bone. 

The inferior dental vessels and nerve enter the jaw-bone 
through the inferior dental canal on the inner surface of the ramus; 
these structures may be cut or torn, but before being cut they should 
be grasped with an artery forceps; later the vessels are tied and the 
forceps removed, liberating the nerve. If the inferior dental should 
bleed in the sawn surface of the bone this may be stopped by plug- 
ging the orifice of the canal with a strand of catgut. The flap of 
soft parts is now drawn forcibly upward, and the bone, still held 
with the bone forceps, dragged downward; so that the outer wall 
of the capsule of the temporo-maxillary joint may be reached with 



OPERATIONS UPON THE FACE. 73 

the point of a sharp knife and incised; the tendon of the external 
pterygoid, which is attached to the front of the neck of the con- 
dyle, is likewise divided. In cutting these structures the knife is 
kept applied close to the surface of the bone in order to avoid the 
internal maxillary and the temporal arteries. The bone may now 
be readily twisted out of its socket. 

If it should be necessary to separate the muscles of the tongue 
from their attachment to the symphysis of the jaw, a thick silk 
ligature should be previously passed through its tip, to be used as 
a tractor to prevent its being drawn backward into the pharynx and 
closing the larynx and interfering with respiration. It is probably 
advisable to introduce such a ligature in all cases. 

The cut edge of the mucous membrane, which was separated 
from the inner aspect of the jaw-bone, is now accurately sutured to the 
corresponding edge of the mucous membrane, which was separated 
from the outer aspect, except for a short space behind through which 
the cavity of the mouth is drained; these sutures should be of silk, 
knotted on the inside of the mouth, and the ends left sufficiently 
long to allow of their ready removal later. 

The edges of the skin are approximated with interrupted sutures 
except at the posterior part where the drain emerges. 

For the purpose of facilitating drainage, the wound is loosely 
packed with iodoform gauze, reaching into the cavity of the mouth. 
This may be removed after a few days, when a sinus is established 
through which all secretions from the mouth may find exit. 

Resection of Half of the Body of the Lower Jaw. — A strong, 
thick suture is passed through the tongue for use as a tractor, if 
this becomes necessary. An incision is made along the lower bor- 
der of the body of the jaw from the middle line in front to the 
junction of the body and ramus just beyond the last molar, behind; 
this incision penetrates to the bone. In many cases the facial artery, 
where it curves over the lower border of the body of the jaw, just 
in front of the masseter, is divided; but frequently this may be 
avoided. If the vessel is cut it must be clamped and ligated. There 
may be added anteriorly a vertical incision which splits the lower 
lip in the middle line; but, as a rule, this is unnecessary, and should be 
avoided. 

With the elevator or knife, working close to the surface of the 
bone, the soft parts are separated from the outer surface of the body 
of the jaw, finally cutting through the mucous membrane close to 



74 HEAD AND FACE. 

the teeth and thus entering the mouth and exposing the outer sur- 
face of the hody of the bone and the teeth. 

The floor of the mouth is now perforated, anteriorly, near the 
middle line, close to the inner surface of the bone, and, after ex- 
tracting a tooth, the Gigli or chain saw is introduced, being carried 
around the jaw with a loop of silk in a strong curved needle, and the 
bone is then sawn through; this section should be made to the side 
of the middle line in order not to disturb the attachment of the 
muscles of the tongue to the symphysis. If the end of the divided 
bone bleeds, this may be controlled by plugging the orifice of the 
canal which contains the nutrient artery. The end of that half of 
the bone which is to be excised is now seized with the bone forceps 
and drawn strongly outward, thus putting the soft parts attached 
to its inner surface (floor of the mouth) upon the stretch. These 
parts are separated from the inner surface of the bone as far back 
as the junction of the body with the ramus — beyond the last molar 
tooth. This may be done bluntly with an elevator, separating sub- 
periosteally, or, if this is contra-indicated on account of the char- 
acter of the disease, these parts, including the mucous membrane, 
may be simply cut away from the bone with the knife. After having 
thus stripped the body of the bone of its soft parts, both upon its 
outer and its inner or buccal surface, the saw is applied just behind 
the last molar tooth and the bone cut through. This may be done 
with the chain or G-igli saw or with a narrow metacarpal saw. "While 
the bone is being divided it should be drawn well downward with 
the bone forceps. 

Hemorrhage from the cut surface of the bone is controlled with 
a plug of catgut, which is packed into the orifice of the dental canal. 

The mucous membrane, which was separated from the outer 
surface of the segment of bone which has been resected, is sutured 
to the cut edge of the parts which were separated from the inner 
surface of the bone. This closes in the cavity of the mouth, and 
may be done with interrupted silk sutures tied within the mouth, 
the ends being left moderately long, so that they may be readily 
removed. 

The incision in the skin is closed in part, leaving the posterior 
end open for drainage. It is probably wise, in most cases, to leave 
a small opening through the mucous membrane also, so that the 
cavity of the mouth may be drained; in this case the gauze, which 
is introduced into the posterior portion of the skin incision, is packed 
into the mouth. 



OPERATIONS UPON THE FACE. 75 

Resection of the Entire Body of the Lower Jaw. — This is anal- 
ogous to the preceding operation, but special care must be exercised 
to guard against the tongue dropping back into the pharynx after 
the attachment of the muscles, which pull it forward, have been 
separated from the inner surface of the symphysis. This accident 
may be prevented by passing a ligature through the tip of the tongue 
by which traction may be made. 

There is also considerable danger of the tongue dropping back 
and obstructing the breathing after the operation, and this accident 
might easily cause the death of the patient; so that the tractor 
should be allowed to remain in the tongue and fixed outside. The 
jaw-bone is divided in the middle line, and then each half is resected 
separately as described in the preceding operation. 

Resection of Part of the Body of the Lower Jaw in Continuity. 
Fkom Within the Mouth. — Precautions must be taken to prevent 
hlood entering the larynx during the operation (see "Kesection of the 
Upper Jaw," etc.). A mouth-gag is introduced and an incision is made 
through the mucous membrane on either side of the teeth, and the 
soft parts separated from the inner and outer surfaces and from the 
lower border of the segment of the jaw-bone that is to be excised, with 
an elevator. A tooth is then extracted and the Gigli saw passed around 
the bone with a loop of silk in a large curved needle and the bone 
divided; this procedure is repeated at the other end of the segment 
of bone which is to be excised. The hemorrhage from the cut ends 
of the bone is controlled by a plug of catgut packed into the dental 
canal. One may separate the soft parts from the surface of the 
bone subperiosteally, as above described, but in most cases this is 
mot permissible on account of the character of the disease. After 
removal of the. segment of bone the edges of the mucous membrane 
may be brought together, at least in part, by interrupted silk sutures. 
A small opening may be made externally through the skin for 
drainage. 

If the anterior portion of the body is resected, necessitating the 
•separation of the tongue muscles from the symphysis, proper meas- 
ures must be taken to guard against the tongue's dropping back 
upon the epiglottis and larynx. The operation done from within 
the mouth is ordinarily rather disadvantageous, as one is unable 
"to properly drain the wound afterward. 

From Without. — An incision is made along the lower border 
of the body of the bone corresponding to that part of the bone 



76 HEAD AND FACE. 

which is to be resected and reaching down to the surface of the bone. 
Usually it is not necessary to split the lower lip. The soft parts are 
separated from the outer surface of the body of the bone with the 
elevator, if permissible, subperiosteal^, and the mucous membrane 
then incised close to the teeth, thus opening into the mouth. Corre- 
sponding to the points at which the bone is to be divided the teeth 
are extracted and incisions made in the floor of the mouth close to 
the bone to allow the passage of the Gigli saw; this is carried around 
the bone with a loop of silk in a full curved needle and the bone 
then divided from within outward. The segment of bone, which has 
been thus loosened and to the inner aspect of which the soft parts 
of the floor of the mouth are still attached, is seized with the bone 
forceps and the soft parts (mucous membrane and muscles of the 
floor of the mouth) are then separated with the elevator or cut with 
the knife close to the surface of the bone and near its alveolar margin. 
Hemorrhage from the bone may be controlled by plugging its nutrient 
canal with a piece of catgut. 

The mucous membrane, which was separated from the outer 
surface of the resected segment, is united to that which was sepa- 
rated from the inner surface with several interrupted silk sutures,, 
tied within the mouth, in this way closing in the cavity of the mouth. 
The external wound is partly closed and drained. 

If the part resected corresponds to the anterior portion of the 
body of the jaw-bone, one should secure the tongue by passing a 
silk suture through its tip. 

Resection of Part of the Body of the Lower Jaw (Not Through. 
Entire Thickness, Not in Continuity) . — Practically as described in the 
preceding operation, working either from within the mouth or without. 
The operation consists in resecting the diseased part of the bone and 
leaving a portion of the body, of greater or less thickness, as a bridge 
to preserve the continuity of the bone and prevent deformity, and to 
facilitate the application of an apparatus. The removal of the bone 
may be effected with a chisel or with the cutting bone forceps. This 
operation is but seldom practiced. 

Extirpation of the Casserian Ganglion (Rose-Andrews). — The 
incision commences at a point near the external angular process, 
curving backward above the zygoma to a point just in front of the 
ear, whence it extends downward to near the angle of the jaw. This 
incision penetrates through the skin and fat only, and pains should 
be taken to avoid injuring the parotid gland, Stenson's duct, and 



OPERATIONS UPON THE PACE. 77 

the facial nerve. The temporal artery, as it ascends in front of the 
ear, may be divided, in which case it will he necessary to ligate it. 
This flap is reflected downward sufficiently to expose the zygomatic 
arch. The temporal fascia is incised along the upper border of the 
zygomatic arch. 

The next step is the division of the zygomatic arch with the 
chain or Gigli saw, both in front and behind, and the segment 
which is thus resected, together with the attached masseter mus- 
cle, is then reflected downward. Before dividing the zygomatic arch 
holes should be drilled through the bone corresponding to the in- 
tended line of section, so that it may be wired back in place after 
the operation has been completed. When this flap, including the 
detached segment of the zygomatic arch and the masseter muscle, 
is turned down, the coraeoid process of the lower jaw and the tem- 
poral tendon, which is attached to it, are exposed. The coraeoid 
process is now divided, first drilling holes for subsequent wiring, 
and together with the attached tendon of the temporal muscle, 
this is turned upward. There is now exposed the internal maxil- 
lary artery, passing from below, forward, and upward across the 
outer surface of the external pterygoid muscle. This vessel is tied 
double and divided. With the periosteum elevator the external 
pterygoid muscle is separated from its attachment to the under sur- 
face of the great wing and from the outer surface of the external 
pterygoid plate of the sphenoid. All hemorrhage should be con- 
trolled by ligature or pressure as the operation progresses step by 
step. Now, with the finger in the wound, one should feel for and 
recognize the sharp edge of the external pterygoid plate, and tracing 
this upward, as a guide, feel or see the foramen ovale at its base 
(see Tig. 18). 

A trephine of small diameter is applied to the base of the skull 
(under surface of the great wing of the sphenoid, which has been 
laid bare by detaching the external pterygoid) anterior and a little ex- 
ternal to the foramen ovale, and here a small button of bone is re- 
moved. After this button of bone has been removed the bridge of 
bone remaining between the trephine opening and the foramen ovale 
is cut away with a rongeur bone forceps. The third division of the 
fifth nerve is now seized with a hook and drawn out through the open- 
ing in the skull to serve as a guide to the Casserian ganglion, and then 
the second division of the nerve is also seized with the hook and pulled 
out through the opening. These trunks are then both divided and 



78 



HEAD AND FACE. 



used as guides to the ganglion, which lies in a direction backward and 
inward from the foramen ovale, within the skull, upon the apex of the 
petrous portion of the temporal bone. The cut ends of the nerves, still 
attached to the ganglion, are steadied in the grasp of a long, narrow 
artery forceps, and with a curette, introduced through the opening in 
the skull, the ganglion is destroyed and scooped out. 




Fig. 21. — Resection of the Casserian Ganglion, etc. KL, Kronlein-Liicke 
incision; RA, Rose- Andrews incision. Dotted lines represent the lines of 
division through the bones; drill holes for subsequent wiring of th.3 frag- 
ments. 



The technique of this operation is difficult, as it is almost im- 
possible to reach the ganglion. There is liability to profuse hemor-' 
rhage which is difficult to control and also to injury of the Eustachian 
tube; so that the danger of infection is great. Oozing can be stopped 
by pressure with a gauze pad. When the operation is finished, the 
parts are replaced, the coracoid being wired to the ramus of the jaw, 



OPERATIONS UPON THE FACE. 79 

the segment of the zygomatic arch fixed in place with wire sutures,, 
and the wound in the skin closed. 

Division of the Second and Third Branches of the Trifacial 
Nerve at the Base of the Skull (Krdnlein's Modification of Lucke's 
Operation). — This operation consists in exposing the second and 
third divisions of the fifth nerve as they emerge from the skull 
and dividing them or twisting them free from their origin. 

An incision marking out a rounded skin-flap, with its convexity 
downward and its base corresponding to the upper border of the 
zygomatic arch, is made. It commences anteriorly, one finger's 
breadth behind the external angular process, and terminates behind,, 
just in front of the tragus. This flap, consisting of the skin and 
subcutaneous fascia, is raised from the deep fascia covering the 
parotid gland and masseter muscle, and is reflected upward, thus- 
exposing the arch of the zygoma and the lower portion of the tem- 
poral fascia, which is attached to the upper border of the arch. 
The incision does not reach low enough to injure the facial nerve 
or Stenson's duct. Bleeding points should be clamped and ligated 
as the operation progresses. 

The temporal fascia, attached to the upper border of the 
zygomatic arch, is now incised along this border of the arch, and 
the arch sawn through: first, posteriorly and then anteriorly. Be- 
fore making this division of the arch holes should be drilled for the 
purpose of wiring the detached segment in position later. In dividing 
the arch anteriorly one should take care to get well forward so as to in- 
clude as much of the length of the arch as possible; the line of division 
should not be from above directly downward, but from above 
obliquely downward and forward. This segment of the arch, carry- 
ing the attached masseter muscle with it, is reflected downward,, 
exposing the coracoid process of the ramus of the lower jaw and 
the attached temporal tendon. This process, after making drill holes 
for subsequent wiring, is then cut away, the line of section extending 
from the deepest part of the sigmoid notch obliquely downward and 
forward so as to include practically all that part of the ramus which 
corresponds to the attachment of the temporal tendon. This seg- 
ment of bone, carrying the temporal tendon, is reflected upward, 
and held thus with a retractor. The external pterygoid muscle, and 
the internal maxillary artery, which passes obliquely across its outer 
surface, are now exposed. It is well to tie the vessel double and 
cut it. With the elevator the attachment of the external ptery- 



80 HEAD AND FACE. 

goid is now separated from the under surface of the great wing of 
the sphenoid and drawn downward. The finger is then introduced 
into the space ahove the upper horder of the muscle and is passed 
inward close to the under surface of the bone (base of the skull), 
feeling for the posterior sharp edge of the external pterygoid plate 
and searching for the foramen ovale, which is directly behind and 
a little external to the root or base of the pterygoid process, external 
pterygoid plate. We should recognize the thick trunk of the in- 
ferior maxillary, or third, division of the fifth nerve as it emerges 
from the foramen ovale; directly behind this, the middle menin- 
geal arter}^, surrounded by the two roots of the auriculo-temporal 
nerve, is seen passing upward to enter the skull through the foramen 
spinosum (see Fig. 18). The inferior maxillary division is seized with 
a hook and drawn forward and cut, and then the stump, grasped with 
a forceps, is twisted free from its origin at the Casserian ganglion. 
Usually the motor root is grasped at the same time and included 
with it. We then penetrate into the spheno-maxillary fossa, and 
in the upper part of this cavity, the superior maxillary, or second, 
division of the fifth nerve, just before it enters the infra-orbital 
canal, is seized with the hook and drawn out and cut, and then like- 
wise twisted away from the Casserian ganglion. The Eustachian 
tube is located close to the inner side of the inferior maxillary, or 
third, division, and, therefore, just as soon as this trunk of the nerve 
is accessible, one should not penetrate deeper into the wound for fear 
of cutting into the Eustachian tube, which would result in certain 
infection of the wound. 

The coracoid process is reunited to the ramus of the jaw with 
a wire suture and the segment of the zygomatic arch is likewise 
replaced and wired. The skin incision is then closed. 

CONGENITAL DEFORMITIES OF THE FACE. 

The Development of the Face. — About the twelfth day the 
arrangement of the head end of the embryo is quite simple. A 
cross section shows it to consist of two tubes, one being situated 
in front of the other. The anterior is the blind, head end of the 
alimentary tube: the future pharynx. The posterior is the enlarged 
neural tube which is later developed into the brain. The anterior 
wall of this upper, head end of the alimentary tube is called the 
"oral plate," and marks the location of the future mouth and face. 



CONGENITAL DEFORMITIES OF THE FACE. 



81 



A sagittal section will also show this relationship, and further that 
the neural tube not only lies behind the alimentary tube, but also 




Fig. 22.— Transverse Section of the Head End of an Embryo Twelve Days 
Old. A, alimentary tube; N, neural tube; NC, notochord; OP, oral plate. 

arches forward above the upper end of the latter like a hood, over- 
riding it anteriorly. This upper part of the neural tube, which 




Fig. 23. — Sagittal Section of the Head End cf an Embryo Twelve Days 
Old. A, alimentary tube; FB, vesicle of the forebrain overriding the end of 
the alimentary tube; N, neural tube; NC, notochord; OP, oral plate (site of 
future mouth), which ruptures during the fourth week. 

projects forward over the end of the alimentary tube, is called the 
vesicle of the forebrain. 



82 HEAD AND FACE. 

In the third week there may be seen, upon either side of the 
head end of the embryo, four transverse plates or ribs of tissue 
which are separated from one another by deep fissures, or clefts. 
The thickened plates are called visceral arches, and the intervening 
spaces, or fissures, visceral clefts. Within the alimentary tube, upon 
its inner aspect, there may be seen corresponding arches and clefts. 
These arches are simply thickenings or ribs in the lateral walls of 
the head end ("schlund," pharynx) of the alimentary tube. Each 
mass consists of mesoblast, covered upon its outer surface by the 
epidermic layer, which covers the whole exterior of the body, and 
upon its inner surface by the endodermic layer, which lines the 
whole inner surface of the alimentary tube. Between the arches, 
at the bottom of any two opposed clefts, the wall of tissue is ex- 
tremely thin; consists practically of the outer (epidermic) and the 
inner (endodermic) layers. The uppermost of these visceral arches, 
that concerned in the formation of the face, is the thickest. It 
extends forward, and in front, where it is narrower, unites in the 
middle line, with its fellow of the opposite side to form the mandib- 
ular arch, which represents the future lower jaw. The second arch 
is less prominent than the first, and as it passes forward is directed 
somewhat upward. This second arch does not reach as far as the 
middle line. The third and fourth arches are still less prominent 
and still shorter. These lower three arches do not join with their 
fellows across the middle line in front, but are continued into the 
plate of tissue which forms the front wall of the (schlund) pharynx. 
From above downward these arches overlap and partially conceal 
each other; so that the third and fourth, especially the fourth, are 
almost entirely concealed by the first and second. The uppermost 
arch appears earliest. The appearance of these arches is the first 
indication that marks the commencement of the formation of the 
face. 

Owing to the progressive growth of the visceral arches, which 
causes a thickening of the parts that immediately adjoin the area 
already mentioned as the oral plate, and on account of the presence 
of the prominent overhanging forebrain vesicle (neural tube) above, 
the oral plate becomes relatively depressed, and we have thus, in 
its stead, a distinct fossa, which is called the oral pit. The oral pit 
is bounded above by the overhanging forebrain vesicle and below 
and upon the sides by the first visceral arches. These are the parts 
which immediately surround the oral pit and which are finally de- 



CONGENITAL DEFORMITIES OF THE FACE. 83 

veloped into the face; the oral pit represents the future oral and 
nasal cavities. „ 

The second, third, and fourth visceral arches are not concerned 
in the formation of the face. 

The next change noticed in the parts about the oral pit is the 
appearance of a thick, rounded mass or process upon the upper hack 
part of the first visceral arch of either side; this is called the supe- 
rior maxillary process. Above, corresponding to the upper margin 




Fig. 24.— Face of Embryo, Fifth Week. Front view. E, eye; IM, inferior 
maxillary process (first visceral arch) joins in middle line with its fellow of 
the opposite side to form the mandibular arch (future lower jaw) ; LN, lateral 
nasal process (outer extremity of the frontal process) ; MN, middle nasal 
process (middle portion of frontal process); NN, nasal notch (future nostril); 
SM, superior maxillary process (upper back part of the first visceral arch) ; 
1, 2, 3, first, second, and third visceral arches. 

of the oral pit, there appears a single broad process, which is devel- 
oped by the forward and downward growth of the anterior wall of 
the vesicle of the forebrain; this is called the frontal process or 
frontal plate, and is really a prolongation of the front wall of the 
vesicle of the forebrain; it grows downward and plays a very im- 
portant role in the development of the face. At this stage the oral 
pit is a five-sided, deep fossa, bounded above by the frontal process 
or frontal plate, below by the mandibular arch (inferior maxillary 
processes), and upon each side by the superior maxillary process. 



84 



HEAD AXD FACE. 



The eyes are located one upon either side of the head, and are 
bounded below by the upper back part of the superior maxillary 
process and internally by the outer border of the frontal process. 

The frontal process, frontal plate, is broad, and consists of a 
middle portion, the middle nasal process, and two lateral portions, 
the lateral nasal processes. 




Fig. 25.— Face of Embryo, Fifth Week. Front view. The anterior portion 
of the visceral arches has been cut away to show the interior of the mouth 
cavity (pharynx), the wall of which shows the visceral arches with interven- 
ing clefts corresponding to those upon the outside. IM, cut surface of infe- 
rior maxillary process; LN, lateral nasal process; 8M, superior maxillary 
process; 1, 2, 3, 4, cut surface of the first, second, third, and fourth visceral 
arches, showing the corresponding clefts between them. Between LN and 
middle nasal process is the nasal notch (future nostril). 



The middle nasal process is quite broad, and its lower free 
border is deeply notched in the middle. The lateral nasal process, 
one on either end of the frontal process, is separated from the middle 
nasal process by a deep notch, the olfactory groove; the floor of 
each olfactory groove is intimately related with the base of the 
cerebral vesicle: organ of smell. 



CONGENITAL DEFORMITIES OF THE FACE. 



85 



During the fourth week the plate of tissue which forms the 
floor of the oral pit heeomes very thin, consisting only of the epider- 
mic and endodermic layers. It is called the "rachenhaut of Kemak," 
or the pharyngeal membrane, and during this week ruptures and so 
establishes a communication from without with the alimentary tube 
— pharynx. 

Somewhat later, about the fifth week, we find that the various 
processes have approached each other, and the appearance begins 




Fig. 26.— Embryo about Fourth Week, seen from Side. 1, 2, 3, 4, visceral 
arches with clefts between them. 



to suggest the ultimate conformation of the face. The superior 
maxillary processes are nearer the middle line, the whole frontal 
process is longer, and its separation into a middle and two lateral 
portions is still more pronounced on account of the increased depth 
of the olfactory grooves. The eyes are fairly well bounded, but are 
still located upon the side of the head. 

About the seventh week we note that the superior maxillary 
process, in part, has become fused with the lateral nasal process 



86 HEAD AND FACE. 

of the frontal plate; this line of fusion corresponds to the position 
of the tear-duct. If union does not occur along this line, we have 
a so-called orbito-nasal or oblique facial cleft. The eye is entirely 
surrounded and is placed more to the front of the face. The middle 
portion of the frontal plate, the middle nasal process, is still notched 
in the center and broad; the extremities of this middle nasal process 
have become fused with the lowest and most internal part of the 
superior maxillary process, and by this union the upper lip is formed 




Fig. 27.— Embryo about Eighth Week. Development of face well advanced. 

and at the same time the olfactory grooves are bounded below, and 
are thus converted into round openings: the nostrils. If the supe- 
rior maxillary process and middle portion of the frontal plate, 
middle nasal process, fail to unite, we have, as a result, a cleft in 
the lip, — harelip; this may or may not reach into the opening of 
the nostril: i.e., may be complete or incomplete according to the 
extent to which the parts have failed to unite. 

The lower edge of the superior maxillary process becomes par- 
tially united with the upper border of the mandibular process, the 



CONGENITAL DEFORMITIES OF THE FACE. 87 

inferior maxillary process, which has also become thickened, and 
in this way the size of the mouth is much diminished. If this union 
falls short of normal we have a characteristic deformity: macrostoma 
or transverse facial cleft. The face, as a whole, is, therefore, at this 
period closed in, hut the nostrils are still far apart, the nose broad, 
and perfectly flat and directed forward, and the upper lip is still 
notched in the middle line. This type of face often persists, and 
we then have a peculiar "pug face." 

The openings for the external auditory meatus are seen low 
down upon either side of the head. 

The external auditory canal is the remains of the posterior part 
of the first visceral cleft: i.e., that between the first and second 
arches. The margins of the orifice of the auditory canal later be- 
come nodulated; these nodules coalesce, and in this way the auricle 
is formed. The Eustachian tube and the tympanum are the remains 
of the corresponding first internal cleft (from pharynx). The ear- 
drum represents the point where the epiderm, at the bottom of the 
outer cleft, and the endoderm, at the bottom of the inner cleft, have 
coalesced with each other. 

At the end of the second month the eyes are located toward 
the front of the face. The nose is still broad and flat, although the 
nostrils are rather closer together. The upper lip, representing the 
middle portion, middle nasal process, of the frontal plate, is still 
notched in the middle line. The cavity of the mouth is fairly well 
closed in by the upper and lower lips. 

To recapitulate: The first visceral arch is eventually developed 
into the inferior maxillary bone and the adjoining soft parts, includ- 
ing the lower lip and the floor of the mouth, and assists in the forma- 
tion of the tongue. The superior maxillary process of the first 
visceral arch is developed into the superior maxillary bone and the 
adjoining soft parts, including the hard and soft palate. The frontal 
plate, its lateral portion, the lateral nasal process, forms the side of 
the nose, including the nasal bones; its middle portion, the middle 
nasal process, forms the bridge of integument between the nostrils, 
reaching from the tip of the nose to the upper lip, and the cartilagi- 
nous and bony portions of the nasal septum (vomer and perpendicular 
plate of the ethmoid); also the middle portion of the upper lip and 
intermaxillary bone. 

The intermaxillary bone was first described by the poet Goethe. 
It is a small, wedge-shaped, bony process which is attached to the 



88 



HEAD AND FACE. 



anterior end of the vomer and fits into a corresponding triangular 
space in the anterior part of the hard palate, and carries the four 
incisor teeth. The line of union between this bone and the palatal 
processes of the superior maxillary may often be plainly seen in the 
adult upper jaw-bone. The anterior palatine canal marks the junc- 
tion of these parts. A non-united, abnormally placed intermaxillary 
bone often complicates harelip. 




Fig. 28.— Face of Embryo about Eighth Week. The various processes that 
go to make up the face have coalesced, but the embryonal type of the face is 
still well marked. Eyes located upon the side of face. Ears low down. Nose 
flat and projecting forward, with nostrils far apart. Upper lip still notched 
in the middle. 



Formation of the Palate. — The superior maxillary process of 
either side gives off, upon its inner aspect, a shelf -like process: the 
palate process. These processes gradually grow toward the middle 
line and unite with each other, and thus form the hard and soft 
palate, the union taking place from before backward, the uvula being 
the last part to unite. Union between the palatal processes is com- 



CONGENITAL DEFORMITIES OF THE FACE. 89 

plete at about the eleventh week. With the formation of the hard 
and soft palate, the nasal cavity is separated from the oral, or mouth, 
cavity. Failure of union between the palatal processes gives rise 
to the various degrees of cleft palate. In front, where the two halves 
of the hard palate join with the intermaxillary bone, there are a 
suture line and the anterior palatine canal. 

The vomer and the perpendicular plate of the ethmoid are de- 
veloped from the middle portion — the middle nasal process — of the 
frontal plate, and divide the nasal cavity into two parts. The junc- 
tion between the lower border of the vomer and the hard palate 
occurs after the two palatal processes have united with each other 
in the middle line. The nasal cavity opens in front upon the face 
through the nostrils and behind into the pharynx through the poste- 
rior nares. 

The Teeth. — The margins of the upper and lower jaw become 
prominent, and in this way form the alveolar processes; the epithe- 
lium covering these processes becomes invaginated, — dips down into 
the substance of the processes, — and from this the teeth are formed. 

The floor of the mouth is developed from the first visceral arch. 

The Tongue. — The tongue is developed, its anterior portion from 
the first arch and its posterior portion from the second and third 
arches. The anterior part — the body and tip — is developed from a 
tubercle which appears in the front part of the mouth at the junction 
of the two halves of the first arch. The back part, the root, is devel- 
oped in the back part of the mouth from the wall of the pharynx, 
from two tubercles at the junction of the second and third arches. 
These two parts of the tongue, the anterior and the posterior, become 
joined, the line of union being indicated by the V-shaped row of 
papilla? upon the dorsum of the adult tongue. At the apex of the V 
there is a dimple, the foramen cascum, which indicates the point of 
junction of the parts of which the tongue is formed. As the tongue 
is developed, it increases rapidly in size, occupying the mouth cavity 
and projecting up into the future nasal cavity. As the palatal 
processes grow inward to meet each other in the middle line, how- 
ever, the tongue is gradually forced down into the mouth cavity 
proper, where it belongs. 

Deformities of the Face. — These consist of abnormal clefts and 
atresias, which may be partial or complete. 

Clefts are due to the entire or partial absence of normal union 
between the original embryonal processes by whose coalescence the 



90 



HEAD AND FACE. 



face is formed. Atresias are caused, on the other hand, by excessive 
union, beyond the normal, between these processes, and as a result 
we get a partial or complete closure of the facial orifices: mouth, 
nostrils, and eyes. Still further, the union between the processes 
may occur to its normal extent, but the lines of union may remain 
permanently marked by cicatricial seams or irregular tags and 
nodules. 

The failure of the embryonal processes properly to coalesce, 




Fig. 29.— Diagram of Congenital Facial Clefts. Shaded portions indicate 
the location of the different congenital fissures. HL, harelip; IM, inferior 
maxillary process; LN, *, lateral nasal process of frontal plate; LN, lateral 
nasal cleft; M.N., middle nasal process of frontal plate; OF, oblique facial 
cleft; SM, superior maxillary process; TF, transverse facial cleft; *, lower 
part of lateral nasal process which takes part in the formation of the upper 
lip, but not of its red border; the free red margin of the lip is formed by the 
union of the lower part of the middle nasal process (MN) and the lower 
part of the superior maxillary process {SM). 



with the resulting clefts, is really due to the incomplete develop- 
ment of the processes themselves; they are deficient: i.e., too small 
to meet each other, and hence the clefts. The clefts vary in degree 
from narrow, incomplete fissures to widely gaping spaces. The mar- 
gins of the clefts may be smooth or they may be irregular and marked 
by nodular processes, tags, etc. 

The congenital deformities of the face may be divided into two 
general groups: — 



CONGENITAL DEFORMITIES OF THE FACE. 91 

(A) Those in which the frontal plate or process is concerned. 
Under this heading we have: — 

1. Lateral clefts of the upper lip and the alveolar process; clefts 
of the palate may also be conveniently included in this group. 

2. Median clefts or notches of the upper lip and deformities of 
the nose. 

3. Notching of the wing of the nose. 

4. Oblique facial fissures, etc. 

(B) Those in which the first visceral arch is involved. In this 
group we have: — 

1. Transverse facial fissures. 

2. Median fissures of the lower lip, lower jaw, and tongue. 

3. Deformities of the lower jaw. 

Deformities in Which the Frontal Plate is Concerned. Lateral 
Clefts of the Upper Lip and of the Alveolar Process and 
Cleft Palate. — Clefts of the upper lip and alveolar process depend 
upon imperfect union of the middle portion, middle nasal process, 
of the frontal plate with the corresponding lower portion of the 
superior maxillary processes: to failure of the intermaxillary bone 
and its accompanying soft parts to unite with the adjoining portion 
of the face. These clefts are always lateral and may be present on 
one or both sides. Clefts of the palate (hard and soft) depend upon 
non-union, partial or complete, of the palatal process of the superior 
maxillary process of either side with each other. These clefts are 
median when the processes of both sides are at fault. If the palatal 
process of one side only is involved, the fissure will be present upon 
the corresponding side of the middle line, the palatal process of the 
other side being joined with the lower border of the vomer, thus 
shutting off the nasal cavity, on that side, from the mouth. 

If union has failed, on both sides, between the middle process of 
the frontal plate, the middle nasal process, and the corresponding part 
of the superior maxillary process of either side (double harelip and fis- 
sure of the alveolar process) and between the palatal processes of the 
superior maxillary processes of either side (cleft of the hard and soft 
palate), we have the most extreme variety of this group of deformi- 
ties. There are found all degrees of this variety of deformity from 
this exaggerated form down to a mere notching of the upper lip 
(incomplete harelip) or bifurcation of the uvula. 

Harelip. — This condition may be incomplete or complete. 

Incomplete harelip consists in a vertical notch in the free mar- 



92 HEAD AND FACE. 

gin of the upper lip. It is located to one side of the middle line 
between the middle segment and the lateral segment of the lip. It 
varies in depth from a barely noticeable notch to a deep fissure 
which may extend almost through the entire lip, leaving but a nar- 
row bridge of integument separating the angle of the notch from 
the nostril. 

In complete harelip the fissure extends all the way through the 
upper lip into the nostril. It may be associated with cleft of the 
alveolar process and with cleft palate. The nose is apt to be un- 
usually broad and flattened, the wing of the nose, on the side corre- 
sponding to the cleft, being carried outward away from the middle 
line. These deformities may involve one or both sides. If double, 




Fig. 30.— Double Complete Harelip. 

those of the two sides may differ from each other, the fissure on one 
side may be complete, that of the other side incomplete, or those of 
both sides may be complete. They may be associated with cleft of 
the alveolar process and with cleft palate, the intermaxillary bone 
often being small and misplaced forward. The entire middle seg- 
ment of the lip may be absent, together with the intermaxillary bone 
and the vomer. In this case the upper lip shows a broad, median 
space, which opens into the nasal cavity. 

Cleft of the Alveolar Process. — With harelip, as already men- 
tioned, there may also be present a cleft of the alveolar process, 
and this may vary from a narrow, incomplete fissure to a broad, open 
space; it may be unilateral or double, and is usually associated with 



CONGENITAL DEFORMITIES OF THE FACE. 93 

cleft palate. If there is no cleft of the hard palate, the cleft of the 
alveolar process terminates at the anterior palatine foramen: the 
meeting point of the palatal process of either side and the inter- 
maxillary bone. If the cleft in the alveolar process involves both 
sides, the intermaxillary bone, which is continuous with the front 
of the vomer, may be placed forward in advance of the rest of the 
alveolar process, especially if cleft palate is also present; so that it 
and the corresponding portion of the upper lip seem to be suspended 
from the point of the nose. In this case the lower tegumentary part 
of the septum of the nose is absent, the soft parts which represent 
the middle part of the lip being continued directly with the tip of 
the nose. This advancement of the intermaxillary bone is due to the 




Fig. 31.— Harelip with (A) Advanced Intermaxillary Portion. 

unrestricted forward growth of the vomer, which is not inhibited as 
is normally the case when it is joined to the palatal processes. If 
the cleft is confined to one side of the alveolar process and the hard 
palate, the intermaxillary bone, as it is carried forward by the growth 
of the vomer, is apt to become markedly twisted upon its long axis, 
so that its anterior surface, instead of being directed forward, looks 
almost directly toward the normal side of the face, presenting its 
prominent sharp lateral edge anteriorly. The intermaxillary seg- 
ment may be entirely absent, as already mentioned. 

Cleft Palate. — The presence of a longitudinal fissure which may 
involve the hard or soft palate or both. It is caused by a failure 
of the palatal processes of the superior maxillary processes to meet 



94 



HEAD AND FACE. 



in the middle line and coalesce. In these cases the hase of the 
skull may be unusually broad and the pterygoid processes unusually 
far apart. 

Cleft of the Hard Palate.— This may be unilateral or double. 
If one-sided, the palatal process of the normal side is seen to be 
united with the lower border of the vomer, shutting off that side 
of the nasal cavity from the mouth, while upon the affected side 
the palatal process is deficient and falls short of meeting its fellow 
of the opposite side, and there is thus left an opening which leads 
into the corresponding half of the nasal cavity. In double cleft 
palate both palatal processes are deficient, and the lower free edge 
of the vomer may be seen between the separated edges of the cleft. 




Fig. 32.— Double Cleft Palate with Advanced Intermaxillary Portion (IM) 
Carrying the Sockets of Two Incisor Teeth. V, vomer (septum of the 
nose). 



Usually the lower border of the vomer does not reach low enough 
to present itself in the fissure between the edges of the cleft, and 
the cleft thus has the appearance of a median cleft when it is, in 
reality, a bilateral, or double, cleft. 

At times we may find the palatal processes of either side prop- 
erly united with each other, but the vomer fails to grow down suffi- 
ciently far to articulate with them, and there is thus left a space 
below the lower border of the vomer through which the two sides of 
the nasal cavity communicate with each other. It should be remem- 
bered that the vomer does not play any part in the formation of the 
hard palate. 

Cleft of the hard palate ends anteriorly, either at the anterior 



CONGENITAL DEFORMITIES OF THE FACE. 95 

palatine foramen, which marks the point of junction between the 
intermaxillary bone and the palatal processes of the superior maxil- 
laries, or else it is combined with a single or double cleft of the 
alveolar process and harelip. It usually ends, posteriorly, in cleft 
of the soft palate. 

In cleft palate, especially if double, the forward growth of the 
vomer is unrestricted on account of its not being joined to the 
palatal processes, and by this forward growth the intermaxillary 
bone and its corresponding soft parts may be carried forward beyond 
the line of the alveolar processes, the intermaxillary bone often being 
bent upward or twisted upon its long axis (see Fig. 32). This ad- 
vancement of these parts adds very much to the difficulty of cor- 
recting the deformity. 

Cleft of the Soft Palate. — The fissure extends from the tip of the 
uvula for a varying distance into the soft palate. It may be simply 
a bifurcation of the uvula, but, as a rule, it extends all the way 
through the soft palate as far as the posterior border of the hard 
palate or for some distance into the hard palate. It may be com- 
bined with a lateral or double cleft of the hard palate. As is the 
case with cleft of the hard palate, there is not only a simple lack 
of union between the two halves of the palate, but an actual defi- 
ciency of tissue which prevents the parts from meeting and coalescing 
in the middle line, and this fact is important in considering the 
operative treatment of this condition. 

With the exaggerated forms of cleft palate there is frequently 
associated imperfect development of the middle nasal process of the 
frontal plate or it may be entirely absent: the intermaxillary bone 
may be absent, with or without absence of the vomer. If the inter- 
maxillary bone, etc., are absent, we have a median cleft of the upper 
lip, or, better, a double harelip with absence of its middle segment; 
and this condition is usually associated with a broad cleft in the 
hard and soft palate, and the nose may be soft and flattened, on 
account of the absence of the nasal septum, etc. This condition 
is apt to be accompanied with defective cerebral development. 

Median Clefts and Notches of the Uppee Lip. — These de- 
formities depend upon exaggeration and persistence of the embryonal 
notch of the middle portion, the middle nasal process, of the frontal 
plate and failure of the nostrils to approach each other. These 
defects are much less frequent than the preceding. There may be 
simply a notch or fissure in the middle of the upper lip reaching part 



96 HEAD AND FACE. 

way through, or this may be combined with a grooving or furrow upon 
the point and dorsum of the nose and a wide separation between 
the nostrils. This condition may be so pronounced that the nose 
appears to consist of two halves completely separated from each 
other and each containing one nostril. Instead of this extreme 
degree of deformity the nose may be simply flattened, the bridge de- 
pressed, the nostrils far apart and looking directly forward: "dog 
nose." The fissure in the upper lip instead of simply notching the 
lip may extend completely through the whole lip and into the inter- 
maxillary bone. This variety of deformity may also be represented 
by a fistula of the tip or dorsum of the nose. 

Latekal Nasal Clefts. — These occur with or without harelip 
and cleft palate; the notch or fissure involves the wing of the nose. 
If they extend upward for a considerable distance through the side 




Fig. 33.— Oblique Facial Cleft Extending into the Temporo-frontal Region. 

of the nose, they terminate above, not in the inner canthus, but to 
the inner side of the inner corner of the eye; they represent the 
embryonal notch between the middle and lateral nasal processes of 
the frontal plate. Fissures of the side of the nose, that resemble 
these, but terminate above in the inner canthus of the eye, are 
varieties of oblique facial clefts. 

Oblique Facial Clefts. — Failure of normal union between the 
lateral process of the frontal plate and the superior maxillary process 
of the first visceral arch. They correspond to the embryonal orbito- 
nasal line of coalescence. These deformities may be very extensive 
or slight: one-sided or double. They commence below at the edge 
of the upper lip, and, after splitting this at the usual harelip site, 
extend upward through the cheek, alongside of the wing of the nose, 



CONGENITAL DEFORMITIES OF THE FACE. 



97 



not into the nostril, like harelip, and terminate above, at the lower 
margin of the eye (lower lid) or inner canthus. They may extend 




Fig. 34.— Incomplete Oblique Facial Cleft. The edge of the upper lip is 
notched and a cicatricial line extends across the cheek to the lower eyelid, 
which is everted. 

beyond the orbit, from its outer corner, upward and outward into 
the fronto-temporal region of the skull. They vary from a narrow. 




Fig. 35.— Transverse Facial Cleft. 



fissure or incomplete notch to a wide, gaping fissure, between the 
edges of which is the eyeball. This class of deformity is frequently 



98 HEAD AND FACE. 

represented in its simplest form by a notch or coloboma of the lower 
or upper eyelid. Instead of a fissure, this deformity may be repre- 
sented by a cicatricial, nodulated seam, indicating the orbito-nasal 
junction. 

Deformities in Which the First Visceral Arch is Concerned. 
Teansveese Facial Clefts, etc. — These are due to a failure of 
the inferior maxillary process of the first visceral arch and its supe- 
rior maxillary process to coalesce to the normal extent. This de- 
formity may be unilateral or double. The cleft extends from the 
corner of the mouth outward through the cheek and exposes the 
teeth: macrostoma. If the reverse of this process occurs, we may 
have a mouth so small as to require surgical interference: micro- 
stoma. 

Median Clefts of the Lowee Lip, Lowee Jaw, and Tongue. 
— These conditions are very rare. They are due to failure of the 
two halves of the first visceral arch (mandibular processes) to unite 
with each other in the middle line. They vary from a slight notch- 
ing of the lower lip, in the middle line, to a complete separation 
through the lower lip, the lower jaw at the symphysis, and the 
tongue. The tongue, by itself, may be split or absent or bound down 
to the floor of the mouth or adherent to the side of the cheek, etc. 

The lower jaw may be imperfectly developed, rudimentary, etc. 
It may be split in the middle line or there may be absence of the 
condyles, etc. As the formation of the face advances the jaw is 
gradually protruded forward, and, if arrested, we have, as a result, 
the receding chin, etc. 

OPERATIONS FOR HARELIP AND CLEFT PALATE, ETC. 

Operations for Harelip. — In speaking of harelip — if single — the 
flap corresponding to the angle of the mouth is called the lateral 
flap, or segment, and the other, the middle; if the harelip is double, 
one speaks of the middle segment and two lateral segments, the right 
and the left. 

Koenig advocates early operation, within a few days after birth. 
Trendelenburg advises delaying the operation until later, operating 
between the third and sixth months, and, if very complicated, waiting 
still longer. Trendelenburg claims that the difficulty in nourishing 
the children is not a good ground for early operation; that children, 
even with a cleft palate in addition to the harelip, can feed from 



OPERATIONS FOR HARELIP, CLEFT PALATE, ETC. 99 

a bottle if it is provided with, a nipple attached to the neck of the 
bottle itself, and especially if the child is assisted by the nurse 
holding the bottle. If the child is able to take the breast it will 
not be necessary to change to the bottle after operation and the 
breast nursing may still be continued. At the time of operation the 
child should be free from intestinal trouble, and there should be 
little or no nasal catarrh. 

For children under one year no anaesthetic is necessary; for 
older children one may use incomplete chloroform anaesthesia. 

The child should be wrapped in a blanket in such a way that 
the arms and legs are confined and then held upright in the arms 
of a nurse who sits opposite the operator. The child's head is 
steadied by an assistant, who thrusts the head a little forward to 
prevent the blood entering the mouth during the operation. 

The instruments that are required consist of a sharp, narrow- 
bladed knife with a sharp point, several tenacula, mouse-tooth 
forceps, and narrow-bladed sharp-edged scissors. The steps of the 
operation consist in freshening the edges of the cleft and suturing. 
In freshening the edges one should cut with a view to providing 
broad, raw surfaces for apposition; they should be cut somewhat 
obliquely, and more taken away from the skin than from the mu- 
cous surface. During this step of the operation the hemorrhage 
may be controlled by an assistant, who compresses either segment 
of the lip between the finger and thumb, or a clamp may be applied 
on either side of the defect in the lip (Trendelenburg). With the 
mouse-tooth forceps the edge of the defect is seized and transfixed 
with a knife, and the incision made with a sawing motion and with 
deliberation. In order to bring the raw surfaces into apposition it 
is occasionally necessary to liberate the flaps, by cutting them free 
from their attachment to the deeper adjoining parts: the alveolar 
process and anterior surface of the superior maxilla. 

As suture, several harelippins may be used, each with a figure-of- 
eight coil of silk floss. Without these pins, or in addition to them, one 
may unite the raw surfaces with one to three heavier silk sutures car- 
ried in a straight or curved needle. These should penetrate deep 
into the substance of the lip, down to, but not through, the 
mucous membrane, and should take a good hold. Between these 
the skin and mucous membrane are brought accurately together, 
edge to edge, with a number of superficial sutures of rather finer 
silk. 



100 



HEAD AND FACE. 



Operations for Incomplete Harelip. Simple Freshening of 
the Opposing Edges and Suture. — This plan would not answer 
even for incomplete harelip, since a notch would remain which 
would increase with time as the scar contracts, especially if the 
cleft is deep. 




I (( 




Fig. 36.— Simple Paring of the Edges of 
the Notch for Incomplete Harelip. 



-riYff'f 



Fig. 37.— Imperfect Result After Sim- 
ple Paring and Suture, Showing the 
Notch still Present. 



Von Graefe proposed a very simple method to increase the 
length of the apposed edges of the freshened surfaces. This method 
will answer, however, only for the very incomplete defects, and not 
for wide or complete splits. It consists in paring the edges of the 
notch by making a circular incision, which arches over the corner of 
the notch. 





Fig. 38.— Von Graefe Method of Paring 
an Incomplete Harelip so as to Increase 
the Length of the Raw Apposed Edges. 



Fig. 39.— Result After Suturing. 



Nelaton Method. — Without removing any tissue, an incision 
is made through the substance of the lip, around the corner of the 
cleft and parallel with its edges, and after converting this incision 
into a vertical one its edges are united with several interrupted 
stitches. 



OPERATIONS FOR HARELIP, CLEFT PALATE, ETC. 



101 




Fig. 40.— Nelaton Opera- Fig. 41. — Incision Con- 
tion for Incomplete Hare- verted into a Perpendicu- 
lip. Line of incision. lar, ready for Suture. 



Fig. 42. — Result After 
Suture. 



Malgaigne proposed to close the defect, especially where the 
defect is considerable, by making use of flaps in addition to fresh- 
ening the edges. In his operation the tissue is removed from the 
angle of the defect only, the second part of the operation consisting 
in the formation of flaps by simply cutting into the substance of 
the lip along either side of the defect, commencing near the angle 
and cutting toward the red border of the lip. The base of the flap 





^Yv ()J , ./»""' u ^jTvr.i,,^ 



Fig. 43.— Malgaigne Oper- Fig. 44. — Flaps Turned Fig. 45. — Result After 

ation for Incomplete Hare- Down, ready for Suture. Parts have been Sutured, 
lip. Paring and formation 
of flaps. 

should be no thicker than the red of the lip; otherwise it is very 
difficult to turn it down. The tongues of tissue thus marked out 
are turned down and sutured together, with the result that the cleft 
is not only filled in, but a little tongue of tissue is left projecting 
beyond the free line of the lip to allow for future retraction. 

The objection to this operation is that, on account of the con- 
siderable torsion to which the flaps are subjected, their nourishment 
is uncertain and they may become gangrenous, especially in very 
young children. 



102 



HEAD AND FACE. 



Mirault's operation is an improvement on Malgaigne's. Only 
one flap is made, and that is taken from the edge of the lateral 
segment. The flap which is thus formed is sutured to the freshened 
edge of the middle segment. This single flap is not likely to become 
gangrenous as is the Malgaigne, because it is not necessary to turn 
it down so far, and, secondly, because its base may be made suffi- 
ciently broad to include the coronary vessels. In forming the flap 
a single cut is made into the substance of the lip proper, striking 
well above the red margin so that the base of the flap corresponds 
to the lower third of the breadth of the lip. This is a very satis- 
factory operation. It has been modified by Simon, Koenig, Esmarch, 
Hagedorn, and others. 




Fig. 46.— Mirault Opera- Fig. 47. 
ation for Incomplete Hare- 
lip. Paring and formation 
of one flap. 



- Parts ready for 
Suture. 



Fig. 48.— Result After Su- 
ture. 



Operations for Complete Harelip. — Cases in which the split 
extends through the entire width of the lip. 

In these cases it is not only necessary to freshen and prepare 
the edges for suture, but one must, in addition, detach the soft 
parts, in order that the raw surfaces may be brought together and 
sutured; one must unite the whole width of the lip from the nasal 
opening down to its free border, and further strive to correct the 
accompanying nasal deformity. It usually suffices to separate the 
outer or lateral segment, that nearer the corner of the mouth, from 
its attachment to the superior maxillary bone. Only in extreme 
cases does it become necessary to detach the other flap as well. To 
separate the flap from the underlying bone one seizes its edge with 
a mouse-tooth forceps, and draws it inward toward the middle line, 
and forward, away from its attachment to the bone. In this way the 
fold of the mucous membrane which attaches the lip to the gum is 



OPERATIONS FOE, HARELIP, CLEFT PALATE, ETC. 



103 



put upon the stretch, and may be incised with the edge of the knife, 
cutting toward the bone (superior maxillary). This incision is car- 
ried sufficiently far and deep to liberate the lateral flap and the 




Fig. 49. — Wellenschnitt for Complete Harelip. Incision, carried around the 
alse of the nose in order to liberate the segments. Formation of flaps by in- 
cision into each segment. 

corresponding side of the nose and to allow of the parts being readily 
apposed without tension. Hemorrhage from this incision is often 
considerable, especially if it is necessary to cut deep, and this is 
given as one of the reasons for waiting in these cases, at any rate, 
until the third or fourth month (Trendelenburg). This hemorrhage, 
however, usually ceases when the sutures are inserted and compres- 
sion applied; still, any spurting vessels that are to be seen should be 
clamped aud ligated with fine catgut. 

Occasionally, in order to free the flap sufficiently it may be 
necessary to make an incision around the wing of the nose; this, 
however, is but seldom necessary (Dieffenbach's Wellenschnitt). The 
Mirault or the Hagedorn operation is usually done for this condition 
of complete harelip. 




Fig. 50.— Hagedorn Oper- Fig. 51. — Parts Freshened 
ation for Single Complete and Ready for Suture. 
Harelip. Lines of incision. 



Fig. 52.— Result After Su- 
ture. 



Hagedorn's operation consists in paring away the edges of each 
flap, first from the margin of the lateral flap, — that nearer the angle 
of the mouth, — and then from the margin of the other flap. A 



104 HEAD AND FACE. 

horizontal incision is then made into the substance of the lateral 
flap and an oblique one into the median flap. Then, with a scissors, 
the long strips of vermilion border which have been pared away from 
the edges of the flaps are snipped off. When the parts are sutured 
there is left a little process hanging from the edge of the lip; this 
retracts in time. 

Operation for Single, Complete Harelip Associated with Cleft of 
the Alveolar Process and Advancement of the Intermaxillary Bone. 
— In these cases the intermaxillary bone, besides being misplaced, 
may be rotated upon its long axis in such a way that it presents, 
anteriorly, a prominent, sharp edge, which would greatly interfere 
with the healing process. 

Under these circumstances it becomes necessary to place the 
bone in its natural position. An effort should be made, by twisting 
it upon its long axis, to set it square so that its sharp, lateral edge 
will not project under the suture line. If necessary, with the bone 
forceps or the chisel the process may be separated forcibly from its 
attachment to the alveolus and brought into position by rotating it 
partly upon its long axis. The vomer, to the front of which the 
intermaxillary is joined, may prevent this replacement, and then it 
may be wise to resect the prominent edge of the intermaxillary with 
a chisel or rongeur, but if we do this we lose an incisor tooth. These 
measures complicate the operation and occasion considerable hemor- 
rhage, and therefore it is often well, with this condition, to defer the 
operation in very young children. After the intermaxillary bone 
has been reduced or resected, closure of the split in the lip may be 
accomplished by any of the methods described above. 

Operation for Double Harelip without a Prominent Advanced 
Intermaxillary Bone. — The middle segment is always found to be 
too short to take part in the formation of the free border of the lip, 
but it may be used to form the middle portion of the lip. From the 
whole of the middle segment and from each lateral segment in part, 
the mucous membrane edge is trimmed away, and a Malgaigne flap 
then made from the edge of each lateral segment. One side may be 
done at a sitting, or one may, by freshening the lateral margins of 
the middle segment and the corresponding margins of the lateral 
segments, transform the condition into a double, incomplete hare- 
lip and later do a second operation to correct this. If the nose is 
flattened and the alse spread out, one should try to correct this 
deformity at the same time by separating the lateral segments of 



OPERATIONS FOR HARELIP, CLEFT PALATE, ETC. 



105 



the lips and the sides of the nose from their deep attachments. 
Instead of the Malgaigne, a double Hagedorn may be done for this 
condition. 

Operation for Double Harelip with Prominent Advanced Inter- 
maxillary Bone. — This may be remedied by resecting the bony part 
of the prominent intermaxillary portion, leaving the soft parts to 
assist in making the lip. The middle segment may be placed very far 
forward upon or near the point of the nose, in which case the cuta- 




'''■f/r/ r / , /7//>? r '' 



Fig. 
gaigne 
Double 



53. — Double Mal- 
Operation for a 
Complete Harelip. 
Paring of edges of defects 
and formation of flaps. 



''rf/r/wrffff 

Fig. 54. — Flaps Turned 
down ready for Suture. 



'''''//■/Orrrs/i'/r'*' 

Fig. 55.— Result After Su- 
ture. 



A « 




^rrrrrrrr''' 






''Trrrr/rrr' 


Parts Ready for 


Fig. 


58. 


-Result After Su 


Suture. 






ture. 



Fig. 56.— Hagedorn Oper- Fig. 57. 
ation for Complete Double 
Harelip. Paring and for- 
mation of flaps. 



neous part of the septum of the nose is absent (see Fig. 31). Under 
these circumstances the soft parts of the middle segment of the lip 
must be used to make the tegumentary part of the nasal septum, and 
then the whole lip must be formed from the two lateral segments 
without the assistance of the middle portion. It may be necessary 
to liberate the flaps by separating them from the alveolar process of 
the superior maxillary or, in addition to this, by making an incision, 
upon either side, around the ala of the nose (Wellenschnitt of Dieffen- 
bach). 



106 HEAD AND FACE. 

An attempt may be made to gradually force the intermaxillary 
segment into place by long-continued pressure. If this method is 
to be tried, the double cleft is closed after having first liberated the 
side flaps by an incision, on either side, around the wing of the nose 
(Dieffenbach's Wellenschnitt), and then an elastic band is applied which 
■exerts pressure, continuously, upon the middle segment. This band- 
age must we worn for a long time. 

Immediate forcible replacement of the intermaxillary portion 
may be done. It is seized with the forceps and broken away from the 
vomer, or the line of fracture may extend upward and backward 
through the vomer proper. The segment is then forced back into 
ju'oper position and the edges of the flaps freshened and sutured. 

Blandin recommends the resection of a triangular-shaped por- 
tion from the nasal septum posterior to the intermaxillary segment. 
The base of the triangular piece of bone which is thus resected 
corresponds in width to the space that intervenes between the mid- 
dle segment and the intermaxillary notch, its apex running upward 
into the septum of the nose. In young children this resection may 
be made with a pair of ordinary strong scissors, but in children 
over ten years of age it will be necessary to use the bone scissors. 
The apex of the resected triangular piece should be directed upward 
and forward, toward the bridge of the nose, in order to avoid the 
anterior palatine vessels. The intermaxillary segment may then 
be readily forced back into proper position and the cleft closed. If 
the anterior naso-palatine artery is cut in removing the triangular 
piece of bone, the hemorrhage will be severe. 

Bardeleben has modified the above procedure in that he first 
separates the periosteum, upon either side of the septum, behind the 
middle segment, and then, with the ordinary strong, straight scissors, 
simply cuts through the septum without attempting to resect a tri- 
angular piece. The middle segment is then pushed back into place, 
the edges of the divided septum sliding past and overlapping. 

As a rule, the attempt to replace the middle segment should 
be made during the first, second, or third year of the patient's life, 
because later the segment becomes too large and the corresponding 
intermaxillary space too small. 

Many surgeons make it a rule to excise the intermaxillary bone 
entirely, and indeed it is very questionable if anything is gained by 
leaving or replacing a deformed, misplaced middle portion. If it is re- 
moved, the four incisor teeth are lost, but a plate can be fitted to sub- 



OPERATIONS FOR HARELIP, CLEFT PALATE, ETC. 107 

■stitute for these. If the intermaxillary bone is allowed to remain and 
is replaced, it is very likely to remain rudimentary and wabbly, and the 
corresponding teeth are apt to be crooked and imperfect. If a con- 
siderable part of the septum of the nose has been removed, in order to 
place the intermaxillary portion in its normal position, the point of the 
nose will be drawn down so close to the front of the face as to give it a 
peculiar flattened, "bird-like" appearance. 

Operation for Cleft Palate. — The cleft may be limited to the 
soft or hard palate or may extend through both. 

The operation upon the soft palate is called staphylorrhaphy; 
that upon the hard palate, uranoplasty. At times cleft palate is 
combined with harelip. This latter condition may be remedied dur- 
ing the first few months of life, leaving the cleft in the palate until 
later: seventh to eighth year. Julius Wolff operates upon cleft 
palate earlier, during the second or third year, and this seems ad- 
visable. The operation for closure of a complete cleft may be done 
in two sittings: closure of the hard palate first and the soft palate 
subsequently at a second sitting. As a rule, however, it is preferable 
to close the entire cleft at one sitting. 

The operation is probably best done with the head in the Eose 
position, the patient lying upon the back, with the head hanging 
over the end of the table, and under complete anaesthesia (chloro- 
form). Some operators advise a preliminary tracheotomy with the 
introduction of a tampon cannula, or an ordinary tracheotomy tube 
may be introduced, in this latter case, packing the pharynx, in addi- 
tion, with a pad of gauze. Blood is thus prevented from entering 
the larynx, and the anaesthetic is administered through the trache- 
otomy tube. Even when these measures are resorted to, the Rose 
position is still preferable. The mouth, teeth, and nasal passages 
should be thoroughly cleansed and disinfected, and during the op- 
eration the mouth and nose may be frequently irrigated with a hot, 
saline solution, which cleanses the parts and checks hemorrhage. The 
corners of the mouth are retracted with curved retractors held by 
an elastic band fastened around the patient's neck. The jaws are 
held apart with a Smith or Whitehead gag, which not only holds 
the jaws open, but at the same time depresses the tongue. If this 
gag is used, the retractors for the side of the mouth may be dis- 
pensed with. Bleeding is controlled by pressure with hot pads on 
long sponge holders, and one should, at short intervals, interrupt 
the operation for this purpose; usually the hemorrhage is simply an 



108 HEAD AXD FACE. 

oozing from the cut edges. By carefully minimizing the loss of blood 
we are enabled, with safety, to operate upon quite young children: 
less than two years of age (Julius Wolff). 

Staphylorrhaphy. — Closure of a split in the soft palate. The 
first step of the operation consists in freshening the edges of the cleft. 
The free extremity of one side of the split uvula is seized with a long 
mouse-tooth forceps, and, while the uvula is thus held taut, it is 
transfixed, near its tip, which is steadied in the grasp of the forceps, 
with a narrow-bladed, sharp-pointed, double-edged knife, and with a 
sawing motion a thin strip is cut away from its margin; the edge 
is pared along the entire extent of the split toward the posterior 




Fig. 59.— Whitehead Gag and Tongue Depressor in Place. For operations 
upon the hard and soft palate. 



border of the hard palate. The opposite edge is then freshened 
in a like manner and the strips finally cut away from the tip of the 
uvula. Care should be taken to freshen the angle of the split. The 
strips should be so cut that the freshened margins present a beveled 
edge, more tissue being taken away from the buccal than from the 
nasal aspect of the soft palate, as this gives us broader surfaces for 
suture. The freshening of the margin of the split may be done with 
long, narrow-bladed scissors instead of with the knife. After the 
edges have been freshened, one should, with sharp tenacula, attempt 
to appose the raw edges in order to estimate what degree of tension, 
if any, exists. It is absolutely necessary that there be no tension 
whatever. In order to overcome tension of the soft palate a liberat- 



OPERATIONS FOR HARELIP, CLEFT PALATE, ETC. 109 

ing incision may be made upon either side. These incisions are made 
with a narrow-bladed, double-edged knife, which is introduced just to 
the inner side of the hamular process. This process, which is located 
behind and internal to the last molar tooth, is very readily felt. 
These incisions pass through the entire thickness of soft palate, from 
behind forward, and divide the tendons of the levator and tensor 
palati as they turn around the hamular process to spread out into 
the soft palate. One may wait with these incisions until after the 
soft palate has been sutured, since they may not be necessary, espe- 
cially if care has been taken to thoroughly detach the soft palate 
from the posterior border of the hard palate and also from the 
adjoining portion of the pterygoid process, which corresponds to the 
most external portion of the posterior border of the hard palate. 
If this separation is thorough, the two halves of the soft palate may 
be readily approximated without tension, and the liberating incisions 
can then be dispensed with (Julius Wolff). Even when the cleft is 
limited to the soft palate, one may with advantage raise a muco- 
periosteal flap, as when closing clefts of the hard palate; so that, 
working underneath this flap, close to the surface of the bone, the 
soft palate may be completely separated from the posterior border 
of the hard palate. This may be done with a periosteum elevator 
bent upon itself near the end to almost a right angle. 

To unite the freshened edges of the soft palate a small, short, 
surgeon's needle with a moderate curve or a short, straight needle 
may be used. The needle is carried in a long needle holder, and as 
it pierces the tissues its end may be seized with an artery forceps 
for the purpose of withdrawing it. A combination needle and holder 
in one piece is preferred by some surgeons. 

The stitches, which may be of silk, silk-worm gut, or silver wire, 
are introduced from before backward, and are not tied until they 
are all placed. Instead of tying the sutures they may be fixed with 
perforated shot. To prevent the suture ends becoming confused 
one may confine them temporarily, until ready to tie them, in in- 
cisions cut in a piece of cardboard. From four to five sutures are 
required, and they should be placed about one-fourth inch apart. 
The edges of the soft palate should be accurately apposed without 
tension and free from hemorrhage. 

Uranoplasty. — Closure of clefts of the hard palate. The op- 
eration of Langenbeck as described by him in 1862. This condition 
is usually associated with cleft of the soft palate, in which case both 



110 HEAD AND FACE. 

should be closed at the same time. The tip of one side of the uvula 
is seized with a long, mouse-tooth forceps and transfixed as described 
above. The paring process is carried forward as far as the poste- 
rior border of the hard palate and then continued along the margin 
of the cleft in the hard palate, close to its edge, cutting through the 
muco-periosteal covering down to the surface of the bone, as far as 
the anterior limit of the cleft. Upon the other side, beginning,, 
again, behind, near the tip of the soft palate, the margin of the 
cleft in the soft palate and in the hard palate is freshened in a 
similar manner. During this step of the operation one should pause- 
occasionally for a few minutes and apply steady, firm pressure with 
a hot pad in order to control the bleeding. 

The next step of the operation is the raising of a muco-periosteal 
flap from the surface of the hard palate upon either side of the 
cleft. An incision, corresponding to the length of the cleft, is made 
upon the surface of the hard palate and close along the inner margin 
of the alveolar process. This incision usually extends from a point 
anteriorly, behind the incisor teeth, to a point posteriorly, beyond 
the last molar tooth. In making this incision we should remember 
the point where the posterior palatine artery emerges from the canal 
in the back part of the palate, and place the incision fairly close to 
the alveolar process so that this vessel may be left in the flap to 
nourish it and also in order that we may avoid the hemorrhage that 
would follow its division. Many surgeons claim that it is a matter of 
indifference whether this vessel is cut or not, as the flap is nourished 
just the same in either case and that the resulting hemorrhage is read- 
ily controlled by pressure; nevertheless one should try to avoid divid- 
ing it. Into this incision a sharp periosteum elevator is introduced, — 
it may be narrow and rather bent near the end, — and with this the 
muco-periosteal layer is lifted away from the surface of the bone and 
thus made freely movable so that it can be brought over to meet the 
edges of the flap on the opposite side. Care should be exercised to 
separate thoroughly the soft palate from the whole posterior border of 
the hard palate. This is accomplished by working close to the surface 
of the bone with a periosteum elevator bent upon itself. If this 
detachment of the soft palate is thorough, it will, in nearly all in- 
stances, do away with the necessity for liberating incisions, etc. 

The apposed edges of the cleft are now sutured together, com- 
mencing in front, behind the incisor teeth, and working backward, 
completing the operation by uniting the edges of the soft palate. As 



OPERATIONS UPON THE LIPS. 



Ill 



already mentioned, the sutures are not tied until after they have 
all been placed. The raw space left on either side of the hard 
palate after raising the muco-periosteal flaps is packed. 

Ordinarily the sutures may he removed after six days. The 
mouth and nose should be irrigated and washed out frequently both 
during and subsequent to the operation. If a preliminary trache- 
otomy has been performed the mouth may be packed, the patient 
breathing freely through the tracheotomy tube. The original defect 
of the hard palate is closed ultimately by bone produced from the- 
periosteal surface of the flaps. 




Fig. 60. — Repair of Cleft Palate. Muco-periosteal flaps raised and edges 
of cleft in hard and soft palate pared. Sutures all introduced and ready for 
tying. 



OPERATIONS UPON THE LIPS. 

Excision of the Whole Lower Lip. — This operation is done for 
malignant disease. At times the angle of the mouth is involved 
and the upper lip is also encroached upon, so that it becomes neces- 
sary, in addition to excising the lower lip, to excise a triangular 
portion of the upper lip. The cutting is done with a scissors, and 
during the operation the bleeding is controlled by compression with 
the fingers. If the jaw-bone is involved in the disease one may resect 
the diseased portion with the chisel or saw, but should leave, if pos- 
sible, a bridge of bone sufficient to preserve the continuity of the 
jaw. 



112 



HEAD AKD FACE. 



Restoration of the Lower Lip After Excision of a Wedge-shaped 
Portion. — After the whole lower lip has been removed, the triangular- 
shaped defect that remains may, in many cases, be remedied by sim- 
ply drawing the edges of the wound together. The edges of the 
wound may be united with several sutures of rather heavier silk 
which go through the entire thickness of the lip down to, but not 
including, the mucous membrane, and these may be placed so as 
to control the hemorrhage at the same time. There are then applied 
additional sutures of finer silk that bring the edges of the wound 
accurately together. As a result, we have a small, rounded, puck- 
ered opening, representing the mouth, which is formed entirely from 







Fig. 61.— Excision of Entire Lower 
Lip, with Resulting Triangular De- 
fect. 



Fig. 62.— Triangular Defect in Lower 
Lip Closed by Suture. 



the upper lip, but this regains an appearance very much like normal, 
after six to eight months. 

Formation of the Lower Lip After Complete Excision. Dieffen- 
bach-Jaesche Method. — To remedy a triangular defect in the lower 
lip. In estimating the area of the flaps required one should allow 
one-third for shrinkage. 

From each corner of the mouth an incision is carried outward 
and somewhat upward into the cheek for a sufficient distance to 
close the defect in the lip, allowing one-third for shrinkage. From 
the end of each of these incisions a second curved incision is then 
carried downward and inward toward the chin so as to terminate 
near the lower border of the jaw and under the angle of the mouth. 



OPERATIONS UPON THE LIPS. 113 

Stenson's duct should be avoided in making these flaps. This second 
incision, being curved, makes the flaps more movable. The mucous 
membrane, corresponding to that part of the incision that reaches 
outward from the corner of the mouth, should be cut upon a higher 
level than the skin in order thus to obtain a mucous membrane flap 
which may be sutured to the edge of the skin to form the free border 
of the new lower lip. For the rest of its extent the incision goes 
through the skin and mucous membrane upon the same level. The 
two flaps are now separated from the lower jaw, avoiding, as far as 
possible, cutting the fold of mucous membrane that is reflected from 
the inner surface of the lips to the gums. If the flaps are not suffi- 
ciently movable to bring them together, the incisions may be pro- 




Fig. 63. — Dieffenbach-Jaesche Operation for Restoring Lower Lip. Dotted 
lines represent the edges of the mucous membrane, which is cut long in order 
to cover over the free margin of the new lip. The edges of the flaps are 
drawn together and the mucous membrane, which was cut long, is sewed 
over the free edge of the new lip. The defect upon each side caused by the 
sliding of the flaps is closed by suture. 

longed downward beyond the lower border of the jaw into the neck 
and the flaps loosened still farther from the lower jaw. The edges 
of the flaps are then united with interrupted silk sutures which in- 
clude the whole thickness of the lip down to, but not including, the 
mucous membrane. A second set of intermediate silk sutures brings 
the edges of the skin and mucous membrane into accurate apposi- 
tion. Corresponding to the free border of the new lip, the edges 
of the mucous membrane flaps, which were intentionally cut long, 
are sutured to the skin. Finally the semilunar defects upon either 
side are closed with sutures. In the male the scar is hidden by the 
beard. 

Beuns Method. — For a quadrangular defect of the lower lip. 
A square cornered flap is taken from either side of the face, includ- 



114 



HEAD AND FACE. 



ing the whole thickness of the cheek, and these are turned down 
into the defect through an angle of ninety degrees. These flaps 
have a good blood-supply. Avoid Stenson's duct. The apposed 




Fig. 64.— Bruns Method of Restoring 
the Lower Lip. Dotted lines indicate 
that the mucous membrane is cut 
longer than the skin in order to pro- 
vide a mucous membrane border to the 
new lip. 




Pig. 65.— Flaps Turned down and 
Joined to Form New Lip. Mucous 
membrane is sutured over the free 
margin of the new lip. The defect 
upon each side of the cheek is closed 
by suture. 



edges of the flaps are united and the mucous membrane sutured to 
the edge of the skin to form the free margin of the new lip. The 
lateral defect on either side is then closed. The scars that result are 
upon the cheek. 





Fig. 66.— Langenbeck Method of Re- 
storing the Lower Lip. An oval nap is 
taken from the region of the chin. 



Fig. 67.— Oval Flap is Raised and Su- 
tured into Place and the Defect thus 
Closed. 



Langenbeck's Method. — Formation of the lower lip for oval 
defect. A long, rounded flap is taken from the region of the chin 
with its base directed upward and outward. Between the upper 



OPERATIONS UPON THE LIPS. 



115 



border of the flap which is thus marked out and the lower margin 
of the defect there is a triangular tongue of tissue. This tongue of 
tissue is partly loosened from its attachment to the underlying tis- 
sues. The long flap is raised from the underlying parts and shoved 
upward, filling in the defect in the lip, and the triangular tongue 
of tissue is brought under it. These flaps are fixed in their new 
position with sutures. The whole defect may be closed over if the 
flaps are sufficiently detached. The great disadvantage of this 
method is that the new lip, upon its free edge and posterior surface, 
is not covered by mucous membrane, and shrinks and contracts as 
it cicatrizes. 





Pig. 6S.— Estlander's Method of Re- 
storing the Lower Lip After Partial 
Excision. A triangular flap is taken 
from the upper lip and cheek. 



Fig. 69. — The Triangular Flap is 
Turned down and Sutured in Place, 
thus Closing the Defect. 



Estlandek's Method. — As large a defect as that left after 
excision of three-fourths of the lower lip may be covered by this 
method. An incision is made reaching from the corner of the mouth 
upward, through the whole thickness of the cheek, to the level of the 
infra-orbital foramen and then downward, past the wing of the nose, 
toward the philtrum, to a point close to the carmine border of the 
upper lip. If the coronary branch of the facial artery is not divided, 
the flap will be well nourished. The flap is then turned down into 
the defect in the lower lip through an angle of one hundred and 
seventy degrees. One may feel the pulsating coronary artery before 
cutting the flap and should positively avoid severing it. 

The resulting deformity is bad, the mouth one-sided, the corner 
of the mouth corresponding to the philtrum. In order to correct this 
feature one might, subsequently, do another operation, extending the 



116 



HEAD AND FACE. 



corner of the mouth outward, but it would be necessary to wait at least 
six weeks, in order to insure a good blood-supply, before undertaking 
this second operation; otherwise there would be danger of gangrene. 
Without doubt this deformity will, in time, correct itself to a consider- 
able degree, so that the secondary operation may not be necessary. 




WD 



Fig. 70. — Dieffenbach Wellenschnitt for 
Restoration of the Upper Lip. An in- 
cision (WD) is carried around each side 
of the nose, extending through the 
cheek. 




Fig. 71.— The Flaps are Liberated 
from the Upper Jaw-bone and are 
Drawn Down into Place and Sutured. 
The raw space upon either side of the 
nose is closed with suture. 



Restoration of the Upper Lip. — Eestoration of the upper lip is 
not often required, as this part is but rarely the seat of disease that 
calls for its excision. 




Fig. 72.— Bruns Method of Restoring 
Upper Lip. A square flap taken from 
either cheek. 



Fig. 73. — Flaps are Turned down into 
Place and Sutured. Defect in either 
cheek is closed with sutures. 



Estlander's Method may be used to close a wedge-shaped 
defect in the upper lip, the flap being taken from the lower lip. 

Dieffenbach's Wellenschnitt. — A curved incision is made 
through the whole thickness of the cheek around the corner of the 



OPERATIONS UPON THE LIPS. 117 

nose. The flaps which are thus marked out are separated from the 
maxillae and then drawn toward the middle line and turned down, 
so that the raw edges of the original defect become the free border 
of the new lip. The two flaps are then united and the edges of the 
mucous membrane and skin sutured together along the free margin 
of the new lip. The mucous membrane corresponding to this margin 
may be cut a little longer than the skin, in order to facilitate the 
union of these edges. After uniting the flaps in the middle line the 
edges of the defect around the side of the nose may be brought 
together with sutures. 

Small, wedge-shaped defects may be closed by simple suture, 
if necessary, combining this with detachment of the cheek by Dief- 
fenbach's Wellenschnitt. 

Beuns Method may also be used to restore the upper lip after 
its complete excision. 



PART III. 

NECK AND TONGUE. 



SURGICAL ANATOMY OF THE NECK. 

The neck is the constricted part of the body that joins the head 
to the trunk. The spinal column passes through the posterior part 
of the neck, inclosing within its canal the spinal cord. The anterior 
part of the neck is made up of important organs and of channels 
that pass between the head and the trunk. 

The Deep Cervical Fascia. — This is an aponeurotic layer that 
serves to bind the structures that comprise the neck, into a com- 
pact, cylindrical mass. This fascia offers a strong barrier to the 
extension of superficial suppurative processes into the deeper parts 
of the neck, and at the same time hinders, to a considerable degree, 
the sjjontaneous evacuation, externally, of pus which is located deep 
in the neck. 

Anteriorly, between the edges of the sterno-mastoid muscle, the 
deep cervical fascia covers the depressor muscles of the hyoid bone — 
the sterno-hyoid, sterno-thyroid, and omo-hyoid. Upon the side of 
the neck it is found beneath the sterno-mastoid, and may be traced 
from the posterior border of this muscle backward across the poste- 
rior triangle of the neck and beneath the trapezius muscle, where 
it serves to bind the long muscles of the neck to the vertebral 
column. 

Above, the deep cervical fascia is attached to the lower border 
of the jaw and to the back of the skull, and, below, to the upper 
border of the sternum, the clavicle, the spine of the scapula, and 
the spinous process of the seventh cervical vertebra: vertebra prom- 
inens. In the middle line of the neck, behind, the deep cervical 
fascia is blended with the ligamentum nucha?, which is prolonged 
deep into the neck to be attached to the tips of the spinous processes 
of the cervical vertebras. The deep cervical fascia is firmly attached 
to the body and horns of the hyoid bone. 

Anteriorly, between the edges of the sterno-mastoid muscles, 
the deep cervical fascia covers the depressor muscles of the hyoid 
bone, and consists of two layers, the anterior of which is attached 
(118) 




Fig. 74. — Section through the Neck, Level of Sixth Cervical Vertebra, to Show Arrangement 
of the Deep Cervical Fascia (Indicated in Red) . BP, trunks of brachial plexus ; C, complexus 
muscle ; EJ, external jugular vein ; ES, oesophagus ; LA, levator anguli scapula? muscle ; OH, 
omo-hyoid muscle: P, platysma muscle; PV, pravisceral space; RV, retrovisceral space; S, 
S', splenius capitis et colli muscle ; SA, scalenus amicus muscle ; SC, semispinalis colli muscle; 
SH, sterno-hyoid muscle ; SM, scalenus medius muscle ; SS, suprasternal space ; ST, sterno- 
thyroid muscle ; ST.M., sterno-mastoid muscle ; SY, sympathetic nerve ; TP, trapezius muscle ; 
TR, trachea ; TY, thyroid gland; V, vertebral artery and vein; VAN, internal jugular vein, 
carotid artery, and pneumogastric nerve inclosed in a mass of loose connective tissue. 



SURGICAL ANATOMY OF THE NECK. 119 

to the anterior and the posterior to the posterior margin of the 
upper border of the sternum. Between the two layers there is a 
space known 'as the suprasternal space, which contains some fat, 
lymphatic tissue, and a venous branch, the anterior jugular, that 
enters the external jugular beneath the attachment of the sterno- 
mastoid. 

The suprasternal space extends upward almost as far as the 
hyoid bone and laterally as far as the anterior edge of the sterno- 
mastoid muscle. 

A suppurative process in this space is pretty effectively shut off 
from the deep parts of the neck by the posterior layer of the deep 
cervical fascia. 

In the front part of the neck, below the level of the hyoid bone, 
the pharynx and oesophagus and the larynx and trachea are bound 
together in a single bundle by a layer of fascia that completely en- 
velops them; the thyroid gland is also included within this sheath 
of fascia and is fixed by it to the trachea. Another layer of fascia 
forms a sheath for the muscles that are contiguous to the vertebral 
column: anteriorly, the recti and longus colli; laterally, the scaleni, 
cords of the brachial plexus, and the levator anguli scapulae; poste- 
riorly, the splenius, complexus, etc. 

Above the hyoid bone the deep cervical fascia reaches from the 
body of the jaw-bone to the hyoid bone. The submaxillary gland, 
surrounded by a mass of loose connective tissue, is lodged in the 
submaxillary triangle, beneath the deep cervical fascia. 

Connective-Tissue Spaces Beneath the Deep Cervical 
Fascia. Prcevisceral Space. — This space corresponds to a mass of 
loose connective tissue that is situated in front of the trachea and 
thyroid gland and beneath the deep cervical fascia and depressor 
muscles of the hyoid bone. 

If an opening is made in the deep fascia and a probe introduced 
into this space, it may be readily forced down into the mediastinum, 
and a collection of pus in this space may readily gravitate along the 
same route into the mediastinum with fatal results. 

Retrovisceral Space. — This is the recess between the pharynx 
and oesophagus in front and the vertebral column behind; it reaches 
from the base of the skull down into the chest. Pus in this space 
may readily find its way down along this path into the chest. 

Vascular Space. — Upon either side of the pharynx and oesoph- 
agus and the larynx and trachea the carotid artery and its adjoining 



120 NECK AND TONGUE. 

structures are found. These structures, beside the carotid artery, 
consist of the internal jugular vein and pneumogastric nerve, sym- 
pathetic nerve, and loop formed by the descendens and communicans 
noni. These structures are not provided with a distinct sheath, but 
are lodged in a mass of loose connective tissue, which may be traced 
all the way down into the thoracic cavity. 

Suppuration may spread along the course of these structures, — 
for example, the internal jugular vein, — and thus invade the chest 
cavity. 

The Back of the Neck. — This region of the neck corresponds to 
the cervical portion of the trapezius muscle. It is limited above by 
the occipital protuberance and superior curved line of the occipital 
bone, below by the vertebra prominens, and upon the sides by the 
edges of the trapezius muscle. 

The skin of this region is intimately united with the subcuta- 
neous connective tissue, which is very dense and is marked by hair- 
follicles and sebaceous glands. Inflammatory processes which attack 
the structures of the skin in this region show but little tendency 
to spread and are excessively painful (carbuncles). 

This region presents two longitudinal, rounded swellings — one 
on either side of the middle line — which correspond to the trapezius 
muscle. Between these, in the middle line, is a depression marked 
by the spinous processes of the cervical vertebras. The spinous 
processes of the cervical vertebras are short and not distinctly felt, 
except the lower ones; that of the seventh, the vertebra prominens, 
is especially prominent. They are joined together by a dense, liga- 
mentous band, — the ligamentum nuchas, — which is continued upward 
as far as the external occipital protuberance. The cervical portion 
of the vertebral canal is roomy and contains the spinal cord. This 
part of the vertebral column lies at a considerable depth from the 
surface, and is well protected by the overlying muscles. 

The Side of the Neck. — This region is quadrilateral; bounded 
above by the lower border of the jaw-bone and an imaginary line 
drawn from the angle of the jaw to the mastoid process; below, by 
the clavicle; in front, by the middle line of the neck; and, behind, 
by the anterior border of the trapezius. It is divided into two tri- 
angles — an anterior and a posterior — by the sterno-mastoid muscle. 

The sterno-mastoid muscle is a most important surgical land- 
mark. It is attached above to the mastoid process and the adjacent 
part of the occipital bone; below, to the inner end of the clavicle 



SURGICAL ANATOMY OF THE NECK. 121 

and the upper end of the sternum. This muscle not only divides 
the side of the neck into an anterior and a posterior triangle, hut, 
being a broad muscle itself, covers important structures not seen in 
either of the triangles; therefore in addition to the triangles one 
might well describe a sterno-mastoid region. 

The side of the neck is covered by the skin, beneath which the 
subcutaneous fat and superficial fascia are found, and, beneath these, 
there is a broad, thin, muscular layer: the platysma. This muscle, 
which is spread out in a thin sheet, extends from the lower border 
of the inferior maxilla downward and backward, being continued 
downward beyond the clavicle, where it is blended with the subcu- 
taneous tissue of the upper part of the chest. The platysma is inti- 
mately united with the skin, and together with it is freely movable 
upon the parts which lie beneath it and with which it and the skin 
are united by loose connective tissue. It will be observed that the 
platysma does not cover the anterior portion of the neck in the 
laryngeal and tracheal regions. 

Beneath the superficial fascia and the platysma — i.e., between 
these and the deep cervical fascia — are found the external and ante- 
rior jugular veins together with some nervous branches which are 
derived from the cervical plexus and from the facial. 

The External Jtjgulak Vein, during efforts of straining and 
in conditions of obstructed venous return, may become distended 
and sufficiently prominent to be recognized beneath the skin. This 
vessel is formed above, behind the angle of the jaw, by the junction 
of the posterior auricular vein and the posterior branch of the tem- 
poro-maxillary vein; it passes straight down the side of the neck, 
crossing the sterno-mastoid muscle from its anterior to its posterior 
border, and, below, pierces the deep cervical fascia, just above the 
clavicle and behind the attachment of the sterno-mastoid to this 
bone, to empty into the subclavian. After it pierces the deep cervical 
fascia and before it terminates in the subclavian, which it does just 
external to the tendon of the scalenus anticus, it receives the supra- 
scapular, transverse cervical, and anterior jugular veins. 

The Anterior Jugular Vein. — This is formed in the hyoid 
region by the junction of several veins from the upper anterior part 
of the neck, and passes downward, anterior to the.edge of the sterno- 
mastoid muscle, between the superficial fascia and platysma and the 
deep cervical fascia; in the lower part of the neck it pierces the 
anterior layer of the deep cervical fascia in front of the sterno- 



122 NECK AND TONGUE. 

mastoid and then passes backward, beneath this muscle, through 
the suprasternal space, to join the external jugular just before this 
vessel enters the subclavian. The external and anterior jugular 
veins are often cut in making incisions in the neck, but may be 
readily clamped and ligated or they may be recognized and ligated 
before they are cut. 

The Nerves that are found in this part of the neck beneath 
the superficial fascia and platysma are some superficial ascending 
and descending branches of the cervical plexus and descending 
branches from the facial; these, however, are of no special surgical 
importance. 

The Anterior Triangle. — The base of this triangle is above, 
and corresponds to the lower border of the jaw and an imaginary line 
drawn from its angle to the mastoid process. Its apex is below at 
the sterno-clavicular articulation; its posterior border is formed by 
the anterior edge of the sterno-mastoid muscle, and its anterior 
boundary is indicated by the middle line of the neck. 

The anterior triangle is subdivided into an upper and a lower 
triangle by the anterior belly of the omo-hyoid; this is a thin, double- 
bellied muscle that swings obliquely across the side of the neck, 
being attached above to the hyoid bone and below and behind to the 
upper border of the scapula. The lower triangle is called the in- 
ferior carotid, and the upper, the superior carotid triangle. The 
anterior triangle presents, in its upper part, a third triangular space: 
the submaxillary triangle. 

The Posterior Triangle. — This is the reverse of the anterior 
triangle. Its apex is above at the mastoid process; its base, below, 
is formed by the clavicle; its anterior border corresponds to the 
posterior edge of the sterno-mastoid muscle and its posterior border 
to the anterior edge of the trapezius. The posterior triangle is sub- 
divided by the posterior belly of the omo-hyoid into two: an upper 
or occipital triangle, and a lower or subclavian triangle. In order 
to demonstrate these triangles it is necessary to draw the posterior 
belly of the omo-hyoid a little upward, as it usually lies pretty near 
the clavicle, being fixed in this position, to the first rib, by a slip 
of the deep cervical fascia. 

Since the sterno-mastoid, as already mentioned, is not a line, 
but a muscle of considerable breadth and covers structures of im- 
portance, one might describe, besides these triangular spaces lying 
in front of and behind the sterno-mastoid muscle, a "sterno-mastoid" 



SUEGICAL ANATOMY OF THE NECK. 123 

region, and we will proceed to do this at once and thus dispose of 
it, and then consider the triangles more in detail. 

The Steeno-mastoid Eegion. — The sterno-mastoid region is. 
covered by the skin and fat (superficial fascia) and to a considerable 
extent by the platysrna. After removing these layers we come down 
upon the surface of the muscle covered by the deep portion of the 
superficial cervical fascia. The fibers of the muscle have an oblique 
direction from above downward and forward, and it is crossed from 
above downward by the external jugular vein. 

To examine the structures that lie beneath the sterno-mastoid, 
we may divide the muscle through its middle and reflect either end. 
Then, after cutting through the deep cervical fascia, there are ex- 
posed the deep muscles which lie beneath the sterno-mastoid and 
which are connected with the vertebral column, the longus colli, 
scaleni, levator anguli scapulas, etc., the cervical plexus of nerves, 
the carotid vessels, internal jugular vein, etc., and numerous lym- 
phatic glands. 

The Lstfeeioe Cabotid Teiangle. — This triangle is bounded 
in front by the middle line of the neck, above and behind by the 
anterior belly of the omo-hyoid, below and behind by the anterior 
border of the sterno-mastoid. " 

This triangle contains the larynx, trachea, thyroid gland, and 
oesophagus. These structures are partly covered over and concealed 
by the sterno-hyoid, sterno-thyroid, and thyro-hyoid 1 muscles. 

The oesophagus, which projects well beyond the left border of 
the trachea, is more accessible in the left triangle than in the right. 
Ascending in the recess between the trachea and the oesophagus is 
the recurrent laryngeal nerve; this nerve enters the larynx between 
the thyroid and cricoid cartilages, behind the articulation of these 
two cartilages. Lying to the outer side of these structures (larynx, 
trachea, and oesophagus) are the common carotid artery, with the 
internal jugular vein upon its outer side, and the pneumogastric 
nerve between them, but on a plane posterior. The middle thyroid 
vein passes outward across this space to enter the internal jugular 
vein, passing across the front of the common carotid artery to reach 
its destination. 

In this triangle the common carotid artery and the internal 
jugular vein lie beneath the anterior border of the sterno-mastoid 



1 The thyro-hyoid is really the continuation of the sterno-thyroid. 



124 



NECK AND TONGUE. 




Fig. 75.— Side of Neck to Show Triangles. DA, anterior belly of the 
digastric; DP, posterior belly of the digastric; EJ, external jugular vein; 
F, facial vein; HO, hyo-glossus muscle; BY, hypoglossal nerve; IJ, internal 
jugular vein; M.H, mylo-hyoid muscle; OH A, anterior belly of the omo- 
hyoid; OHP, posterior belly of the omo-hyoid; PA, post-auricular vein; PJ, 
posterior jugular vein; 8 A, scalenus anticus muscle; 80, subclavian artery; 
8.TY, sterno-thyroid muscle; T, temporal vein. 



SURGICAL ANATOMY OF THE NECK. 125 

muscle, which is the guide to them and which must be drawn out- 
ward (backward) in order to expose them. Lying still deeper in this 
part of the neck, beneath the carotid artery and the internal jugular 
vein, are the inferior thyroid artery, which passes inward and upward 
behind these vessels to reach the lower part of the thyroid gland, 
and the vertebral artery, which enters the foramen in the root of 
the transverse process of the sixth cervical vertebra. The sympa- 
thetic nerve is also found deep in this space behind the carotid 
vessels, resting upon the muscles which cover the front of the ver- 
tebral column, and in this situation it presents its middle cervical 
ganglion. 

The Superior Carotid Triangle. — This space is bounded 
behind by the anterior border of the sterno-mastoid, above and in 
front by the posterior belly of the digastric and the stylo-hyoid, and 
below and in front by the anterior belly of the omo-hyoid. The 
floor of this space is formed by the constrictor muscles of the phar- 
ynx and the thyro-hyoid and a part of the hyo-glossus muscles. It 
contains the upper part of the common carotid artery and its bifur- 
cation into the internal and external carotids, which division occurs 
upon a level with the upper border of the thyroid cartilage. The 
internal jugular vein lies in close contact with the outer side of the 
common carotid artery and its continuation, the internal carotid; 
and the pneumogastric nerve still holds its place between the artery 
and vein, but on a plane posterior to both. 

The vessels in this triangle are superficial, not being covered 
by the anterior edge of the sterno-mastoid, but lying anterior to it. 
The edge of the muscle is here also the guide to the vessels. A 
chain of lymphatic nodes is located along the front border of the 
sterno-mastoid muscle, and some of them are in very close proximity 
to the internal jugular vein. 

In this triangle, the external carotid, as it ascends to a point 
behind the angle of the jaw, describes a slight curve with the con- 
vexity forward, and lies rather beneath the posterior belly of the 
digastric and stylo-hyoid and upon a plane anterior to the internal 
carotid, giving off several important branches: among them the 
superior thyroid, which passes to the upper part of the thyroid 
gland; the lingual, which passes forward beneath the hyo-glossus 
muscle to supply the tongue; and the facial, which passes upward 
and outward over the lower border of the jaw. The occipital and 
the posterior auricular are derived from the posterior aspect of the 



126 NECK AND TONGUE. 

external carotid artery and ascend in a direction upward and back- 
ward. 

The hypoglossal nerve arches forward across the external carotid 
artery upon a level with the origin of the occipital artery. 

In this space the facial vein is joined by a large branch from 
the temporo-maxillary, and then passes downward and outward 
across the external carotid and internal carotid arteries to enter the 
internal jugular vein. This vein is often cut during extirpation of 
glands in this triangle and gives rise to a copious hemorrhage, which 
is readily controlled by pressure with the finger in the wound and 
artery forceps. It may often be recognized and tied double before it 
is cut. 

The Submaxillaey Teiangle. — The submaxillary triangle is 
bounded above by the lower border of the jaw and an imaginary line 
drawn from the angle of the jaw to the tip of the mastoid process, 
below and in front by the anterior belly of the digastric muscle, and 
below and behind by the posterior belly of the digastric and the 
stylo-hyoid muscle. The apex of the triangle corresponds to the 
attachment of these muscles to the hyoid bone. When the coverings 
of this triangle — consisting of the skin, subcutaneous fat, platysma, 
and deep fascia — are reflected, we find it fairly well occupied by the 
submaxillary gland, which rests in a bed of loose connective tissue,, 
and various lymph-nodes. The back part of this triangle is crossed 
by the facial artery, which passes upward and forward over the upper 
border of the submaxillary gland to reach the lower border of the 
jaw, over which it curves on to the side of the face, grooving the 
bone just in front of the attachment of the masseter muscle. The 
facial vein, which lies superficial to the facial artery, after receiving 
the submental vein, also crosses the posterior part of the submaxil- 
lary triangle, passing downward and backward across (superficial to) 
the posterior belly of the digastric and stylo-hyoid muscles and, after 
uniting with a large branch from the temporo-maxillary vein in the 
upper part of the superior carotid triangle, enters the internal 
jugular. 

After the submaxillary gland has been raised out of its bed, its 
duct, Wharton's, may be seen passing forward beneath the posterior 
edge of the mylo-hyoid muscle to open anteriorly in the floor of the 
mouth. The gland may be isolated and cut away from its duct, and 
then" the floor of the triangle is exposed to view. The floor of the 
triangle is formed, for the most part, by the mylo-hyoid muscle, 



SURGICAL ANATOMY OF THE NECK. 12? 

whose fibers have an oblique direction, and the hyo-glossus, which 
lies upon a deeper plane than the mylo-hyoid and forms the posterior 
part of the floor of the triangle; the fibers of the hyo-glossus muscle 
run straight up and down from the hyoid bone to the under surface of 
the tongue. The lingual artery lies beneath the hyo-glossus muscle. 
The submental branch of the facial artery passes forward parallel 
with and close to the inner surface of the body of the jaw, resting 
upon the mylo-hyoid muscle. The hypoglossal nerve may be seen 
passing forward, entering the submaxillary triangle from beneath the 
posterior belly of the digastric muscle. In the triangle this nerve 
rests upon the hyo-glossus muscle, disappearing anteriorly beneath 
the posterior border of the mylo-hyoid muscle. Accompanying the 
hypoglossal nerve is the lingual vein, which passes backward and 
enters the facial. 

The hypoglossal nerve forms the base of a second smaller tri- 
angle, which corresponds to the apex of the submaxillary triangle 
and which is called the lingual triangle. 

The Lingual Teiangle. — The base of the lingual triangle, 
which is above, is formed by the hypoglossal nerve; its borders, 
anterior and posterior, by the respective bellies of the digastric. 
The apex of the triangle is located beloAV where this muscle is at- 
tached to the hyoid bone. The floor of the triangle is formed by 
the fibers of the hyo-glossus muscle. Directly beneath this muscle, 
in the space marked out as the lingual triangle, the lingual artery 
is located, and in this situation it is very readily found and ligated. 
The hyo-glossus muscle is picked up with mouse-tooth forceps and 
snipped through, when the lingual artery comes into plain view and 
may be easily surrounded with a ligature in a carrier. 

The Occipital Triangle. — This space is bounded in front by 
the posterior border of the sterno-mastoid, behind by the anterior 
border of the trapezius, and below by the posterior belly of the omo- 
hyoid. This triangle is of but little surgical importance. It is cov- 
ered by the skin, superficial fascia (fat), by the platysma in part, 
and by the deep cervical fascia. Beneath the deep cervical fascia 
there is a mass of loose fat. Lying upon the deep fascia (superficial 
to it) is the posterior jugular vein, which, below, at the posterior 
border of the sterno-mastoid muscle, joins the external jugular. A 
chain of lymphatic nodes, which lie along the posterior border of 
the sterno-mastoid in this triangle, are frequently diseased and re- 
quire removal. The space is crossed by the superficial descending 



128 NECK AND TONGUE. 

branches of the cervical plexus. The spinal accessory nerve emerges 
from the posterior border of the sterno-mastoid, at the junction of 
its upper and middle thirds, and passes obliquely downward and 
backward across this space, beneath the deep cervical fascia, and 
disappears under the anterior border of the trapezius muscle, which 
it supplies. The floor of this space is formed, from above downward, 
by the splenius, the levator anguli scapulse, and the middle and 
posterior scaleni. 

The Subclavian" Triangle. — This triangle corresponds to the 
lower part of the posterior triangle. It is covered by the skin, fat, 
and superficial fascia, the platysma, and deep cervical fascia, and is 
crossed by the superficial descending branches of the cervical plexus. 
In the front part of this space, just behind the posterior border of 
the sterno-mastoid muscle, the external jugular vein pierces the deep 
cervical fascia. After the integument, etc., including the deep cer- 
vical fascia, have been incised, the boundaries of the subclavian tri- 
angle may be sought for. These are, below, the clavicle; in front, the 
posterior border of the sterno-mastoid muscle; and, above, the poste- 
rior belly of the omo-hyoid; this latter muscle lies low in the neck, 
close to the clavicle, and in order to demonstrate the triangle it may 
be necessary to draw it somewhat upward. 

Crossing the space from without inward, just above the clavicle, 
are the transversalis colli and suprascapular veins; these form a 
plexus beneath the deep cervical fascia and terminate in the ex- 
ternal jugular; the external jugular vein enters the subclavian 
just external to the tendon of the scalenus anticus. The external 
jugular vein, after piercing the deep cervical fascia and immedi- 
ately before it terminates in the subclavian, also, as a rule, receives 
the anterior jugular vein. This latter drains the front of the neck, 
originating above in the hyoid and suprahyoid regions. In the 
subclavian triangle there is also found (beneath the deep cervical 
fascia) a mass of lymphatic nodes, fat, and loose connective tissue 
which communicates with the lymphatics of the breast and axilla 
and which may become involved in disease of the breast. The floor 
of the subclavian triangle is formed by the scalenus anticus and 
scalenus medius muscles. In order to expose the scalenus anticus 
muscle, the sterno-mastoid, which conceals it, must be drawn forward 
(inward). When the scalenus anticus is thus exposed the phrenic 
nerve may be seen passing obliquely downward and inward across 
its anterior surface, descending into the chest across the front of 



SURGICAL ANATOMY OF THE NECK. 129 

the first part of the subclavian artery. Beneath the venous plexus 
above mentioned, and lying close upon the muscles that form the 
floor of the triangle, are the transversalis colli and suprascapular 
arteries: branches from the first part of the subclavian. Emerging 
from between the scalenus anticus and the scalenus medius and 
passing obliquely downward and outward are the three cords of the 
brachial plexus. They disappear beneath the clavicle into the axil- 
lary space. The third part of the subclavian artery is found below 
the cords of the brachial plexus, deep in the subclavian triangle, 
below the level of the clavicle, resting in the groove upon the upper 
surface of the first rib, external to the attachment of the tendon of 
the scalenus anticus. The tendon of the scalenus anticus is the 
guide to the artery, and is readily recognized in the inner or forward 
part of the subclavian triangle as a tense cord and may be followed 
downward with the finger as far as its attachment to the first rib. 
The subclavian vein lies some distance away from the artery in front 
of, and internal to it, the artery and vein being separated from each 
other by the tendon of the scalenus anticus. 

As the subclavian artery emerges from the chest it arches out- 
ward and forward to reach the first rib. That portion of the sub- 
clavian which lies behind the tendon of the scalenus anticus is the 
second part of the artery; the part which lies to the inner side of 
this tendon is the first part; and that which lies external to the 
tendon of the scalenus anticus, resting upon the upper surface of 
the first rib, is the third part of the artery: the part that is usually 
ligated. The second and first parts of the subclavian artery, the parts 
behind and internal to the tendon of the scalenus anticus, are in 
direct relation with the dome of the pleura and the apex of the 
lung, which projects upward into the root of the neck, beneath the 
scaleni muscles, for a distance of 3 to 3 1 / 2 cm. above the level of 
the clavicle. In tying the third part of the subclavian artery one 
should not mistake for it one of the cords of the brachial plexus, 
which lie above. The artery is deep, and rests directly upon the first 
rib. The subclavian vein is pretty well separated from the artery, 
lying in front of and internal to it and upon a rather lower level 
than the artery. By drawing the shoulder down we depress the 
clavicle, and may thus make the artery more accessible. 

The Front of the Neck. — This part of the neck may be divided 
into the suprahyoid region, the part above the hyoid bone, and the 
infrahyoid region, the part below the hyoid bone. The infrahyoid 



130 NECK AND TONGUE. 

region presents for consideration the larynx, trachea, and thyroid 
gland, and the oesophagus, which lies behind these. 

The Hyoid Bone. — This is a horseshoe- or IT- shaped hone, 
with a body and two lateral horns, which are prolonged backward, 
one on either side, and two lesser horns, directed upward. 

In the natural position of the head the hyoid bone is on a level 
with the lower border of the inferior maxillary bone, and is not dis- 
tinctly recognized until the head is thrown back. It is not station- 
ary, but may be said to be about opposite the fourth cervical ver- 
tebra. To it are attached numerous muscles, coming from different 
directions. To the upper surface of its body is attached the base or 
root of the tongue; from its lower border is suspended the larynx. 
The epiglottis is placed behind the body of the bone, and is attached 
to its posterior surface. To the upper surface of its lateral horn 
is attached the middle constrictor of the pharynx, and it thus serves 
to support the wall of the pharynx and provide a fixed point for 
the action of the muscles in deglutition. 

Supeahyoid Kegion. — This is the space between the hyoid bone 
and the lower border of the jaw. This region is covered with skin, 
superficial fascia (fat), platysma, and deep fascia; the deep fascia is 
attached to the body and cornua of the hyoid bone. Beneath the 
platysma, between it and the deep fascia, are several venous branches 
which go to form the anterior jugular. Upon removal of the deep 
fascia a triangular space is exposed: the submental triangle. The 
apex of this triangle corresponds to the symphysis of the* lower jaw, 
its sides to the anterior belly of either digastric, and its base to the 
hyoid bone. Its floor consists of the mylo-hyoid muscle, with its 
raphe in the middle line. This space contains, beneath the deep 
fascia, several lymphatic nodes, which are occasionally the seat of 
disease and may demand extirpation. Beneath the mylo-hyoid, upon 
either side, in the floor of the mouth, the sublingual glands are 
lodged. The floor of this space is, at times, cut through in opera- 
tions upon the lower jaw and in order to reach the tongue. 

Infrahyoid Eegion. — This is the region below the hyoid bone. 
The skin is but loosely attached to the underlying structures; be- 
neath the skin are fat and the deep cervical fascia. The platysma 
is not met with in this part of the neck. Below the hyoid bone may 
be felt the thyroid cartilage, that of either side uniting in the middle, 
line "to form the prominence "Adam's apple." The Adam's apple 
is not prominent in the female or child, and is not, therefore, a good 



SURGICAL ANATOMY OF THE NECK. 



131 



surgical guide. Below the thyroid the cricoid cartilage may be felt. 
This is located opposite the sixth cervical vertebra, and marks the 
point where " the omo-hyoid muscle crosses the common carotid 




Fig. 76.— Front of the Neck. GO, cricoid cartilage; DA, anterior belly of 
digastric; E, hyoid bone; MH, mylo-hyoid muscle; SH, sterno-hyoid muscle; 
S.T7, sterno-thyroid muscle; TO, thyroid cartilage; TR, trachea; TY.O, 
isthmus of thyroid gland. 



132 NECK AND TONGUE. 

artery. The cricoid is a ring of cartilage which is rather narrow 
anteriorly, but of considerable breadth posteriorly; it is always 
very readily felt, and is therefore a good guide. From the cricoid 
down to the upper border of the sternum the space is occupied 
by the trachea. Above, at its commencement at the cricoid carti- 
lage, the trachea is quite superficial, lying just beneath the integu- 
ment; but lower down it gets to lie deeper, farther away from 
the surface, and is less accessible. Just below the cricoid cartilage 
the isthmus of the thyroid gland lies transversely across the front 
of the trachea, each lobe of the gland extending outward and upward 
beneath the sterno-hyoid and sterno-thyroid muscles, reaching up- 
ward upon the side of the thyroid cartilage and getting into close 
proximity to the common carotid artery and its adjoining structures. 
Between the cricoid cartilage and the isthmus of the thyroid gland 
there is usually a space about one-half inch wide. On either side 
of the middle line, passing from the hyoid bone and thyroid carti- 
lage down to the sternum, are two long, flat, ribbon-like muscles, 
one superimposed upon the other: the sterno-hyoid and sterno- 
thyroid. The sterno-thyroid lies beneath the sterno-hyoid, being 
partly concealed by the latter. The sterno-thyroid is attached to 
the side of the thyroid cartilage and does not reach the hyoid bone, 
but is continuous with the short thyro-hyoid muscle, which is at- 
tached to the hyoid bone. The attachments of these muscles are 
indicated by their names. The inner edges of these muscles do not 
meet in the middle line of the neck, but are connected with each 
other through the intervening deep cervical fascia. They partly 
cover the trachea and sides of the larynx and the lateral lobes of 
the thyroid gland. Between the edges of the muscles, in the middle 
line, from above downward, and covered only by the interposed deep 
fascia, are the thyroid and cricoid cartilages, the isthmus of the 
thyroid gland, and the trachea. 

Between the hyoid bone and the upper border of the thyroid 
cartilage there is a space which is filled in by the thyro-hyoid mem- 
brane. This membrane is pierced on either side by the superior 
laryngeal vessels and the internal laryngeal branches of the supe- 
rior laryngeal nerve. This membrane may be cut in attempts at 
suicide: cut throat. Between the lower border of the thyroid carti- 
lage" and the upper border of the cricoid there is also a space which 
is filled in by a membrane: the crico-thyroid. This may also be 
divided in cut throat. Above the hyoid bone, running transversely 



SURGICAL ANATOMY OF THE NECK. 133 

inward and anastomosing with the hranch of the opposite side, is 
the hyoid branch of the lingual artery. Below the hyoid bone there 
is a similar transverse branch, the hyoid, which is derived from the 
superior thyroid and which passes likewise inward, anastomosing 
across the middle line with its fellow of the opposite side. A third 
transverse branch passes inward, above the cricoid cartilage, upon 
the membrane between the lower border of the thyroid cartilage 
and upper border of the cricoid cartilage. This is the crico-thyroid 
branch of the superior thyroid artery. It also anastomoses with its 
fellow of the opposite side. Below the level of the cricoid cartilage 
no arterial branches cross the middle line except through the isth- 
mus of the thyroid gland. 

The oesophagus lies behind the trachea, closely applied to its 
posterior wall, and when empty is flattened out against the vertebrse. 
It projects a considerable distance to the left of the trachea, and 
is therefore easier to reach through an incision upon the left side 
of the neck than upon the right. Above, the oesophagus is con- 
tinuous with the pharynx, into the commencement of which the 
larynx opens, the orifice of the larynx being protected by the over- 
hanging epiglottis, which is situated below and behind the root of 
the tongue. The posterior wall of the larynx, which is formed by 
the broad posterior portion of the cricoid cartilage, is in close rela- 
tion with the front wall of the pharynx. Only a thin layer of con- 
nective tissue intervenes between the anterior wall of the pharynx, 
which consists merely of a layer of mucous membrane, and the 
posterior part of the larynx, which is made up chiefly of the broad 
posterior part of the cricoid cartilage. When the pharynx is empty 
it is flattened out against the vertebral column, and the larynx, under 
these circumstances, also lies close to the vertebral column. 

From the cricoid cartilage down, the oesophagus and trachea, 
although in close proximity to each other, form two distinct tubes, 
which may be readily separated, one from the other. The posterior 
wall of the trachea, which is in direct relation with the oesophagus, 
is devoid of cartilaginous bands, and therefore a foreign body, lodged 
in the eesophagus, might press upon this contiguous, non-carti- 
laginous portion of the wall of the trachea and cause symptoms of 
strangulation. In the recess between the trachea and oesophagus, 
on either side, the recurrent laryngeal nerve ascends to enter the 
lower back part of the larynx behind the articulation which exists 
between the cricoid and thyroid cartilages. 



134 NECK AND TONGUE. 

The Laryngeal Kegion is covered in front by skin and deep 
fascia, but laterally by the muscles, the sterno-hyoid and sterno- 
thyroid and thyro-hyoid, and by the lobes of the thyroid gland. 

The interior of the larynx may be examined after splitting the 
thyroid cartilage, taking care to make this section in the midle line, 
between the anterior attachments of the vocal cords. The true and 
false vocal cords are then exposed to view. The true cords are the 
lower, and are attached anteriorly, upon either side of the middle 
line, to the thyroid cartilage, midway between the lowest part of the 
ineisura in its upper border and the lower border; posteriorly the 
true vocal cords are attached to the arytenoid cartilages, which rest, 
swivel-like, upon the upper surface of the cricoid cartilage. 

The false vocal cords are the loose folds of mucous membrane 
which are situated above the true cords, inclosing much loose con- 
nective tissue; these may readily become cedematous — oedema glottis 
— and act as a dangerous obstruction to respiration. 

The Thyroid Gland. — The isthmus is the narrowest part of 
the thyroid gland. It joins the two lobes of the gland across the 
middle line, resting transversely upon the upper part of the trachea. 
At times there projects from the upper border of the isthmus a 
process of glandular tissue, which is located in front of the larynx 
and which may be encountered in operations in this locality. The 
thyroid gland is fixed to the cricoid and thyroid cartilages by bands 
of connective tissue. These bands connect the isthmus of the gland 
to the cricoid cartilage and the lateral lobes, adjacent to the isthmus, 
to the sides of the thyroid cartilage. It is necessary to divide those 
bands that connect the isthmus to the cricoid cartilage before the 
isthmus can be dislocated downward in order to expose the upper 
rings of the trachea in performing the operation of high trache- 
otomy. The two lobes of the thyroid gland, one on each side, are 
prolonged backward and upward upon the sides of the trachea and 
larynx, reaching as far back as the oesophagus and thus getting into 
close relationship with the common carotid artery and its adjacent 
structures. As the recurrent laryngeal nerve of each side ascends 
between the trachea and oesophagus to enter the lower, posterior part 
of the larynx it lies beneath the corresponding lateral lobe of the 
thyroid gland. The isthmus of the thyroid lies just beneath the skin 
and deep fascia, whereas the lateral lobes extend upward and back- 
ward underneath the sterno-hyoid and sterno-thyroid muscles. 

On account of the intimate relationship that exists between the 



SURGICAL ANATOMY OF THE NECK. 135 

thyroid gland and the trachea, tumors involving the gland may- 
press upon the trachea and push it to one side; so that if trache- 
otomy becomes necessary in these cases it may be difficult to locate 
the trachea. When the thyroid is enlarged by tumors, etc., it may 
be seen to rise and fall with the larynx in movements of swallowing. 
The thyroid is supplied by the superior and inferior thyroid arteries 
of each side, and drained by the superior, middle, and inferior thy- 
roid veins. At times an arterial branch from the transverse portion 
of the arch of the aorta ascends upon the front of the trachea to 
reach the lower part of the gland: the arteria thyroidea ima. 

The Suprasternal Region is the space in the lower front part 
of the neck above the upper border of the sternum and limited on 
either side by the anterior border of the sterno-mastoid. The sur- 
face shows a depression here known as the suprasternal fossa, or 
fossa jugularis. This region is covered by the skin, beneath which 
lies the deep cervical fascia, which splits into two layers, an anterior 
and a posterior; these layers are attached below to the anterior and 
posterior edges of the upper border of the sternum, inclosing a space 
— the suprasternal — between them which is occupied by some con- 
nective tissue and lymphatic glands. A communicating venous 
branch which connects the anterior jugulars of either side is also 
included between these two layers. The suprasternal space is shut 
off from the mediastinum by the posterior layer of the deep cervical 
fascia, and pus in this space is thus hindered from breaking into the 
mediastinum and is more apt to open externally through the skin. 
Beneath the deep fascia lies the trachea, its anterior surface being 
readily accessible for operation. This part of the trachea may be 
lengthened by throwing the head back: partly by drawing the 
trachea out of the chest and partly by stretching it. 

If the trachea is incised transversely the wound gapes, and, if 
completely severed, it retracts into the chest to such an extent that 
it may be difficult or impossible to reunite it. At times the arteria 
thyroidea ima ascends in front of this lower part of the trachea and 
might complicate an operation upon this part of the tube. 

Descending obliquely downward and outward, from the lower 
part of the thyroid gland, are the inferior thyroid veins. These 
enter the right and left innominate veins or both may enter the left 
innominate, within the chest, behind the first piece of the sternum. 
The inferior thyroid veins are large and lie one on either side of 
the middle line. As they descend they get farther away from the 



136 NECK AND TONGUE. 

middle line, so that they are not likely to he encountered in the 
operation of low tracheotomy if the incision is kept strictly in the 
median line. 

The Blood-vessels of the Neck. The Common Caeotid Akteky. 
— This vessel ascends in the neck from hehind the sterno-clavicular 
articulation to the level of the upper horder of the thyroid cartilage, 
where it divides into the external and internal carotid. The course 
of the artery is indicated hy a line drawn from the sterno-clavicular 
articulation to a point midway between the angle of the jaw and the 
mastoid process. The muscular guide to the artery is the anterior 
border of the sterno-mastoid. 

The common carotid is crossed about the level of the cricoid 
cartilage by the omo-hyoid muscle; so that the lower part of the 
artery lies in the inferior carotid triangle and the upper part in 
the superior carotid triangle. The artery is more accessible for 
ligation in the upper triangle. In the lower part of its course, 
below the omo-hyoid, the artery lies beneath the anterior edge of the 
sterno-mastoid, whereas above, in the superior carotid triangle, it 
does not lie beneath the edge of the sterno-mastoid, but rather in 
front of it, and is here quite superficial, being covered only by the 
integument, platysma, and deep cervical fascia. Opposite the thy- 
roid cartilage the lateral lobe of the thyroid gland comes into close 
relation with the artery, the latter grooving the gland. In its course 
up the neck the artery is accompanied by the internal jugular vein, 
which lies close upon its outer side, and by the pneumogastric nerve, 
which lies between the vein and the artery, but on a plane posterior 
to both. These structures are lodged in a loose, connective-tissue 
bed, which is continuous below with the connective tissue of the 
mediastinum. 

Upon the front of the artery, opposite the middle of the thy- 
roid cartilage, the descendens and communicans noni form a loop 
from which some branches are given off to supply the depressor mus- 
cles of the hyoid bone. Posteriorly the artery rests upon the trans- 
verse processes of the lower cervical vertebras and the attachments 
of the vertebral muscles. The sympathetic nerve lies behind the 
artery and is united rather closely to the fascia that covers the pre- 
vertebral muscles. Below, opposite the sixth cervical vertebra, the 
inferior thyroid artery, which arises from the first part of the sub- 
clavian, curves inward, behind the carotid, etc., to reach the lower 
part of the thyroid gland. To the inner side of the artery are the 



SURGICAL ANATOMY OF THE NECK. 137 

trachea and oesophagus, and, higher up, the larynx and the lower 
part of the pharynx. The larynx projects forward between the 
arteries of either side. Ascending between the trachea and the 
oesophagus is the inferior, recurrent, laryngeal nerve. Opposite the 
thyroid cartilage the artery, as mentioned above, is in close relation 
with the lateral lobe of the thyroid gland. Upon the outer side of 
the artery the internal jugular vein is situated, and in close proxim- 
ity to the vein a chain of lymphatic nodes. The common carotid 
artery is crossed above the omo-hyoid muscle by the superior thyroid 
vein and about its middle — i.e., below the omo-hyoid — by the middle 
thyroid vein. Both these veins terminate in the internal jugular. 
Lower in the neck the artery is crossed by the anterior jugular vein, 
which, as a rule, terminates in the external jugular. 

The artery is covered by the integument, superficial fascia, 
platysma, and deep fascia. The lower part of the artery lies beneath 
the sterno-mastoid, and this muscle must therefore be drawn aside 
in order to expose the vessel. Above, upon a level with the thyroid 
cartilage, the artery lies quite superficial, not being overlapped by 
the sterno-mastoid, but in front of it and here its pulsation may be 
both felt and seen. 

The Inteenal Caeotid is continued upward in the same course 
as the common carotid, lying alongside of the pharynx. The internal 
jugular vein lies along its outer side, and the pneumogastric nerve 
lies between both, but on a plane posterior. At the base of the skull 
the artery enters the carotid canal in the petrous portion of the 
temporal bone, and after traversing this canal enters the cranium 
through the middle lacerated foramen. In the neck the internal 
carotid lies in the superior carotid triangle, covered by the anterior 
edge of the sterno-mastoid; it is situated deeper than the external 
carotid and upon a plane posterior to it. The stylo-glossus and stylo- 
pharyngeus muscles, as they pass forward to the tongue and to the 
side of the pharynx, are interposed between the internal and ex- 
ternal carotids. Behind, the artery rests upon the transverse proc- 
esses of the upper cervical vertebra? and upon the rectus capitis 
anticus major muscle. The sympathetic nerve, with its superior 
ganglion, lies behind the artery, between it and the anterior ver- 
tebral muscles. Internally the artery is in relation with the side of 
the pharynx. The superior laryngeal nerve descends between it and 
the pharynx. At its origin the artery lies quite superficial, being 
covered by the integument, platysma, and deep fascia and over- 



138 NECK AND TONGUE. 

Japped by the anterior margin of the sterno-mastoid muscle. In the 
upper part of its course it lies deep in the neck beneath the poste- 
rior belly of the digastric and stylo-hyoid muscles and the parotid 
gland and the stylo-pharyngeus and stylo-glossus muscles, these two 
latter muscles separating it from the external carotid. 

At the base of the skull the internal jugular vein leaves the in- 
ternal carotid artery and enters the skull through the jugular fora- 
men. This foramen is located external and posterior to the opening 
which marks the commencement of the carotid canal. Just below 
the base of the skull the glosso-pharyngeal nerve passes forward be- 
tween the internal jugular vein and the internal carotid artery and 
then continues forward, below the stylo-glossus muscle, to reach the 
side of the base of the tongue. Just above the level of the hyoid 
bone the hypoglossal nerve curves forward between the artery and 
the vein. The spinal accessory, at the base of the skull, is situated 
between the internal carotid artery and the internal jugular vein, 
but passes backward and outward to reach the deep surface of the 
sterno-mastoid muscle. 

The External Caeotid Artery, at its origin, is located in the 
superior carotid triangle in front of the internal carotid artery. It 
passes upward to a point between the posterior border of the ramus 
of the jaw and the mastoid process, and here, within the substance of 
the parotid gland, divides into the temporal and internal maxillary. 
As it ascends upon the side of the neck it describes a gentle curve 
with the convexity forward and is placed upon a plane anterior to the 
internal carotid, giving off many branches to the muscles and struct- 
ures in the neck and to the tongue. It lies in front of the anterior 
border of the sterno-mastoid, being covered only by the skin, 
platysma, and deep fascia; higher up, on a level with the angle of 
the lower jaw, it is covered by the posterior belly of the digastric 
and stylo-hyoid, and at its bifurcation into its terminal branches it 
lies deep within the substance of the parotid gland. 

The external carotid artery does not lie as deep in the neck as 
the internal carotid; upon a level with the angle of the lower jaw 
the^e two vessels are separated from each other by the stylo-glossus 
and stylo-pharyngeus muscles (together with the glosso-pharyngeal 
nerve). Both these muscles arise from the styloid process and pass 
forward, between the external and internal carotid arteries, in their 
course to reach the side of the tongue and the pharynx. 

As the external carotid artery lies within the parotid gland it 



SURGICAL ANATOMY OF THE NECK. 139 

is crossed, upon a level with the lower border of the lobe of the ear, 
by the divisions of the facial nerve. The temporo-maxillary vein, 
which is formed by the junction of the temporal and internal maxil- 
lary veins, also lies superficial to it. Below the angle of the jaw 
the artery is crossed by the temporo-facial vein; this vessel is formed 
by the facial and a large branch from the temporo-maxillary, and 
after receiving the lingual and sometimes the superior thyroid, ter- 
minates in the internal jugular. 

Below the level of the hyoid bone the external carotid gives off 
the superior thyroid. This branch passes forward and downward to 
the lateral lobe of the thyroid gland and gives branches to the 
larynx. The next branch given off above the superior thyroid is the 
lingual. This vessel passes forward, beneath the digastric and stylo- 
hyoid muscles and beneath the hyo-glossus, to supply the tongue. 
The next branch above is the facial. The facial is directed forward 
and upward and curving over the inferior border of the lower jaw, 
in the groove just in front of the masseter muscle, ascends upon 
"the side of the face, nose, etc. At its origin the facial artery lies 
beneath the posterior belly of the digastric and stylo-hyoid mus- 
cles close to the posterior border of the submaxillary gland, which 
it grooves' and supplies; here it gives off its submental branch, which 
runs forward upon the under surface of the mylo-hyoid muscle 
dose to the body of the lower jaw. From its posterior aspect, upon 
-a level with the origin of the facial, the external carotid artery gives 
off its occipital branch. This vessel passes upward and backward 
across the internal jugular vein and ascends beneath the anterior 
border of the sterno-mastoid muscle to reach the occipital region of 
the head. Above the origin of the occipital, also from its posterior 
aspect, the external carotid gives off the posterior auricular. This 
vessel courses upward and backward, running close behind the ear 
.and supplying this and the mastoid region. The hypoglossal nerve 
swings forward across the outer side of the external carotid artery 
upon a level with the origin of the occipital. 

The Inteenal Jtjgulae Vein lies close to the outer side of 
~the common carotid artery and its continuation, the internal ca- 
rotid. This vessel is large, as big around as the little finger, very 
thin walled, and lies in the same connective-tissue bed with the 
artery and the pneumogastric nerve. It is formed above, at the 
base of the skull, by the union of the lateral (sigmoid) and inferior 
petrosal sinuses. These vessels emerge from the interior of the 



140 NECK AM) TONGUE. 

skull through the jugular foramen, "which is situated behind and 
external to the conimeneenient of the carotid canal: the pnenmo- 
gasfaac, spinal accessory, and glosso-pharyngeal nerves also emerge 
frori the iraninni through the jugular foramen. Just outside the 
skull the lateral and the inferior petrosal sinuses join and form a 
bulbous dilatati liich marl:- the : ommeneement of the internal 

jugular rein. At the root xf the neck the internal jugular termi- 
nates by joining with the subclavian to form the innominate. Ir. its 
course through the neck the vein receives a number of large 
branches: the temporo-faeial, lingual, and superior and middle thy- 
roids. A chain of lymphatic nodes is situated along the outer side 
of the vein, close to its -wall, and these may be diseased and require 
extirpation. On the right side, in the root of the neck, where the 
internal jugular unites with the subclavian, the right lymphatic duet 
is seen to enter the vessel. TTpon the left side of the neck the 
thoracic duet enters the vein at its junction with the subclavian; 
the thoracic duet arches over the third part of the subclavian artery 
and across the front of the :endon of the scalenus antieus in order 
to reach the vein. 

Tee Subclavian Aeieet. — This ssel upon the right side is 
deri~ei from the mnominate, which bifurcates bellied the right 
sterno-clavicular articulation into the common carotid and sub- 
clavian. The left sol - .iven off from the left end of the 
transverse irt :: the arch :: the aorta and ascends in the upper 
part of the ehest as far as the left - .no-clavicular articulation. 

From the sterno-clavicular articulation, upon either side, the 
e belavian artery arches outward across the root if the neck and 
passes into the axilla tc become the axillary. In the root of the 
neck the artery is found in the subclavian triangle resting directly 
upon the first rib. 

The tendon of the scalenus antieus, at its attachment, is situated 
in front ::' the subclavian artery, and thus, for purposes of descrip- 
tioL. --el into three parts. The first part of the 

corresponds to that portion which is included between its 
■ . .in and the inner margin of the tendon of the scalenus ant: - 
the second part of the artery corre- ads to the portion immediately 
bind the tendon of the 8( leu s, and the thn art of the artery 
reaches from the on: of the ten n of the scalenus antieus 

tc "lae point where if enters the axilla to become the axillary. The 
first and second parts of the artery are in intimate relation with the 



SURGICAL ANATOMY OF THE NECK. 141 

apex of the lung and dome of the pleura; the third portion rests 
upon the upper surface of the first rib. The trunks of the brachial 
plexus in their course through the subclavian triangle are situated 
above the subclavian artery. The subclavian artery gives- off several 
large branches; from its first part the vertebral, internal mammary, 
and thyroid axis (inferior thyroid, suprascapular, transversalis colli); 
from the second part, the superior intercostal. The origin of these 
branches varies in different individuals and in the same individual 
upon either side. 

The subclavian vein is the continuation of the axillary. It 
passes inward across the root of the neck, beneath the clavicle and in 
front of the scalenus anticus tendon, resting upon the upper surface 
of the first rib and lying in front and to the inner side of the artery. 
It is situated a considerable distance away from the artery, from 
which it is separated by the tendon of the scalenus anticus. The 
subclavian vein joins with the internal jugular to form the innomi- 
nate. Upon the right side where these two veins join they receive 
the right lymphatic duct, and upon the left side, at their junction, 
they receive the thoracic duct. 

The Ineeeioe Thyeoid Aeteey is seen deep in the lower part 
of the inferior carotid triangle. It is a branch of the thyroid axis 
which arises from the first part of the subclavian, and curves upward 
and inward, passing inward, behind the common carotid artery, about 
the level of the transverse process of the sixth cervical vertebra in 
order to reach the lower part of the thyroid gland. As this vessel 
passes behind the common carotid artery, etc., it is crossed from 
above downward by the sympathetic nerve. This nerve usually 
descends in front of the inferior thyroid artery, but sometimes be- 
hind it. Just before the artery reaches the thyroid gland it is crossed 
by the recurrent laryngeal nerve, which ascends in the space between 
the trachea and the oesophagus to reach the larynx. 

The Veetebeal Aeteey lies deep in the lower part of the 
neck. It arises from the first part of the subclavian between the 
scalenus anticus muscle in front and the longus colli behind and 
enters the foramen in the base of the transverse process of the sixth 
cervical vertebra. The prominent tubercle on the transverse process 
of this vertebra is a good guide to the artery. The artery may be 
reached through the subclavian triangle by drawing the sterno- 
mastoid forward toward the middle line or by nicking or incising its 
posterior border. 



142 



NECK AND TONGUE. 



OPERATIONS UPON THE NECK. 

Tracheotomy means opening into the air-passage either for 
relief when obstruction exists or as a preliminary step to other op- 
erations; for example, extirpation of the larynx, amputation of the 
tongue, etc. 

In 1869, as a preliminary to excision of the jaw, ISTussbaum per- 
formed a tracheotomy and tamponed the pharynx with a compress 
to prevent blood from entering the larynx during the operation, the 
anaesthetic being administered through the tracheotomy tube. 

Tampon of the Trachea. — Trendelenburg uses a tracheotomy 
tube which is surrounded by a thin, balloon-like structure provided 
with a cannula so that it may be inflated after it has been introduced 




Fig. 77.— Tracheotomy Tube. 




Fig. 78.— Trendelenburg Tampon Can- 
nula. T, tube to inflate balloon. Anaes- 
thetic is given through a long tube and 
funnel attached to tracheotomy tube. 



into the trachea, in this way plugging the trachea and preventing the 
entrance of blood, etc. The anaesthetic is administered through the 
tracheotomy tube, to which a long rubber tube provided with a fun- 
nel is attached; in the bottom of the funnel there is a wad of cotton 
upon which the anaesthetic is dropped. The tracheotomy tube and 
tampon may be allowed to remain in the trachea for seven or eight 
days after the operation. 

The Site of Operation. — The opening into the air-passage 
may be made: — 

1. JThrongh the trachea above the isthmus of the thyroid gland 
(high tracheotomy). This is the preferable operation and usually 
includes, in addition, division of the cricoid cartilage (crico-trache- 
otomy). 



OPERATIONS UPON THE NECK. 143. 

2. Through that part of the trachea which is covered by the 
isthmus of the thyroid gland (median tracheotomy). 

3. Through the trachea below the isthmus of the thyroid gland 
(low tracheotomy). This operation is rather less preferable, because 
at this level the trachea lies deeper — farther away from the surface,, 
and, besides, one may meet the inferior thyroid veins or some of 
their branches or there may be an arteria thyroidea ima present. 
This is the site usually selected for a preliminary tracheotomy in 
conjunction with operations upon the larynx; for example, extirpa- 
tion of the larynx. 

4. Through the crico-thyroid membrane. This is really a laryn- 
gotomy, but it is well to include it with the tracheotomies. 

High Tracheotomy (Crico-tracheotomy). — This is the op- 
eration usually performed, and has the advantage that no vessels- 
of moment are met with; and that this part of the air-tube is- 
located quite superficially, near the surface. 

The patient lies upon the back with the shoulders raised and the 
head thrown back. If the symptoms of suffocation are urgent, one 
may dispense with an anaesthetic or may give simply a few whiffs 
of chloroform. The operation may be done under cocain ansesthesia. 

By palpation, the ring-like cricoid cartilage, which is the best 
landmark, is readily located. In men the prominent thyroid carti- 
lage may be felt and seen as Adam's apple, but in women and chil- 
dren this is not prominent and is not, therefore, a good guide. 

An incision is made through the skin and subcutaneous fat from 
the lower border of the thyroid cartilage — just above the cricoid — 
downward, in the middle line of the neck, for a distance of one and 
one-half inches. In making this skin incision some small tributaries 
of the anterior jugular vein may be encountered; to these clamps- 
are applied and the skin retracted, exposing thus the deep cervical 
fascia, which unites the edges of the sterno-hyoid muscles of either 
side with each other. This layer of fascia is incised along the middle 
line, corresponding to the incision in the integument. The edges of 
the wound being now retracted, there are exposed, above, the cricoid 
cartilage and just below the cricoid, lying transversely across the 
front of the trachea, the isthmus of the thyroid gland. The isthmus 
of the thyroid gland is located about one-half inch below the cricoid 
cartilage, to which it is connected by a process of the deep cervical 
fascia. This slip of fascia covers or conceals the upper two rings 
of the trachea; so that, in order to expose. these, it is necessary to> 



1-14 NECK AND TONGUE. 

pick up this band and snip it transversely, after which the isthmus 
may he drawn downward and the upper rings of the trachea exposed 
to view. 

The next step is to enter the air-passage, but before doing this 
all bleeding points should be clamped. At times, during the opera- 
tion, the larynx moves violently up and down in forced efforts at 
respiration, and in order to steady it a tenaculum must be employed. 
This is introduced into the larynx above the cricoid cartilage, pierc- 
ing the crico-thyroid membrane, and hooks the cricoid cartilage 
firmly upon its posterior aspect a little to the right of the middle 
line. The operator holds this tenaculum with the left hand, thus 
steadying the larynx and trachea, and, with a sharp-pointed knife 
held short in the right hand, the cricoid and one or two upper rings 
of the trachea are cut deliberately from above downward. One 
guards the knife blade in order to avoid injuring or perforating the 
posterior wall of the trachea. Having made an opening in the air- 
tube about one-half inch long and still retaining the tenaculum 
which was hooked into the cricoid to the right of the middle line, 
a second tenaculum is now hooked into the other side of the cricoid, 
to the left of the middle line, and the incision in the air-passage 
thus held open while the tube is being -introduced. 

Occasionally the thyroid gland has a well-marked middle lobe 
occupying the site of the isthmus and ascending upon the front of 
the cricoid. This extra lobe is seldom present, but, when it is, it 
must be dislocated downward in order to expose the cricoid and the 
upper part of the trachea. Usually it is not necessary to apply any 
ligatures, as the cut vessels cease bleeding after a few minutes' ap- 
plication of the artery forceps; still, if any spurting vessels are met, 
they should be ligated. The edges of the skin may be brought to- 
gether with two interrupted catgut sutures, one above and the other 
below the tube. 

The tube is held in place by a tape tied around the neck and 
the wound dressed with gauze packed loosely about the wound and 
the tube. 

Low Tracheotomy. — The opening is made into the trachea 
below the isthmus of the thyroid gland. This is not usually the site 
of choice, although it is at times indicated. This part of the trachea 
lies farther away from the surface, deeper, and one may meet the 
inferior thyroid veins, which descend in front of the trachea, al- 
though they usually lie well to either side of the middle line, thus 



OPERATIONS UPON THE NECK. 145 

leaving the line of incision free. At times there is an arteria thy- 
roidea ima ascending in front of this part of the trachea: a rather 
unusual condition. 

The incision, in the middle line of the neck, commences above 
at a point just below the cricoid cartilage, and is continued down- 
ward toward the sternum, for a distance of one and one-half to 
two inches. The incision penetrates first through the skin and fat, 
and is then continued deeper through the deep cervical fascia, ex- 
posing the front of the trachea. After the trachea has been exposed 
all bleeding points must be clamped; usually the hemorrhage is only 
venous and ceases after the artery forceps have been applied for a 
few minutes. The operator is now ready to make the opening in 
the trachea, which should be placed below the level of the isthmus 
of the thyroid gland; the isthmus may be drawn upward toward 
the cricoid cartilage in order to give more room. All bleeding should 
be controlled before the trachea is opened. 

Before making the incision in the trachea a tenaculum is intro- 
duced into the trachea, just below the isthmus of the thyroid gland 
and a little to one side of the middle line, to steady the trachea, and 
with a sharp-pointed knife, held short by the blade, an incision is 
made into the trachea from below upward, cutting two or three 
rings. Still steadying the trachea with the first tenaculum, a second 
tenaculum is introduced into the incision in the trachea, and while 
it is thus held open the tube is introduced. The tenacula are not 
withdrawn until the tube is in the trachea. 

Any spurting vessels or large veins may be ligated, and one or 
two stitches may be taken in the skin wound. The left innominate 
vein is not in danger if, in incising the trachea, the knife is not 
carried below the level of the sternum. 

Median Tkacheotomy. — The opening into the trachea is made 
beneath the isthmus of the thyroid gland, which is divided in order 
to expose this part of the trachea. This operation can be done 
rapidly. 

The incision passes through the skin and fat and reaches from 
the cricoid cartilage downward, in the middle line of the neck, for 
a distance of one and one-half to two inches. The incision is then 
carried deeper through the deep fascia, between the edges of the 
sterno-hyoid muscles, when the isthmus of the thyroid gland is ex- 
posed. The isthmus is divided and the trachea recognized. In 
dividing the isthmus we cut several venous branches, which bleed 



146 NECK AND TONGUE. 

and must be clamped. The bleeding should be controlled before the 
trachea is opened. Bleeding points may be clamped and their liga- 
tion postponed until after the tube has been introduced into the 
trachea if time is limited. The trachea is steadied with a tenaculum 
and incised, and the tube introduced, as in the foregoing operation. 

Transverse Laryngotomy. — This is an emergency operation 
and may be rapidly performed. One may open the windpipe, after 
locating the cricoid cartilage and using this as a guide, by cutting 
transversely through the skin and crico-thyroid membrane: i.e., 
between the upper border of the cricoid and the lower border of the 
thyroid cartilage. There is some probability of wounding the crico- 
thyroid artery, a small branch, yet this is not very likely as the in- 
cision is made transversely: parallel with the course of the artery. 

Thyrotomy. — Division of the thyroid cartilage may be either 
incomplete or complete. 

Incomplete Thyrotomy. — The incision is placed in the middle 
line of the neck and commences, above, at a point just below the 
upper border of the thyroid cartilage, and is continued downward 
to a point just below the cricoid cartilage; it is about one and one- 
half to two inches long and reaches through the skin and deep 
fascia, exposing the cricoid and thyroid cartilages. The edges of the 
wound are retracted and the crico-thyroid membrane incised, thus 
entering the larynx. In incising the crico-thyroid membrane the 
crico-thyroid branches may be cut; these are small branches, but 
they should be clamped if they bleed, as even a small quantity of 
blood sucked into the wind-pipe may seriously embarrass respira- 
tion. We then proceed to enlarge the opening into the larynx by 
dividing the cricoid cartilage and the lower part of the thyroid 
cartilage, to an extent sufficient to permit the extraction of foreign 
bodies, etc. One should avoid, if possible, incising the thyroid carti- 
lage beyond the level at which the true vocal cords are attached. 

If this operation is done for the removal of a foreign body, one 
may close the opening in the larynx and omit the introduction of a 
tube; still it is probably not unwise to insert the tube and leave it 
for a few days in all cases, because, as a result of the operation, there 
may be some oedema of the glottis caused. 

Complete Thyrotomy consists of a median section through the 
thyroid cartilage. This operation is done for the purpose of ex- 
ploring the interior of the larynx and for the removal of foreign 
bodies, growths, etc. 



OPEEATIONS UPON THE NECK. 147 

During the operation the trachea must be kept clear of blood. 
The operation should be performed with the patient in the Rose 
position unless a tampon cannula is used, when the patient may be 
placed in the usual tracheotomy position with the shoulders raised 
and the head thrown back. The tampon cannula may be introduced 
through a preliminary high tracheotomy, done at the same sitting, 
previous to opening the larynx, or else the cannula may be inserted 
through the incision that is made in the larynx and which may be 
prolonged downward, through the cricoid and upper rings of the 
trachea for this purpose. Instead of a high tracheotomy, a prelimi- 
nary, low tracheotomy may be performed and the tampon cannula 
introduced at this point. 

The incision is placed in the middle line of the neck, reaching 
from the hyoid bone, above, to a point below the level of the cricoid 
cartilage. The incision extends through the skin and deep fascia 
and exposes the thyroid cartilage. 

The next step is to open the larynx. The point of the knife 
is introduced through the crico-thyroid membrane between the 
cricoid and the lower border of the thyroid cartilage. In doing this 
the crico-thyroid branch may be cut and should be clamped and tied. 
Now, with a curved probe-pointed knife, which is introduced into 
the larynx and passed upward between and beyond the vocal cords, 
the thyroid cartilage is split into its two halves from within outward, 
in the middle line, throughout its entire length up to or into the 
thyro-hyoid membrane. The thyroid cartilage may also be divided 
from without inward. At times the thyroid cartilage is ossified, and 
a strong scissors or thin saw is necessary in order to accomplish its 
division. 

After the thyroid cartilage has been split its edges are held 
apart with sharp retractors or tenacula, and the interior of the 
larynx may then be freely explored. We may, in addition, divide the 
cricoid cartilage and the upper rings of the trachea if this has not 
already been done or if more room is required or in order to intro- 
duce a tampon cannula. 

In cutting into the thyro-hyoid membrane one should avoid the 
superior laryngeal vessels and nerve, which pierce this membrane 
upon either side to enter and supply the larynx. 

It may not be necessary to suture the two halves of the thyroid 
cartilages, as these often adapt themselves very well without suture, 
especially if the cricoid cartilage has not been divided. It is probably 



148 NECK AND TONGUE. 

wise, however, in all cases, to introduce two or three chromicized 
catgut sutures through the perichondrium to hold the edges of the 
two halves of the thyroid cartilage in contact or one silver wire suture 
may he passed through each edge of the cartilage. The incision 
in the skin may be partly closed with catgut sutures. 

The tampon cannula, if used, may be left in place for a few 
clays if it is well borne, as it prevents the entrance of blood and dis- 
charge into the trachea and lungs. 

Laryngectomy (Extirpation of the Larynx). — This operation 
should be preceded by a low tracheotomy, which may be done a 
week or more in advance of the major operation in order to accustom 
the patient to the presence of the tube and to bring about fixation 
of the trachea to the skin, etc., of the neck. 

If the preliminary tracheotomy has not been done, one should 
operate with the patient in the Eose position, or, if the operation 
is done with the patient in the customary tracheotomy position, it 
will be necessary, as soon as the larynx has been isolated and all the 
vessels that supply it ligated, to cut the larynx away from the trachea 
below and then, at once, introduce the tampon cannula into the 
upper end of the trachea. The preliminary tracheotomy, with the 
introduction of the tampon cannula, is probably the most preferable 
plan. The incision is made in the middle line from the hyoid bone to 
a point below the cricoid cartilage; to this incision a second trans- 
verse incision may be added which extends outward, parallel with 
the hyoid bone, between the hyoid bone and upper border of the 
thyroid cartilage, as far as the anterior border of the sterno-mastoid 
muscle, thus making a T-shaped incision. This latter supplementary 
incision is especially advantageous if the lymphatic glands, etc., are 
involved in the pathological process. 

The incision extends through the skin and subcutaneous fat and 
deep cervical fascia, and exposes the thyroid cartilage. 

The edges of the sterno-hyoid muscles are next recognized and 
the muscle of either side divided transversely either partially or 
completely. The parts being now retracted, we expose the sterno- 
thyroid and thyro-hyoid muscles, which are attached upon either 
side of the thyroid cartilage, the lateral lobes of the thyroid gland 
being situated beneath the sterno-thyroid muscles. 

We now begin the isolation of the larynx, separating all the 
soft parts either with an elevator or with the knife, the edge of the 
instrument working close to the surface of the thyroid cartilage. If 



OPERATIONS UPON THE NECK. 149 

we use the elevator, this is pushed under the thyrohyoid muscle, 
between it and the thyroid cartilage, and the attachment of this 
muscle separated from the side of the thyroid cartilage, separating 
the attachment of the sterno-thyroid at the same time; this separa- 
tion may be accomplished in part with the knife. These two mus- 
cles are really one and the same continuous muscle; so that, after 
they have been detached from the thyroid cartilage, they hang 
together as one continuous flat band. Instead of detaching these 
muscles as described they may be simply cut away from the sides 
of the thyroid cartilages with the knife. The soft parts are now 
retracted and a tenaculum is hooked into the side of the thyroid 
cartilage, and with this the larynx is drawn forward and to one side, 
so that we are enabled to reach the superior laryngeal artery and its 
accompanying nervous branch, as they pierce the side of the thyro- 
hyoid membrane to enter the larynx; the vessel is tied double and 
cut. The lateral lobe of the thyroid gland, which lies upon the side 
of the larynx (in the natural relation of the parts being covered by 
the sterno-thyroid muscle), is readily separated from the side of the 
larynx with the elevator or the finger. At this stage of the opera- 
tion the superior thyroid artery, which ramifies upon the upper front 
surface of the thyroid gland, is usually met with. This vessel need 
not be cut. The thyroid isthmus is also liberated from its attach- 
ment to the cricoid cartilage and pushed downward out of the way. 

The crico-thyroid branch of the superior thyroid, which runs 
forward and inward transversely across the crico-thyroid membrane, 
may be cut and should be clamped and tied. There is also an in- 
ferior laryngeal branch, from the inferior thyroid, which accom- 
panies the inferior laryngeal nerve into the larynx; it enters the 
lower back part of the larynx, behind the articulation between the 
cricoid and thyroid cartilages, beneath the lateral lobe of the thy- 
roid gland; this branch may be cut and should be tied. The small 
transverse branch, from the superior thyroid, which runs transversely 
inward across the thyro-hyoid membrane, below the hyoid bone, to 
anastomose with its fellow of the opposite side, is also cut and tied. 

The larynx is now drawn to the other side, and while the soft 
parts are retracted the above described procedures are repeated upon 
this side. 

The isolation of the larynx is continued. The soft parts are 
strongly retracted to one side and with a sharp hook or vulsella the 
larynx is drawn to the opposite side; then, with the knife, the in- 



150 NECK AND TONGUE. 

ferior constrictor of the pharynx is separated from the side of the 
thyroid cartilage. This muscle is attached upon the side of the 
thyroid cartilage close to its posterior border, which may be readily 
felt by the fingers in the wound. This muscle is separated from the 
cricoid cartilage also. Care should be exercised to work close to the 
surface of the cartilage in separating this muscle so as to avoid 
opening into the pharynx, and also to avoid division again of the 
vessels that have already been divided and tied. The parts are then 
separated in a similar manner upon the other side of the larynx. 

We are now ready for the final step of this part of the operation: 
the separation of the larynx from the hyoid bone above, from the 
anterior wall of the pharynx behind, and from the trachea below. 

The knife is introduced through the thyro-hyoid membrane be- 
tween the thyroid cartilage and the hyoid bone, and this membrane 
is cut in a direction outward and backward, at the same time draw- 
ing the side of the larynx forward with a sharp hook or vulsella. 
In performing this step of the operation one should avoid again cut- 
ting the superior laryngeal artery upon the proximal side of its 
ligature if it has already been divided and tied. The other half of 
the thyro-hyoid membrane is then cut in a similar manner. If it 
is desired to excise the epiglottis also, and this is usually wise, a 
probe-pointed knife may be introduced through the incision in the 
thyro-hyoid membrane, between the upper border of thyroid cartilage 
and the hyoid bone, in a direction upward and backward; so that, 
as the cut is made, the blade of the knife passes between the base 
of the tongue and the epiglottis. The finger in the mouth may 
serve to guide the knife. If the epiglottis is to be left, we cut di- 
rectly backward between the upper border of the thyroid cartilage 
and the hyoid bone, thus leaving the epiglottis attached to the poste- 
rior aspect of the hyoid bone and to the root of the tongue. The 
front of the larynx is now seized with a sharp hook or vulsella forceps 
and drawn directly forward; so that its posterior wall, composed of 
the broad posterior part of the cricoid cartilage, may be separated 
from the anterior wall of the pharynx; the anterior wall of the 
pharynx is very thin, consisting practically only of a layer of mu- 
cous membrane. If the growth involves the anterior wall of the 
pharynx, this part may be excised together with the larynx. If the 
pharynx is not involved in the disease, the separation of the larynx 
from the pharynx is not difficult. 

After the separation of the larynx from the pharynx has been 



OPERATIONS UPON THE NECK. 151 

completed to a point below the level of the cricoid cartilage, the 
larynx is cut away from the trachea, from behind forward, below 
the level of the cricoid cartilage. In thus severing the larynx from 
the trachea the inferior laryngeal arteries and nerves are cut, and, 
if the vessels have not already been tied, they should be secured as 
they spurt. Thus the extirpation is complete. 

Instead of operating as described above, we may, after freeing 
the larynx upon the sides, etc., complete the operation by cutting 
the larynx away from the trachea below the level of the cricoid 
cartilage, packing the stump of the trachea at once with a pad to 
prevent the entrance of blood (a preliminary tracheotomy having 
been done); and then, drawing the larynx forward with a sharp hook 
or vulsella, this is separated from the anterior wall of the pharynx 
from below upward; and, as the final step of the operation, the 
larynx is cut away from its attachment to the hyoid bone by carry- 
ing the knife through the thyro-hyoid membrane. 

The superior laryngeal arteries, that enter the larynx upon the 
sides, are best secured before beginning the actual isolation of the 
larynx, but they may be again divided accidentally during the final 
steps of the operation, and in this case should be again clamped and 
tied; other vessels may be secured as they are encountered during 
the course of the operation. The wound is best left open. If the 
accessory lateral skin incisions have been made, and the sterno- 
mastoids have been divided, these parts may be brought together 
with sutures. The opening in the pharynx especially, if it has been 
necessary to remove a considerable part of its wall, may be closed in 
part by interrupted silk sutures with their ends left long to facilitate 
their removal later. 

One should arrange good drainage, with the head low, so as to 
avoid the entrance of wound secretions into the trachea. It is well 
to leave the tampon cannula in the trachea for a few days if it has 
been used during the operation. The wound should be properly 
packed and the dressings changed at rather frequent intervals. 

Feeding is carried on through a tube introduced into the stom- 
ach either through the mouth or through the wound in the pharynx. 
If a tracheotomy has not preceded the laryngectomy by a week or 
more, the stump of the trachea should be sutured to the skin in order 
to prevent too great retraction of the trachea. In cases where the 
disease has not spread beyond the larynx, the operation is compara- 
tively easy and not accompanied by much hemorrhage. 



152 NECK AND TONGUE. 

Before proceeding with the radical operation the larynx may 
be split in the middle line for the purpose of exploration. It may 
be that in some early cases the removal of one-half of the larynx 
will suffice. 

Extirpation of Half of the Larynx. — This operation is analogous 
to the preceding. The larynx is first split in the middle line without 
injuring the vocal cords. 

It is a less difficult and dangerous operation, and recurrence 
is no more frequent after this less radical operation, if the disease 
is limited to one side of the larynx, than after complete extirpation. 
The function is good after the partial operation. 

External (Esophagotomy. — This operation is usually done for 
the removal of a foreign body impacted in the oesophagus. 

The patient lies upon the back, with the shoulders raised and 
the head thrown back and over toward the right side. 

A soft rubber tube is introduced into the oesophagus as far as 
it will go to serve as a guide. The oesophagus is approached through 
an incision in the left side of the neck. 

The incision is made about three inches long, corresponding to 
the anterior border of the sterno-mastoid muscle, the midpoint of 
the incision being upon a level with the cricoid cartilage; it is car- 
ried through the skin and subcutaneous fatty layer, including the 
platysma, and exposes the anterior edge of the sterno-mastoid mus- 
cle. The sterno-mastoid is then drawn aside and the underlying 
layer of deep cervical fascia is incised, when the internal jugular 
vein and the common carotid artery, lying in their connective-tissue 
sheath and crossed by the anterior belly of the omo-hyoid muscle, 
are exposed. These vessels are drawn outward with a blunt re- 
tractor. The lateral lobe of the thyroid gland, partly covered by the 
sterno-hyoid and sterno-thyroid muscles, is then recognized. These 
structures are drawn toward the middle line with a blunt retractor. 
The trachea, which may now be readily felt with the fingers, is a 
guide to the oesophagus, the oesophagus being located posterior to 
the trachea and protruding well beyond its left border. The tube 
in the oesophagus assists in locating it, and the foreign body, if 
present, may also be felt. The middle thyroid vein, as it passes 
outward from the thyroid gland to enter the internal jugular, may 
be met with, and, if it is in the way, may be cut and tied. The 
inferior thyroid vein may also be seen. 

The oesophagus is entered in the inferior carotid triangle, — i.e., 



OPERATIONS UPON THE NECK. 153 

below the omohyoid, — and, if necessary, this muscle may be drawn 
to one side or divided. The recurrent laryngeal nerve, as it ascends 
to enter the larynx, lies in front of the oesophagus, in the space 
between the trachea in front and the oesophagus behind, and should 
be avoided in incising the oesophagus. The nerve, during the opera- 
tion, is not encountered, and may be avoided by making the opening 
in the oesophagus well upon the side and thus keeping away from 
the front of the tube. 

The wall of the oesophagus is picked up with two mouse-toothed 
forceps, and an incision made corresponding to its long axis and of 
sufficient length to permit the extraction of the foreign body or any 
other necessary manipulation. 

In incising the oesophagus one should make a clean cut in order 
to avoid getting between the layers of the wall of the tube, which 
may readily happen owing to the looseness of the tissue between 
its muscular and mucous coats. Some oesophageal branches of the 
inferior thyroid may be divided in making the opening in the wall 
of the oesophagus and these must be clamped and ligated. 

The wound in the wall of the oesophagus may be closed with 
several interrupted sutures of silk or chromicized catgut, but the 
external wound in the neck, leading down to the incision in the 
oesophagus, should be packed and left unsutured. 

If the object of the operation is to establish a permanent fistula 
(cesophagostomy), the edges of the incision in the oesophagus, includ- 
ing its mucous and muscular coats, may be fixed to the edges of the 
skin incision with several interrupted silk stitches. 

Ligation of Blood-vessels. The Common Cakotid Artery. — 
The common carotid may be tied either above or below the point 
where the omo-hyoid crosses it, which is upon a level with the cricoid 
cartilage. It is ligated preferably and more readily in the so-called 
superior carotid triangle: above the crossing of the omo-hyoid. 

The linear guide to the common carotid is a line drawn from 
a point midway between the angle of the jaw and the mastoid process 
to the sterno-clavicular articulation. The muscular guide is the 
anterior border of the sterno-mastoid muscle. 

The incision is made about two inches long, corresponding to 
the anterior border of the sterno-mastoid, its midpoint upon a level 
with the cricoid cartilage. This incision penetrates through the 
skin and subcutaneous fatty layer, including the platysma, and 
should expose the anterior border of the sterno-mastoid muscle. 



154 



NECK AND TONGUE. 



The edge of the sterno-mastoid should be recognized and drawn 
outward, and then, after carefully incising the underlying layer of 
deep cervical fascia, — the fascia that separates the vessels from the 
sterno-mastoid muscle, — the vessels, surrounded by some loose con- 
nective tissue, are exposed — first, the internal jugular vein, big and 
thin-walled, lying to the outer side of the artery, and then the com- 
mon carotid, whose pulsation is readily felt and seen and which lies 
to the inner side of the vein. The pneumogastric nerve, which is 




Fig. 79. — A, incision for removal of lower jaw; B, incision for ligation of 
lingual artery and Kocher's amputation of tongue; C, incision for ligation of 
common carotid and for cesophagotomy. 



located between the artery and vein, but behind them, is not seen. 
The anterior belly of the omo-hyoid is seen as it crosses the vessels 
opposite the cricoid cartilage. The loop formed by the descendens 
and communicans noni may also be recognized upon the front of 
the vessels. The superior thyroid vein crosses the artery from 
within outward above the omo-hyoid muscle, and the middle thyroid 
vein below this muscle. If these vessels are cut, they should be 
clamped and tied. 

The connective-tissue sheath which incloses the artery should 



OPERATION'S UPON THE NECK. 155 

be picked up with mouse-tooth forceps, and nicked with the point 
of the knife _ in the direction of the long axis of the vessel; into 
the opening thus made, a director is introduced, and, working close 
to its wall, the vessel is separated all around, taking care to avoid 
the pneumogastrie nerve, which lies posteriorly. A blunt-pointed 
aneurism needle is then introduced into the opening and carried 
around the artery from without inward, entering between the artery 
and the vein. The ligature is then drawn around the vessel, and 
we are ready to tie. The ligature should be of ordinary catgut and 
tied with a square knot. After the ligature is in place and before 
it is tied the parts should be again inspected in order to make sure 
that the nerve is not included. Some surgeons tie the artery double 
and divide it between the ligatures, but this is probably unnecessary. 
The incision is closed with a catgut suture. 

The Exteexal Caeotid. — The ligation of the external carotid 
is practiced as a preliminary to many bloody operations about the 
mouth, jaws, etc., and to control hemorrhage from parts supplied by 
its branches when the branches themselves are not accessible. The 
linear guide to the artery is the same as that for the common carotid; 
the muscular guide is the anterior edge of the sterno-mastoid. At 
the upper border of the thyroid cartilage the common carotid artery 
bifurcates into the external and internal carotids, and it is close to its 
origin, near the upper border of the thyroid cartilage, that the ex- 
ternal carotid is ligated. The incision commences at the level of the 
hyoid bone and is carried downward, for a distance of about two 
inches, along the anterior border of the sterno-mastoid. The in- 
cision penetrates through the skin, fat, and platysma muscle down 
to the deep cervical fascia, exposing the edge of the sterno-mastoid 
muscle, which should be recognized. The edges of the incision are 
drawn apart with blunt-pronged retractors and the deep cervical 
fascia is then incised. 

The pulsation of the artery, within its connective-tissue sheath, 
may now be both seen and felt. The external carotid artery lies a 
little in front of the anterior edge of the sterno-mastoid. The in- 
ternal carotid, together with the internal jugular vein and pneumo- 
gastrie nerve, lies posterior to the external carotid, beneath the 
anterior edge of the sterno-mastoid. Corresponding to the upper 
border of the thyroid cartilage, the loose connective tissue that in- 
vests the artery is picked up with a thumb forceps and snipped with 
the point of the knife, cutting in a direction corresponding to the long 



156 NECK AND TONGUE. 

axis of the vessel; into the opening which is thus made a blunt 
director is introduced and worked around the vessel, sticking close 
to its wall. Through the path thus made by the director a ligature 
is carried around the vessel in the eye of an aneurism needle. The 
ligature is then tied and the incision closed. After the ligature has 
been carried around the artery it may be left untied, with its ends 
hanging out of the incision, to be tied only in case an emergency 
arises calling for its use. 

The Internal Carotid. — The ligation of the internal carotid 
is but seldom called for. The internal carotid may be tied through 
an incision similar to that for ligation of the external carotid. The 
vessel is found underneath the anterior edge of the sterno-mastoid, 
which is the muscular guide to it. The internal carotid has the 
same relations to the internal jugular vein and pneumogastric nerve 
that the common carotid has, the internal carotid being really the 
continuation of the common; and these structures must be avoided 
in isolating the vessel and passing the ligature. 

The Subclavian Artery. — The third part of the subclavian 
artery is tied after it is exposed in the subclavian triangle. 

The patient is placed with the shoulders somewhat raised and 
the head thrown back and turned toward the opposite side, the arm 
being drawn down to depress the shoulder. The incision corresponds 
to the middle third of the clavicle. It is placed just above the 
clavicle, and extends from the anterior border of the trapezius for- 
ward and inward almost as far as the outer border of the sterno- 
mastoid muscle; the incision falls a little short of the edge of the 
sterno-mastoid muscle in order to avoid the external jugular vein. 
The incision in the skin may be made by drawing the integument of 
the neck downward over the surface of the clavicle and then cutting 
through it, down upon the surface of the clavicle; when the skin 
is released, the incision is found to lie just above and parallel 
with the clavicle. This incision reaches through the skin, fat, and 
platysma down to the deep fascia. The deep fascia, which reaches 
from the edge of the trapezius muscle behind to the sterno-mastoid 
in front, is now incised, avoiding the external jugular vein, which 
pierces the deep cervical fascia behind the outer edge of the sterno- 
mastoid muscle. Beneath the deep fascia the venous plexus, formed 
by the transversalis colli and suprascapular, is encountered. These 
veins may be wounded, but are readily clamped; often, however, 
they can be avoided as the knife may be discarded after the deep 



OPERATIONS UPON THE NECK. 157 

fascia has been incised. Beneath the deep fascia there is also a con- 
siderable quantity of loose fat and connective and lymphatic tissue. 

The posterior belly of the omo-hyoid muscle, which lies pretty 
low down near the clavicle, is now sought and must be drawn upward 
to show the subclavian triangle, of which it forms the upper bound- 
ary, the anterior boundary being formed by the sterno-mastoid and 
the inferior boundary by the clavicle. 

"Within the triangle, passing transversely outward, are the trans- 
versalis colli and suprascapular arteries. These vessels should be 
avoided. The tendon of the scalenus anticus, which is the guide to 
the subclavian artery, may be felt as a tense cord passing straight 
up and down beneath the posterior or outer border of the sterno- 
mastoid and attached below to the first rib. If this tendon is fol- 
lowed downward as far as its attachment to the first rib, one may 
locate the subclavian artery as it passes outward and forward from 
behind the tendon of the scalenus anticus muscle, resting directly 
upon the upper surface of the first rib. That part of the subclavian 
artery which lies upon the first rib is the part which is ligated. The 
subclavian vein lies a considerable distance to the inner side of and 
anterior to the artery, the tendon of the scalenus anticus interven- 
ing between them, and is not apt to be encountered during the op- 
eration. "Within the triangle, above the subclavian artery, may be 
seen the three cords of the brachial plexus. These pass obliquely 
downward and outward from behind the scalenus anticus muscle, and 
should not be mistaken for the artery, which is the lowest structure 
in this triangle and rests directly upon the upper surface of the first 
rib. These structures may all be exposed by blunt dissection, sepa- 
rating with the finger or handle of the knife, after the deep fascia 
has been incised. 

With blunt retractors the wound is held open and the con- 
nective-tissue sheath, which envelops the artery, picked up and 
snipped with the scissors and the artery then separated from the 
adjoining structures with a blunt director, working around the artery 
close to its wall. The aneurism needle is passed around the artery 
from without inward, avoiding the cords of the brachial plexus. The 
subclavian vein, which lies below and internal to the artery, is not 
apt to be in the way. 

It should also be remembered that the dome of the pleura 
reaches above the clavicle into the subclavian triangle, and that 
the subclavian artery (second part), as it lies behind the tendon of 



158 NECK AND TONGUE. 

the scalenus anticus, rests upon the pleura, and care should be taken 
to avoid injuring this structure, especially in making way for the 
passage of the ligature. 

The ligature is tied with a square knot, deep in the wound, 
without lifting the artery too much out of its bed. 

The Lingual Aeteky. — This operation is usually performed 
in combination with Kocher's amputation of the tongue. The 
lingual is a vessel of considerable size, that of each side supplying 
the corresponding half of the tongue. In order to prevent the 
entrance of blood into the larynx during the amputation of the 
tongue, the patient is placed in the Eose position, or, if a preliminary 
tracheotomy has been done and a Trendelenburg tampon cannula 
introduced, or if an ordinary tracheotomy tube has been introduced 
and the pharynx tamponed, one may operate with the patient in the 
ordinary position, the shoulders somewhat raised, and the head 
thrown back and over toward the opposite side. 

An incision is made which corresponds to the boundaries of the 
submaxillary triangle. It commences in front, at the symphysis 
mentis, and is carried down to the hyoid bone, thence backward 
above and parallel with the greater horn of the hyoid bone and then 
in a direction upward and backward toward the mastoid process as 
far as the angle of the lower jaw (see Fig. 79). 

This incision penetrates through the skin, fat, and platysma, 
down to the deep fascia. The apex of the flap, which is thus marked 
out, is seized with the fingers and reflected upward upon the side 
of the face as far as the lower border of the jaw-bone. In reflecting 
this flap we may, toward the back, cut the external jugular vein, 
and this should be clamped and tied. The deep fascia is then incised 
and the submaxillary gland exposed. This gland, which is lodged 
in a bed of loose connective tissue, is seized with toothed forceps 
and enucleated, together with the adjoining lymphatic nodes. This 
is accomplished by cutting with the knife close to the gland or by 
blunt dissection with the handle of the knife or with the finger, 
the gland being finally cut away from its duct, which disappears 
anteriorly beneath the posterior border of the mylo-hyoid muscle on 
its way to open into the anterior part of the floor of the mouth. 
The facial artery, if not previously cut, is usually divided in enucleat- 
ing this gland, and should be tied when cut, or, still better, it may 
be tied, before it is cut, close to its origin and before it reaches the 
submaxillary gland. 



OPERATIONS UPON THE TONGUE. 159 

The facial vein is also usually divided during this part of the 
operation; this vessel bleeds freely, hut may be clamped and ligated. 
After the submaxillary gland has been removed, the boundaries of 
the submaxillary triangle are readily made out; above, the lower 
border of the jaw, and, below, in front, and behind, the anterior and 
posterior bellies of the digastric muscle. The floor of the submaxil- 
lary triangle is formed in front by the oblique fibers of the mylo- 
hyoid and behind by the perpendicular fibers of the hyo-glossus, 
which muscle lies on a deeper plane than the mylo-hyoid, being 
partly overlapped by the posterior margin of the latter. Passing 
from behind, horizontally forward, above and parallel with the hyoid 
bone and lying directly upon the hyo-glossus muscle is the hypo- 
glossal nerve; this nerve disappears anteriorly beneath the poste- 
rior edge of the mylo-hyoid muscle. This nerve marks the upper 
boundary of the lingual triangle, which is really the apex of the 
submaxillary triangle. The base of the lingual triangle is formed 
by the hypoglossal nerve, and its lower borders, in front and behind, 
by the anterior and posterior bellies of the digastric. The floor of 
the lingual triangle is formed by the hyo-glossus, and beneath this 
muscle the lingual artery, accompanied by a vein, is located; so that, 
if this muscle is picked up with tooth forceps and snipped through 
with the knife or scissors, the lingual artery is readily found and 
may be hooked up with an aneurism needle and tied. Locating 
and tying the lingual artery in this triangle is very simple. We are 
then ready to proceed with the amputation of the tongue. 

Should it be desirable to tie the lingual artery without remov- 
ing the submaxillary gland, one may, after cutting through the deep 
fascia, draw the gland up out of the way and then proceed as above. 
In this case it is not necessary to make such an extensive incision. 

OPERATIONS UPON THE TONGUE. 

Amputation of the Tongue (Kocher), with Preliminary Ligation 
of the Lingual Artery. — Amputation of the tongue according to the 
method of Kocher has many advantages: the hemorrhage is easily 
controlled, diseased glands are readily removed, and the incision is 
well placed for drainage. 

The position of the patient, etc., has been described in connec- 
tion with the ligation of the lingual artery. 



160 NECK AND TONGUE. 

An incision, as described above for the ligation of the lingual 
artery, is made upon the side of the neck, laying bare the boundaries 
of the submaxillary triangle. The lymphatic nodes and submaxillary 
gland are then excised and the lingual artery sought for and tied; 
it is not necessary to ligate the lingual of each side, yet this may be 
clone with advantage, especially if the lymphatics of both sides are 
involved, as they can then be extirpated at the same time that the 
vessel is ligated. 

After having excised the submaxillary lymphatic nodes and 
gland and tied the lingual artery and secured all bleeding points, 
an incision is made with the knife through the floor of the sub- 
maxillary triangle, — i.e., through the mylo-hyoid muscle and the 
mucous membrane of the mouth, — close to the inner surface of the 
body of the lower jaw. This opening may be farther enlarged with 
the scissors or fingers. The tip of the tongue is then seized with a 
forceps and drawn out into the wound in the neck, through the 
opening in the floor of the mouth, and making considerable traction, 
first to one side and then to the other, the tongue is separated from 
its attachment to the floor of the mouth, as far back toward the base 
as possible. This is done with the blunt-pointed curved scissors, 
snipping through the septum of the tongue and working close to its 
under surface. During this step of the operation, and while traction 
is being made upon the tongue, one should examine occasionally with 
the finger for bands, etc., which tend to bind the tongue within the 
mouth. The anterior pillars of the fauces, which are attached to the 
sides of the tongue, near its base, should be cut close to the surface 
of the tongue, and then it will be observed that the organ can be 
drawn out of the mouth for a considerable distance, when it may be 
amputated quite close to its root. This is done with the scissors. 

The half of the tongue, corresponding to the side upon which 
the lingual has been tied, may be cut through without occasioning 
any bleeding; but, if the lingual artery of the other side has not 
been previously tied, the hemorrhage, when this second half of the 
tongue is cut through, may be embarrassing, as there may be some 
difficulty in catching the cut end of the artery. This, however, may 
be provided against by seizing the base of the tongue with a toothed 
clamp behind the point where it is intended to amputate it before 
cutting through; so that, when we divide this half of the tongue, 
we may puli the stump forward, and seize the divided vessel, when 
it spurts, with an artery clamp. 



OPERATIONS UPON THE TONGUE. 161 

The wound in the side of the neck may he closed with inter- 
rupted silk-worm gut sutures, except its posterior part, which is left 
open and packed to carry off the secretions, etc., from the mouth. 
The packing should he introduced well into the cavity of the mouth. 
The patient is fed through a stomach tune, which is passed through 
the mouth or through the nose. This tube may be passed before the 
patient recovers from the ansesthetic. 

Amputation of the Tongue (Regnoli-Billroth). — This method 
is applicable to those cases where the floor of the mouth is consid- 
erably involved in the disease. 

The patient is placed in the Eose position, or if a preliminary 
tracheotomy has been done and a Trendelenburg tampon cannula 
introduced into the trachea, or if an ordinary tracheotomy tube has 
been introduced and the pharynx has been tamponed, the patient 
may lie in, the usual position with the shoulders raised and the head 
thrown back. 

An incision is made along the lower border of the body of the 
jaw about 6 cm. long, the midpoint of the incision corresponding to 
the symphysis mentis. This incision penetrates through all the soft 
parts down to the bone and extends backward, upon either side, 
nearly as far as the anterior edge of the masseter muscle. In making 
this incision, the facial artery, as it turns up over the lower border 
of the jaw-bone, just in front of the masseter, may be avoided. 

From either end of this incision additional ones are made which 
reach straight downward as far as the hyoid bone, passing through 
the integument and the platysma. Through the lateral incisions, 
on either side, the lingual artery may be sought and tied, at the 
same time extirpating any diseased glands, etc. 

The cavity of the mouth is now entered by severing the muscles 
attached to the inner surface of the body of the lower jaw with a 
knife. They should be cut fairly close to the bone, and the point 
of the knife may be guided with the finger in the mouth. Those 
muscles that are attached to the inner aspect of the symphysis 
in the middle line are divided first. A suture should be passed 
through the tip of the tongue or it may be seized with a toothed 
clamp in order to exercise traction and prevent its falling back into 
the pharynx and obstructing the breathing during the course of the 
operation. 

After a sufficiently large opening has been made in the floor 
of the mouth, the tongue is drawn through the wound, under the 



162 NECK AND TONGUE. 

jaw, and may then be removed together with the floor of the mouth 
as far back as the epiglottis. 

If the lingual arteries have not been previously ligated, the base 
of the tongue should be seized with a vulsella forceps before it is 
amputated, in order to facilitate the clamping of these vessels in the 
stump of the tongue. 

The flap of skin and soft parts is replaced and the wound closed 
except posteriorly, on one or both sides, where the incision is left 
open and packed in order to drain the cavity of the mouth. 

Extirpation of the Tongue through the Floor of the Mouth, with 
Division of the Lower Jaw. — The operation is preceded by a trache- 
otomy and the introduction of a Trendelenburg tampon cannula, 
or an ordinary tracheotomy tube may be used and the pharynx tam- 
poned. A soft rubber tube for feeding purposes may be passed into 
the stomach, before the patient recovers from the anaesthetic, either 
through the mouth or the nose. 

Sedillot's Method, with Division of the Lowek Jaw in the 
Middle Line. — The first incisor tooth of the lower jaw is extracted. 
An incision is made, as in the Eegnoli-Billroth operation, along the 
lower border of the jaw and reaching as far as the masseter on either 
side. The lower lip is then split in the middle line, the incision being 
carried down to the bone through the gum and periosteum. The 
lower jaw is then sawn through with a metacarpal or a chain or a 
Gigli saw, and the muscles and the mucous membrane composing the 
floor of the mouth incised close to the inner surface of the body of 
the lower jaw-bone. 

Each half of the jaw is now drawn well outward, away from the 
middle line, thus giving very free access to the tongue and to the 
floor of the mouth. The tongue and that part of the floor of the 
mouth which is involved in the disease may then be extirpated. 

If the Unguals have not been previously tied, they may be 
clamped after the tongue has been amputated, drawing the stump 
of the tongue forward with a vulsella in order to facilitate this. 

The tonsils and the pillars of the fauces may also be reached 
in this operation, and, if the lower jaw-bone is involved, it can be 
resected in part. Diseased lymphatic glands in the neck may also 
be excised through this incision, which may be made as extensive 
as necessary. 

One should attempt to bring the raw surfaces in the mouth 
together, at least in part, with interrupted chromicized catgut or 



OPERATIONS UPON THE TONGUE. 163 

silk sutures, their ends being left long to facilitate their removal 
later. 

The two' halves of the jaw are brought together and carefully- 
wired, and the incision closed except at its posterior part on one or 
both sides, where it is left open for packing and drainage. 

Langenbeck's Method, with Division of the Lower Jaw 
on one Side. — Upon the side corresponding to the disease an in- 
cision is carried from the corner of the mouth through the lower 
lip as far as the lower border of the jaw, whence it is continued 
downward through the integument of the neck as far as the side 
of the hyoid bone. The upper part of this incision splits the lip 
and gum, passing through the periosteum down to the bone; the 
lower part of the incision passes through the skin, fat, and platysma. 
All bleeding points are clamped. 

Through the lower part of the incision, after cutting through 
the deep fascia, the submaxillary gland and the neighboring dis- 
eased lymphatic nodes of this side may be removed, and the lingual 
artery tied as it lies in the lingual triangle, above the hyoid bone 
and beneath the hyo-glossus muscle. 

The canine tooth of the lower jaw is now extracted and an open- 
ing made in the floor of the mouth so as to allow the use of the chain 
or wire saw with which the jaw-bone is divided. The section through 
the jaw should be, not straight up and down, but obliquely from 
above downward and inward toward the symphysis, so that the tend- 
ency to dislocation caused by the pull of the masseter muscle may 
thus be counteracted. The jaw-bone may be divided with a narrow, 
flat saw or with a chain or wire saw. 

The segments of the divided jaw-bone, especially the shorter 
piece, are now drawn well apart with sharp retractors, and the soft 
parts, muscles and mucous membrane, which form the floor of the 
mouth, separated from their attachment to the inner surface of the 
bone, as far back, if need be, as the anterior pillars of the fauces. 
The tongue is then seized with the toothed forceps and drawn well 
forward and over toward the well side and removed. One may ex- 
cise the floor of the mouth, the pillars of the fauces, and the tonsils, 
if they are diseased, and also resect a part of the jaw-bone if this 
is involved. 

If the Unguals have not been previously ligated, we may clamp 
them in the stump after the tongue has been amputated. The seg- 
ments of the jaw-bone are brought into apposition and wired, and 



164 NECK AND TONGUE. 

the wound in the soft parts, except its lower part, which is left open 
and packed to carry off the secretions from the mouth, is closed with 
interrupted silk-worm gut sutures. 

One should try to diminish the raw surface left in the buccal 
cavity as much as possible by drawing the parts together with' sepa- 
rate chromicized catgut sutures. 

Billeoth's Method, with Bilateeal Division of the Lowee 
Jaw. — This is probably not so satisfactory as the preceding opera- 
tions, owing to the difficulty of getting union of the loose segment 
of the jaw. 

The canine tooth upon either side of the lower jaw is extracted, 
and an incision made from each corner of the mouth, through the 
lower lip, gum, and periosteum, down to the bone, and continued 
downward, in the neck, through the skin, fat, and platysma as far 
as the hyoid bone. 

Corresponding to the place upon either side where the canine 
tooth has been extracted the lower jaw is sawn through, from its 
upper border downward to its lower border; this may be done with 
the chain, wire, or flat saw. 

The soft parts, which correspond to the floor of the mouth and 
which are attached to the middle, loose segment of the jaw-bone, are 
separated upon the inner aspect of the bone, and the flap of soft 
parts, which includes the free middle segment of the bone, is re- 
flected downward. 

The lingual arteries may be ligated and diseased glands re- 
moved through the incisions in the neck previous to amputating the 
tongue, or the arteries may be clamped and ligated in the stump 
after the tongue has been cut away. We gain free access to the 
floor of the mouth, tonsils, etc., in this operation. 

The segments of the jaw are finally wired together and the 
incisions closed except the lower part, upon one or both sides, which 
may be left open and packed for drainage. 

Extirpation of Half of the Tongue (Whitehead). — The patient 
may be placed in a half-sitting posture. Anaesthesia is not complete. 
A liberal dose of morphin may be administered hypodermically 
shortly before the operation, and only sufficient chloroform used to 
keep the patient fairly quiet. In this way sufficient reflex is retained 
to enable the patient to keep the larynx clear of blood by coughing 
and expectorating. 

This operation is advisable when only half of the tongue is to 



OPERATIONS UPON THE TONGUE. 165 

be removed, or, if the whole tongue is to be extirpated, where the 
disease is limited and has not involved the floor of the mouth. 

One or both lingual arteries may be previously tied through a 
small incision upon either side of the neck. 

The jaws are separated with a gag and the mouth held wide open 
with flat retractors placed in either corner. A strong silk suture is 
passed through the tip of the tongue, and with this as a tractor the 
tongue is drawn well forward and split down the middle with sharp 
scissors. The diseased half of the tongue is then separated from the 
floor of the mouth and amputated as far back toward the root of 
the organ as desired. If the lingual artery has not been tied as a 
preliminary step to the operation, the bleeding vessel must be seized 
with the artery forceps in the stump of the tongue and ligated. In 
excising a portion of the tongue one should cut wide of the apparent 
diseased area. If the disease has approached near the middle line 
it is probably better to sacrifice the whole tongue, in which case the 
second half of the tongue may be amputated in a similar manner. 

This operation will probably suffice for early cases where the 
floor of the mouth and the lymphatics are not yet involved. 



PART IV. 

THE THORAX. 



THE SURGICAL ANATOMY OF THE THORACIC WALL. 

The Skeleton of the Thorax. — The thorax consists of a conical 
cage of bone and cartilage. Entering into its construction are the 
dorsal vertebrae, ribs, sternum, and interposed costal cartilages. The 
spaces between the ribs and costal cartilages are filled in, and the 
walls of the chest thus completed, by the intercostal muscles. 

The thoracic cavity is rather cone-shaped, with its base below 
and its small end above, and is somewhat flattened from before back- 
ward. 

The upper orifice of the thorax is kidney-shaped, narrow from 
before backward, and broader from side to side. It is bounded in 
front by the upper border of the sternum, behind by first dorsal 
vertebra, and laterally, on each side, by the first rib. The first rib 
is set very obliquely; so that its anterior end strikes a much lower 
level than its posterior end. The upper border of the sternum is 
opposite the intervertebral cartilage between the second and third 
dorsal vertebras. 

The lower opening of the thorax is large. It is bounded by the 
lower border and tip of the twelfth rib, the tip of the eleventh and 
the costal cartilages of the tenth, ninth, eighth, and seventh ribs. 
Anteriorly, in the middle line, is the ensiform cartilage; posteriorly 
is the body of the last dorsal vertebra. 

A transverse section through the middle of the thoracic cavity 
shows it to be rather heart-shaped, owing to the projection forward 
of the bodies of the vertebras. On either side of the vertebral col- 
umn there is a longitudinal recess, which serves to deepen the space 
for the accommodation of the lungs; this is called the fossa pul- 
monis. The cartilages of the lower ribs, the seventh to the tenth, 
meet at the lower end of the sternum and form an angle the apex 
of which corresponds to the ensiform cartilage. This is known as 
the costal angle. 

The thoracic cavity is closed in, below, by the diaphragm, which 
projects upward, dome-like, into the cavity of the chest, forming its 
(166) 



SURGICAL ANATOMY OF THE THORACIC WALL. 167 

floor and at the same time the roof of the abdominal cavity. By the 
projection of the diaphragm upward into the chest the capacity of 
the chest cavity is diminished and that of the abdomen correspond- 
ingly increased. In the living body the chest appears to be broader 
above, at the shoulders, than below at the waist; this appearance is 
due to the broad shoulder girdle, which partially encircles the chest 
above and which is made up of the clavicle and the scapula of either 
side. 

The space within the chest consists of an air-tight compartment 
on either side, each containing one of the lungs, and a middle space 
called the mediastinum, in which are lodged the heart and the great 
vessels at its base, the trachea, oesophagus, thoracic duct, and the 
thymus gland or its remains. 

The Doksal Vektebk^;. — These are twelve in number and 
form the back part of the skeleton of the chest. They give stability 
to the thorax and at the same time, on account of the presence of 
the elastic intervertebral pads, free motion is allowed in all direc- 
tions. 

This part of the vertebral column shows a sagittal curve with 
its concavity forward and a slight lateral curve with its concavity 
toward the left (aorta). 

The Eibs are twelve in number (may be eleven or thirteen) on 
each side. They are flat bones articulated behind to the vertebrae 
and directed obliquely downward and forward. They form the bony 
frame-work of the back, sides, and part of the front of the chest. 

The lower the rib is situated, the greater is its inclination down- 
ward. They increase in length from the first to the eighth. 

The first to the seventh are true ribs: i.e., they are each con- 
nected individually, through their cartilages, with the sternum. 

The eighth to the twelfth are false ribs: their cartilages do not 
articulate with the sternum. The eighth, ninth, and tenth ribs are 
indirectly connected with the sternum through the junction of their 
respective costal cartilages with those of the ribs which immediately 
adjoin them above. 

The eleventh and twelfth are floating ribs; they are short and 
their cartilages are free. 

The lower border of each rib, upon its inner aspect, is grooved 
for the lodgment of the corresponding intercostal vein, artery, and 
nerve, that being their order from above downward. 

The first rib is important surgically. It is very short, and its 



168 THORAX. 

surfaces look almost directly upward and downward. It is set so 
obliquely that its posterior end, head, articulates with the upper 
part of the body of the first dorsal vertebra, whereas its anterior 
end, at its attachment to the sternum, is upon a level with the inter- 
vertebral pad between the second and third dorsal vertebras. The 
inner border of this rib presents a tubercle for the attachment of 
the scalenus anticus muscle; external to this tubercle, upon the 
upper surface of the rib, there is a groove for the subclavian artery. 
The subclavian vein also passes across the upper surface of the first 
rib, but internally to the artery, the tendon of the scalenus anticus 
being interposed between the two vessels. 

The inner border of the first rib is in direct relation with the 
dome of the pleura and the apex of the lung. 

The Costal Caetilages. — These are the elastic bands which 
join the ribs to the sternum (except the eleventh and twelfth). The 
cartilage of the first rib is very short. The first and second costal 
cartilages, as they pass to the sternum, are directed somewhat down- 
ward like their ribs. The cartilage of the second rib articulates 
with the sternum at the junction of the manubrium with the glad- 
iolus. The cartilage of the third rib is directed horizontally; the 
cartilages of the fourth, fifth, sixth, and seventh ribs are directed 
upward with increasing obliquity as they pass to the sternum. The 
cartilages of the eighth, ninth, and tenth make quite a sharp turn 
upward toward the sternum at the angle of junction with their ribs, 
and do not reach the sternum directly, but are fixed each to the 
cartilage immediately above, and finally, through the junction of the 
cartilage of the eighth rib with that of the seventh, to the sternum. 
The cartilages of the eleventh and twelfth ribs are short and free. 

The Steknttm. — This bone is rarely fractured, owing to the 
elasticity of the parts with which it articulates. It consists of a 
manubrium, or handle; a gladiolus, or body; and a cartilaginous tip, 
the ensiform or xiphoid cartilage. The junction between the manu- 
brium and the body is marked by a prominent transverse line, and 
presents an angle directed forward: angulus Ludovici. This trans- 
verse ridge, which is readily felt under the skin, is an important 
landmark in counting the ribs: it corresponds to the articulation of 
the costal cartilage of the second rib with the sternum. 

The ensiform cartilage varies in length and shape; its lower 
extremity is usually on a level with the tenth dorsal vertebra; it 
may be bifurcated or deflected to one side. The junction of the 



SURGICAL ANATOMY OF THE THORACIC WALL. 169 

ensiform cartilage with the body of the sternum corresponds with 
the line that marks the lower border of the heart as it lies within 
the chest behind the sternum. 

The Muscles of the Chest Wall. The Inteecostal Muscles 
are placed between the ribs and costal cartilages, and consist of two 
sets: external and internal. 

The External Intercostals. — The fibers of the external inter- 
costals have a direction similar to those of the external oblique 
muscle of the abdomen: that is, from above downward and forward. 
In front, between the costal cartilages, the muscular fibers are ab- 
sent, their place being taken by aponeurotic bands, the ligamenta 
intercostalia anterior, which represent the muscles. 

The Internal Intercostals. — The direction of the fibers of the 
internal intercostal muscles is the reverse of those of the external. 
They correspond to the internal oblique muscle of the abdomen, 
and their fibers have a similar direction: upward and forward. Be- 
hind, the internal intercostals are deficient, their place being occu- 
pied by aponeurotic sheaths: the ligamenta intercostalia posterior. 

The Teiangttlaeis Steeni is situated anteriorly within the 
chest. It is a thin sheet of muscle which is attached along the 
lateral border of the posterior aspect of the sternum. It spreads 
upward and outward in four or five processes, which are attached 
separately to the inner surfaces of the cartilages of the second to 
the sixth ribs. The internal mammary artery is located between 
this muscle and the costal cartilages. The triangularis sterni is the 
transversus thoracis anterior of Henle. 

The Musculi Stjbcostales are a few sets of muscular fibers 
that are found upon the internal surfaces of the posterior ends of 
the ribs near the vertebral column; the direction of the fibers of 
these muscles is similar to that of the internal intercostals: they 
reach from the inner surface of one rib to the first or second rib 
above. These muscles correspond to the musculus transversus 
thoracis posterior of Henle, and together with the triangularis sterni 
are the analogues of the transversus abdominis, the most internal, 
deepest, of the flat muscles of the abdomen. 

The Fasciae of the Chest. — A thin fascia covers the outer surface 
of the ribs and the external intercostals. A similar fascia is spread 
over the inner surface of the ribs and the internal intercostals, tri- 
angularis sterni, and subcostales. This fascia corresponds to the 
fascia transversalis of the abdomen, and is known as the fascia endo- 



170 THORAX. 

thoracica. The fascia endothoracica is also spread over the thoracic 
surface of the diaphragm. It lines the whole inner surface of the 
thoracic cavity, and is everywhere interposed between the parietal 
layer of the pleura and the inner surface of the chest, serving thus 
to bind the pleura to the chest wall and at the same time to 
strengthen it. Upon the posterior surface of the sternum this fascia 
iorms a strong fibrous layer. Above it projects into the root of 
the neck together with the dome of the pleura, which it strengthens 
and fixes to the vertebrae and to the deep surface of scaleni muscles, 
etc. 

The Internal Mammary Artery supplies the front part of the 
intercostal spaces and the diaphragm and gives perforating branches 
to the muscles of the chest and to the mammary gland. At its origin 
from the first part of the subclavian artery it lies behind the sub- 
clavian vein, resting upon the pleura, and is crossed by the phrenic 
nerve. It passes down into the thoracic cavity and descends along- 
side of the sternum, a distance of from 5 to 10 mm. intervening 
between it and the lateral border of this bone. Behind the seventh 
costal cartilage the internal mammary artery divides into the 
musculo-phrenic and the superior epigastric. The musculo-phrenic 
continues downward parallel with the free border of the ribs, sup- 
plying branches to the intercostal spaces. The superior epigastric 
enters the posterior sheath of the rectus, anastomosing with the deep 
epigastric, which is derived from the external iliac, and in this way 
forms an important communication between this trunk and the sub- 
clavian. The internal mammary artery is accompanied by two veins, 
one upon either side, but above these two unite to form a single 
vein, which lies to the inner side of the artery. The artery is also 
accompanied by a chain of lymphatic glands. 

Within the chest the artery rests upon the costal cartilages and 
the internal intercostal muscles, alongside the sternum, and is sepa- 
rated from the parietal pleura by the fascia endothoracica and the tri- 
angularis sterni muscle. Opposite each intercostal space the internal 
mammary gives off an intercostal branch, which, passing outward, 
divides into two, and these, anastomosing with the intercostal 
branches from the aorta, serve to establish a communication between 
the subclavian and the aorta. These intercostal branches are located 
between the internal and the external intercostal muscles close to 
the upper and lower borders of the contiguous ribs. The internal 
mammary gives off perforating branches, which pass forward through 



REGIONS OF THE CHEST. 171 

the intercostal spaces to supply the muscles of the hreast and the 
mammary glands. Those which pass through the second, third, and 
fourth intercostal spaces are large, and are distributed to the mam- 
mary gland. 

The Diaphragm. — The lower orifice of the thorax is closed in 
by the diaphragm. This is a musculo-tendinous partition which 
separates the thorax from the abdominal cavity. It forms the floor 
of the thoracic cavity and the roof of the abdomen. The thoracic 
surface of the diaphragm is covered by the fascia endothoracica and 
the diaphragmatic portion of the parietal pleura. Its middle part 
from before backward forms the floor of the mediastinum, and upon 
either side of this it forms the bottom of each pleural cavity. 

The position of the diaphragm, immediately after death, corre- 
sponds with that found at the end of quiet expiration during life, 
but after a short time, owing to the further collapse of the lungs, 
it reaches to a still higher level. 

Luschka places the highest point reached by the diaphragm 
at the end of forced expiration upon the right side at the level of 
the fourth rib. Most authors say that this is too high and give, in- 
stead, the fourth intercostal space. Upon the left side the dia- 
phragm does not reach as high as upon the right by the breadth 
of one rib. 

The upper orifice of the thoracic cavity is shut in on either side 
by the arching subclavian artery, scalenus anticus and medius mus- 
cles, and the fascia endothoracica. This fascia is intimately blended 
with the dome of the pleura, and attaches the same to the adjacent 
fixed points. 

THE REGIONS OF THE CHEST. 

The following imaginary lines serve to facilitate the location of 
points upon the chest: — 

1. The midsternal, which passes through the middle of the 
sternum. 

2. The lateral sternal, which corresponds to the lateral border 
of the sternum. 

3. The mammary, which is drawn through the nipple. 

4. The parasternal, which is drawn midway between the lateral 
horder of the sternum and the mammary line. 

5. The axillary, which is located midway between the anterior 
and the posterior borders of the axilla. 



172 THORAX. 

6. The scapular passes through the lower angle of the scapula. 
The chest is divided into a number of regions as follows: — - 

1. The sternal. 

2. The upper anterior pectoral, which is subdivided into a 
clavicular, an infraclavicular, and a mammary. 

3. The lower anterior pectoral. 

4. The lateral pectoral. 

The Sternal Region.- — This region corresponds to the sternum- 
It is depressed below the level of the rest of the chest, especially 
in muscular subjects and in females. 

The skin of this region, in the male, is usually covered with hair 
and is rich in sweat-glands. The subcutaneous tissue is poor in fat 
and allows ready palpation of the sternum beneath. The skin and 
periosteum covering the sternum are so intimately blended with each 
other that separation between these two layers is somewhat difficult,, 
and, therefore, collections of blood or pus beneath the skin in this 
region remain circumscribed, as is the case in the subcutaneous tissue 
of the scalp. Above, we observe the upper notched border of the- 
sternum with the sterno-clavicular articulation upon either side and 
the attachment of the tendon of the sterno-mastoid. Below is the 
ensiform cartilage, to which is attached the linea alba. The junction 
of the manubrium with the body of the sternum is marked by a 
prominent transverse ridge and presents an angle directed forward: 
the angle of Ludovici. The sternum forms the anterior wall of the- 
mediastinal space, and its posterior surface is in close relation with 
the pleura and the edges of the lungs. Below, the heart, inclosed 
in the pericardial sac, lies close behind the sternum. 

The Upper Anterior Pectoral Region. — This area corresponds to 
the region of the pectoralis major muscle, and shows the prominence 
of the breast surmounted by the nipple and the areola. The skin is 
soft, especially in women, and during lactation is marked by blue 
lines, which correspond to large superficial veins. The skin is freely 
movable, owing to the looseness of the subcutaneous tissue, which 
is rich in fat and within which the mammary gland is contained. 
The mammary gland is freely movable upon the underlying pec- 
toralis major muscle. The anterior surface of the pectoralis major 
is covered by a thin, cellular fascia, which also lines the posterior 
aspect of this muscle. Beneath the pectoralis major are the pec- 
toralis minor and the subclavius muscle. The pectoralis major and. 
minor form the front wall of the axilla. 



REGIONS OF THE CHEST. 173 

The Pectoealis Majoe is a broad, flat muscle which occupies 
all of this region. It takes its origin from the cartilages of the six 
or seven upper ribs and from the edge of the sternum: the sternal 
portion of the muscle. It also arises from the inner half of the 
anterior surface of the clavicle: the clavicular portion of the mus- 
cle. From these points of origin the fibers converge to form a flat 
tendon, about two inches broad, which is attached to the outer edge 
or lip of the bicipital groove: a depression which marks the upper 
part of the front of the humerus. The pectoralis major muscle is 
covered by a thin fascia, which dips down between its fasciculi and 
from which the overlying fat and mammary gland are readily sepa- 
rated. This fascia is rich in lymphatics, which may become involved 
in disease of the mammary gland. Below, this fascia is continuous 
with the superficial fascia which covers the abdominal muscles and 
laterally with that which covers the serratus magnus. It dips down 
into the space between the deltoid and the pectoralis major, and is 
there continuous with the loose fascia that invests the pectoralis 
minor and the posterior surface of the pectoralis major. 

The Pectoealis Minor. — This muscle is exposed by dividing 
the tendon of the pectoralis major close to its insertion and reflect- 
ing the muscle downward. The pectoralis minor arises from the tip 
of the coracoid process; passing downward and inward and becoming 
broader, it is attached to the third, fourth, and fifth ribs. The 
pectoralis minor is invested by a fascia which is continued upward 
and inward beyond the upper border of the muscle, covering in the 
first part of the axillary artery and adjoining structures and the sub- 
clavius muscle. This layer of fascia is called the costo-coracoid 
membrane and is attached to the under surface of the clavicle and 
to the first rib. It is somewhat thickened, and perforated by various 
vascular and nervous branches, which pass to and from the axillary 
vessels and adjacent nerves. 

The Subclavius Muscle. — This muscle is exposed after the 
costo-coracoid membrane has been removed. It arises from the 
under surface of the clavicle and passing downward and inward is 
attached to the cartilage of the first rib. 

This upper anterior pectoral region may be considered as the 
clavicular, the infraclavicular, and the mammary regions. 

The Clavicular Kegion. — The clavicle can be readily pal- 
pated beneath the freely movable integument which covers it from 
its inner end, where it articulates with the sternum, to its outer end, 



174 THORAX. 

where it articulates with the acromion process of the scapula. The 
acromion process of the scapula forms the most external and promi- 
nent point of the shoulder. 

Beneath the skin in the clavicular region are found the platysma 
and the deep fascia. 

To the upper surface and posterior border of the clavicle are 
attached, internally, the sterno-mastoid muscle, and externally the 
trapezius. To the inner half of the front surface of the clavicle is 
attached the pectoralis major muscle (clavicular portion), and, to 
its outer half, the deltoid muscle. 

The under surface of the clavicle shows, at its inner end, the 
attachment of the rhomboid ligament. This ligament extends be- 
tween the under surface of the clavicle and the cartilage of the first 
rib. External to this the subclavius muscle arises from the under 
surface of the clavicle. 

The inferior surface of the outer end of the clavicle is con- 
nected with the coracoid process of the scapula by strong ligamentous 
bands. 

Beneath the clavicle, between it and the first rib, the blood- 
vessels and nerves pass from the root of the neck into the axilla. 

The Infeaclaviculak Eegion. — This is the region below the 
clavicle. Between the pectoralis major and the deltoid muscle, close 
to the clavicle, there is a triangular depression, the fossa of Mohren- 
heim: the infraclavicular fossa. 

In the space, or groove, between the pectoralis major and the 
deltoid are lodged the cephalic vein and the descending branch of 
the acromio-thoracic artery, which is given off from the axillary. 
If the two muscles are widely separated, we expose the upper part 
of the pectoralis minor, covered by its fascia, some loose connective 
tissue and fat, and the coracoid process. This process is readily felt 
underneath the skin, and in thin persons can be seen. 

If the pectoralis major is cut away from its attachment to the 
clavicle and from the upper part of the sternum and reflected down- 
ward, the infraclavicular region proper is uncovered. The pectoralis 
minor muscle is now more freely exposed. The cephalic vein may 
be seen passing from without inward across the pectoralis minor 
into a mass of fat and connective tissue on the inner side of the 
muscle, where it disappears through an opening in the costo-coracoid 
membrane to reach the first part of the axillary vein, which lies 
underneath this membrane. 



REGIONS OF THE CHEST. 175 

The acromio-thoracic and branches of the superior thoracic 
which are derived from the axillary artery are seen to emerge through 
openings in the costo-coracoid membrane, as is also the external 
anterior thoracic nerve, which supplies the pectoralis major. 

The costo-coracoid membrane is a sheet of fascia which is con- 
tinued from the inner or upper border of the pectoralis minor mus- 
cle upward and inward, and is attached to the under surface of the 
clavicle and to the first rib; it covers in the first part of the axillary 
artery and the structures that accompany it and the subclavius mus- 
cle. When the costo-coracoid membrane is removed, we expose the 
first part of the axillary artery and its acromio-thoracic and superior 
thoracic branches, the cords of the brachial plexus, which lie above 
the artery, and the axillary vein, which lies below and internal to the 
artery. The cephalic vein may be seen passing across the axillary 
artery to enter the axillary vein. All these structures are gathered 
together into a single bundle, and are accompanied by a mass of 
fat, connective tissue, and lymphatics (see Fig. 183). 

The Mammaey Eegion (Beeast). — The mammary gland is 
rudimentary in the male and naturally well developed in the female. 
It rests upon the pectoralis major muscle from the third to the sixth 
rib. In unmarried and in young females it is hemispheroidal, firm, 
and projects forward; but after child-bearing, and especially in some 
races more than others, it is pendulous, and hangs down over the 
lower part of the thorax. 

The skin of this region is thin and fine and is freely movable 
upon the underlying tissue. The superficial veins may show through 
the skin as irregular blue streaks. The skin of the nipple is espe- 
cially thin and pigmented, and may be fissured and split, and shows 
the orifices of the milk-ducts, fifteen to twenty in number, as very 
fine, needle-point openings; through these infection may reach the 
mammary gland tissue proper. 

In the unpregnant the nipple is depressed and pinkish, but is 
prominent and dark colored during pregnancy. The nipple is sur- 
rounded by a pigmented area, areola, which is fixed to the under- 
lying tissue and marked by little nodules which correspond to se- 
baceous and sweat-glands. 

In the unmarried the mammary gland proper is small, the promi- 
nence of the breast being due chiefly to the abundance of the fatty 
tissue in which the gland is imbedded. It does not reach its full 
development until after pregnancy. The mammary gland is a teg- 



176 THORAX. 

mentary organ inclosed within its own proper fibrous capsule and 
lodged in the subcutaneous fat. It consists of a number of lobules, 
which are separate and distinct from each other; so that the secre- 
tion of milk and nursing may be continued even after one or more 
lobules have become the seat of a suppurative process. Between 
the mammary gland and the anterior surface of the pectoralis major 
muscle there is a layer of loose fatty tissue, which permits the gland 
to be freely moved about upon the surface of the muscle. 

Occasionally a process of gland tissue almost entirely discon- 
nected from the main gland may be found lying under the border 
of the pectoralis major, dipping beneath the muscle into the axilla. 
This process of gland tissue is often difficult to recognize. All the 
ducts of the gland converge from the periphery toward the nipple; 
they may become occluded and distended, giving rise to cystic tumors 
whose contents consist of milk or of a buttery material: galactocele. 

The arteries of the breast consist of perforating branches from 
the internal mammary, especially the second and third and branches 
of the long thoracic from the axillary. Of the veins, the superficial 
ramify beneath the skin and the deep ones accompany the arteries. 

The lymphatics are important and of these there are two sets: 
those of the integument and those which drain the gland proper. 
The lymphatics of the integument are very superficial and numerous, 
especially upon the nipple and in the areola; corresponding to the 
region of the areola, they form a fine capillary net-work which 
spreads outward toward the periphery, some branches dipping in- 
ward to enter a plexus which surrounds the milk-ducts beneath the 
skin of the areolar region. The lymphatics from the gland proper, 
from the acini and substance of the gland, are abundant. Accord- 
ing to Sappay, they all tend toward the surface and end as good- 
sized vessels in the plexus already mentioned which surrounds the 
milk-ducts beneath the skin of the areola. The lymph from this 
subareolar plexus is collected into two main channels: one above 
and one below the nipple. These lymphatic vessels pass outward 
toward the outer border of the gland, and, after being joined by one 
or two vessels from the periphery of the gland, terminate in the 
nearest lymphatic nodes, which are found near the anterior wall of 
the axilla in the neighborhood of the third and fourth ribs, being 
covered usually by the edge of the pectoralis major. These are, as 
a rule, the first lymphatic nodes to become involved in disease of 
the mammary gland. The lymphatic nodes in the root of the neck 



MEDIASTINUM AND CONTENTS. 177 

also receive tributaries from the breast, and may be found involved 
when the mammary gland is diseased. 

The Lower Anterior Pectoral Region. — This is the area which 
lies between the lower limits of the pectoralis major muscle and 
the free border of the ribs. This region is important surgically only 
on account of the structures which lie beneath it, within the chest 
and abdomen. 

The Lateral Pectoral Region. — This space is included between 
the border of the pectoralis major in front and that of the latissimus 
dorsi behind. It presents the ribs covered by serrations of the ser- 
ratus magnus and by the latissimus dorsi and obliquus abdominis 
externus. 

The arteries of this region are derived from the axillary (long 
thoracic) and intercostals. The posterior thoracic nerve is found in 
this region descending upon the serratus magnus, which it supplies. 

THE MEDIASTINUM AND CONTENTS. 

The mediastinum is a space within the chest, between the two 
pleural cavities, which is occupied by the heart and pericardium, the 
thymus or its remains, the trachea, oesophagus, aorta, and several 
nerves, and a mass of loose connective tissue and lymphatics. 

Eather more of the space lies to the left of the middle line 
than to the right. It is limited in front by the sternum, behind by 
the vertebral column, and its floor is formed by the diaphragm. 
Above, the loose connective tissue of this space is continuous into 
the root of the neck with that which surrounds the oesophagus and 
trachea and the great vessels in the neck. Laterally the mediastinum 
is walled off on either side from the pleural cavity by the parietal 
pleura (mediastinal portion of the parietal pleura). 

The mediastinum, as mentioned above, is not an empty space, 
but is fairly closely occupied by various organs. In the lower part 
of this space, in front, is the heart, inclosed within its pericardial 
sac; behind the heart, between it and the vertebral column, the 
space is not large, and is occupied by the oesophagus, thoracic duct, 
thoracic aorta, vena azygos, vena hemiazygos, and various nerves. 
In the upper part of the mediastinum, in front, is the thymus or its 
remains, and behind this the trachea and oesophagus, the latter lying 
just in front of the vertebral column. Immediately above the base 
of the heart are the great vessels connected with the heart — the arch 



178 



THORAX. 



of the aorta, vena cava superior, pulmonary artery and its branches 
— and the bifurcation of the trachea. A number of lymphatic glands 
which communicate with the lymphatics of the neck and axilla are 
packed in between these structures. 

The Pericardium. — The heart, occupying the lower anterior part 
of the mediastinum, lies close to the anterior wall of the chest 
(sternum) inclosed within its own serous sac, the pericardium. The 
pericardium, as a thin serous layer, is closely applied to the whole 
surface of the heart and to the great vessels at its base for a part of 



?%f 



!"> Mfc 




Fig. 80. — Transverse Section through Thorax just Above the Heart and 
Root of the Lungs. A, A, aorta; ES, oesophagus; LPA, left pulmonary artery; 
MP, mediastinal pleura passing forward to the posterior aspect of the root 
of the lung; PA, pulmonary artery; PE, pericardium; PN, phrenic nerve; 
PP, parietal layer of pleura; PS, space between parietal and visceral layers 
of the pleura; RB, right bronchus; RPA, right pulmonary artery; 8, ster- 
num; YA, vena azygos; TC, vena cava superior; VP, visceral layer pleura. 



their extent; above, after inclosing the first or ascending part of the 
arch of the aorta, it is reflected as a thin, loose, membranous sac, 
which completely envelops the heart and is attached below by its 
broad base to the dome of the diaphragm. The highest limit, or the 
apex, of the pericardial sac is that portion which incloses the first part 
of the arch of the aorta. Its broad base, which is below, corresponds 
to its attachment to the diaphragm. The pulmonary artery is also 



MEDIASTINUM AND CONTENTS. 179 

included within the pericardial sac as far as its bifurcation, but its 
two divisions are not included. The vena cava superior is also 
partially invested. 

In front, the pericardial sac is in relation with the sternum 
and the costal cartilages, from which it is separated by the inter- 
posed pleura and the edges of the lungs. Behind the lower part of 
the sternum there is a triangular space — with its apex above upon a 
level with the fourth costal cartilage, a little to the left of the 
middle line, and its base below, corresponding to the junction of the 
body of the sternum with the ensiform cartilage: i.e., on a level 
with the articulation of the sixth costal cartilage — where the peri- 
cardium lies in direct relation with the posterior surface of the 
sternum. Corresponding to this area the pleura and the edge of the 
lung are not interposed between the sternum and the pericardial 
sac. Occasionally, according to some descriptions, the edge of the 
left pleura fails to reach the left border of the sternum behind the 
fifth costal cartilage and fifth intercostal space, and under these 
circumstances one could puncture through the fifth space close to 
the left border of the sternum and enter the pericardial sac without 
meeting the pleura. In all cases the edge of the left lung is notched 
in this region, incisura cardiaca; so that, although one might en- 
counter the pleura in puncturing in this situation, he would not, 
in any case, meet the lung. Corresponding to the incisura cardiaca 
is the region of the "cardiac impulse," and here the heart is most 
exposed. Behind, that part of the pericardial sac which covers the 
left auricle is in close relation with the oesophagus. The trachea 
bifurcates just above and close to that part of the pericardial sac that 
covers the left auricle. On each side the pericardium is firmly ad- 
herent to the mediastinal portion of the parietal pleura, and between 
the apposed layers of both these structures, upon either side, the 
phrenic nerve descends in its course to reach and supply the dia- 
phragm. 

The Heart. — The heart, inclosed within the pericardial sac, is 
located in the lower anterior part of the mediastinum, almost com- 
pletely surrounded by the lungs, which show a hollowed-out cavity 
on their internal surface corresponding to the size and shape of 
the heart. The impression upon the left lung is deeper than that 
upon the right. 

Behind the heart is the vertebral column, and in the space be- 
tween the heart and the spinal column, in the lower back part of 



180 THORAX. 

the mediastinum, are the oesophagus, accompanied by the pneumo- 
gastric nerves; the thoracic aorta and thoracic duct; the vena 
azygos, which lies to the right of the vertebral column; and the 
vena hemiazygos, which lies to the left of the column. 

The heart, with its long axis directed downward, forward, and 
to the left, rests with its posterior surface, which is composed chiefly 
of the left ventricle, upon the central tendon of the diaphragm. 
Here the diaphragm is somewhat flattened, and to the right of the 
middle line is perforated for the passage of the vena cava inferior. 
This vessel, after passing through the diaphragm, enters almost im- 
mediately the lower contiguous part of the right auricle. 

The anterior surface of the heart, composed mainly of the right 
ventricle and auricle, lies close to the posterior surface of the ster- 
num and costal cartilages, from which it is separated, for the most 
part, by the pleura and the lungs, these being interposed between 
the heart and the sternum and costal cartilages. 

The base of the heart, which is directed upward and backward 
toward the spinal column, is made up of the auricles; the right 
auricle is placed anteriorly, and receives above the vena cava supe- 
rior and below the vena cava inferior; the left auricle forms the 
posterior part of the base, lying close to the oesophagus, and receives 
the pulmonary veins from either lung. 

The apex of the heart, the lowest part of the left ventricle, is 
found in the fifth left intercostal space midway between the para- 
sternal and mammary lines. 

Above the heart are the arch of the aorta, with the superior 
vena cava placed close upon the right side of its first or ascending 
part, the pulmonary artery and its bifurcation, the bifurcation of 
the trachea, and a mass of lymphatic glands and fat. 

The Outlines of the Heart upon the Chest Wall. — The 
lower border of the heart corresponds to the line of junction between 
the body of the sternum and its ensiform cartilage. The upper 
border of the heart corresponds to the upper border of the third 
costal cartilage. To the right of the sternum lies the right auricle, 
its boundary corresponding to a curved line which is drawn from the 
articular end of the third costal cartilage downward and through the 
fifth costal cartilage close to its articulation with the sternum. The 
right ventricle reaches over for a considerable distance to the left 
of the sternum, with a portion of the left ventricle adjoining and 
forming the left border of the heart. The apex, the extreme end 



MEDIASTINUM AND CONTENTS. 



181 



of the left ventricle, is situated in the fifth intercostal space midway 
between the parasternal and the mammary lines. 

One-third of the heart lies to the right and two-thirds to the 
left of the middle line. 

The pulmonary orifice, valve, corresponds to a line which is 




Pig. 81. — Outline of Heart and Location of Valves. A, aortic orifice, left 
semilunar valve (dotted line) ; P, orifice of pulmonary artery, right semi- 
lunar valve; T.M., line of right and left auriculo-ventricular orifice. Upper 
part of line corresponds to left auriculo-ventricular orifice, mitral valve. 
Lower part of line corresponds to right auriculo-ventricular opening, tri- 
cuspid valve. Position of the diaphragm is indicated by the curved line that 
passes below the inferior border of the heart. 



placed upon the junction of the third costal cartilage with the left 
border of the sternum, half of the line upon the cartilage and half 
upon the sternum. 

The aortic orifice, valve, may be indicated by a line drawn from 



182 THORAX. 

the junction of the third costal cartilage with the left border of the 
sternum, just below the line indicating the pulmonary valve and 
diverging from this, as far as the middle line, to a level with the 
third space. 

The auriculo-ventricular openings are represented by a line ex- 
tending from the lower border of the third left costal cartilage, one 
finger's breadth beyond the left border of the sternum, downward 
and toward the right, across the body of the sternum, as far as the 
junction of the sixth right costal cartilage with the right border of 
the sternum. The lower part of this line represents the tricuspid 
(right auriculo-ventricular) orifice and the upper part represents the 
mitral (left auriculo-ventricular) orifice. 

The Thymus. — The thymus body in the newborn is located in 
the upper front part of the mediastinum behind the sternum and 
in front of the upper part of the pericardial sac. Its upper portion 
reaches well upward, in front of the trachea, into the root of the 
neck. In the upper part of the mediastinal space the thymus lies 
directly in front of the trachea, the left innominate vein, which 
passes from left to right, across the front of the trachea, being in- 
terposed between them. In the root of the neck the thymus lies 
upon the front of the trachea, and is in relation, on either side, with 
the common carotid artery and the internal jugular vein. 

The lower part of the thymus lies behind the body of the ster- 
num and in front of the great vessels at the base of the heart, dip- 
ping down between the pericardial sac and the edges of the lungs 
and pleura. 

"The thymus increases in size from birth until the second year, 
and then remains stationary or atrophies slowly until puberty. After 
puberty it atrophies rapidly, undergoing fatty changes. 

The Arch of the Aorta. — The arch of the aorta is well sur- 
rounded by the lungs, the edges of which nearly meet behind the 
sternum. 

It arises from the left ventricle, and at its origin lies behind 
the root of the pulmonary artery. It first passes upward, forward, 
and toward the right as far as the right border of the sternum; it 
then turns backward and toward the left, arching over the left bron- 
chus; and near the upper border of the body of the fourth dorsal 
vertebra, upon its left side, it turns downward and is continued as 
the thoracic aorta. 

The arch, as it passes backward and to the left over the left 



MEDIASTINUM AND CONTENTS. 183 

bronchus, reaches its highest point, which is upon a level with the 
upper border of the first costal cartilage. 

The Ascending Paet of the Aech. — Upon the right side and 
close to the ascending or first part of the arch lies the superior vena 
cava, which enters the upper part of the right auricle; this part of 
the arch and the superior vena cava are situated in front of the root 
of the right lung. The vena azygos, passing forward from the right 
side of the vertebral column, crosses the root of the right lung and 
empties into the vena cava superior through its posterior wall. 

The Teansveese Paet of the Aech. — The transverse part of 
the arch passes from right to left and from before backward, from 
the right border of the sternum to the left side of the body of the 
fourth dorsal vertebra, arching over the root of the left lung. Its 
upper border is upon a leve. ■•■ th the upper border of the first costal 
cartilage. From the upper aspect of the transverse part of the arch 
are given off the innominate and the left common carotid and sub- 
clavian arteries. 

Below the transverse part of the arch is the pulmonary artery 
and its bifurcation, the branches passing transversely- — -one to the 
hilum of each lung — and lying in front of the bronchi. Behind the 
transverse part of the arch, in the back part of the mediastinum, 
the trachea and the oesophagus are located. 

In front of the transverse part of the arch are the sternum, 
the thymus or its remains, and the edges of the pleura and the edges 
of the lungs, which nearly meet directly behind the sternum. A 
little above and in front of the transverse part of the arch, passing 
from left to right across the middle line, is the left innominate vein. 
The left superior intercostal vein passes forward from the third left 
intercostal space near the spinal column and enters the left innomi- 
nate in front of this part of the arch. To the left of the middle line, 
the left pneumogastric nerve descends in front of and close to the 
transverse part of the arch, and gives off its recurrent laryngeal 
branch, which curves around the arch and ascends into the neck. 
Also descending in front of the transverse part of the arch, but 
nearer the middle line than the left pneumogastric, is the left 
phrenic nerve. 

The Pneumogastric Nerves. — These pass through the thoracic 
cavity, in close relation with the oesophagus, on their way to the 
stomach. 

The right pneumogastric, at the root of the neck, lies between 



184 THORAX. 

the common carotid artery and the internal jugular vein. It de- 
scends into the chest, across the front of the first part of the sub- 
clavian artery, between it and the subclavian vein. Within the chest 
it passes obliquely backward, close to the right side of the trachea 
and across the posterior aspect of the root of the right lung, where 
it takes part in the formation of the posterior pulmonary plexus. 
The nerve then approaches the middle line and descends upon the 
posterior surface of the oesophagus and through the oesophageal 
opening in the diaphragm, to be distributed to the posterior sur- 
face of the stomach. 

The left pneumogastric dips into the chest between the left 
carotid and subclavian arteries, behind the left innominate vein, and, 
descending across the front of the left end of the transverse part 
of the arch of the aorta, is continued downward, behind the root of 
the left lung and thence upon the front surface of the oesophagus 
and through the diaphragm, to be distributed to the anterior surface 
of the stomach. 

The Inferior Eeoureent Branches. — Upon the right side 
the inferior recurrent is given off from the pneumogastric as it 
passes across the front of the first part of the subclavian artery. 
Curving around this vessel, it ascends in the neck, in the recess be- 
tween the oesophagus and the trachea, to enter the lower part of the 
larynx. 

Upon the left side the recurrent is given off as the pneumo- 
gastric passes across the front of the transverse part of the arch of 
the aorta. It winds around the lower border of this part of the 
arch and ascends in the neck, having a similar relation to the oesoph- 
agus and trachea as that of the right side. 

The Phrenic Nerves. — In the root of the neck the phrenic nerve 
of either side may be seen crossing the front of the scalenus anticus 
tendon in a direction from above downward and inward. After en- 
tering the chest they pass down in front of the root of either lung; 
the left, in its course, passes across the front of the transverse part 
of the arch of the aorta parallel with the left pneumogastric, but 
more internally, nearer the middle line; the right passes down upon 
the right side of the superior vena cava. They then descend between 
the pericardium and the mediastinal portion of the pleura as far as 
the diaphragm, which they supply. 

The Trachea. — This is an elastic membranous tube which is put 
upon the stretch when the head is extended. Set into its wall are 



MEDIASTINUM AND CONTENTS. 185 

a number of cartilaginous plates, each forming part of a circle. 
These cartilaginous plates are absent in the posterior part of the 
trachea. 

The trachea is the continuation of the larynx. It begins in 
the neck below the cricoid cartilage at the sixth cervical vertebra, 
and in this part of its course lies quite superficial. As it passes 
downward it gets to lie deeper, farther away from the surface. In 
the chest, opposite the fifth dorsal vertebra, just above the base of 
the heart, the trachea divides into the two bronchi. 

In front of the trachea, in the upper part of the mediastinum, 
are the sternum, the thymus or its remains, connective tissue, and 
fat. It is crossed from left to right and obliquely from above down- 
ward by the left innominate vein; into this vein in front of the 
trachea, one on each side of the middle line, empty the inferior thy- 
roid veins. 1 Occasionally a large arterial branch, the thyroidea ima, 
arises from the upper aspect of the transverse part of the arch of 
the aorta and ascends upon the front of the trachea. Lower down, 
the trachea is crossed by the transverse part of the arch of the aorta 
and the vessels arising from the superior aspect of this vessel. The 
innominate and left carotid arteries, at their origin, are placed in 
front of the trachea. The right pneumogastric, in the upper part 
of the chest, lies close to the right side of the trachea. The oesoph- 
agus is situated behind the trachea. It is intimately related to the 
posterior, non-cartilaginous wall of the trachea; so that foreign 
bodies lodged in the oesophagus may, by pressure upon the posterior 
wall of the trachea, seriously narrow its lumen and produce symp- 
toms of strangulation. In the immediate neighborhood of the bifur- 
cation of the trachea are twenty to thirty lymphatic nodes. 

The (Esophagus. — The oesophagus is the continuation of the 
pharynx, and consists of a thick muscular coat with a mucous mem- 
brane lining. The mucous membrane is connected with the mus- 
cular coat by a very loose submucous connective tissue. 

When collapsed, the oesophagus appears as a flat, transverse 
band, with the mucous membrane thrown into longitudinal folds, 
and upon cross section it shows a stellate figure. 

The oesophagus commences behind the cricoid cartilage on a 
level with the sixth cervical vertebra; it descends through the neck 
and thorax, piercing the diaphragm upon a level with the tenth 



1 The right inferior thyroid often empties into the right innominate. 



186 THORAX. 

dorsal vertebra, and terminates at the cardiac end of the stomach 
upon a level with the eleventh dorsal vertebra. 

In the neck and upper part of the thorax, as far as the fourth 
dorsal vertebra, the oesophagus lies close to the front of the vertebral 
column, but from this point downward it gets to lie farther away, 
and as it passes through the diaphragm it is located quite some dis- 
tance in front of and to the left of the tenth dorsal vertebra. 

The oesophagus, throughout its course, is surrounded by loose, 
cellular tissue by which it is connected with adjoining structures. 
The average length of the oesophagus is about 35 cm., and the dis- 
tance from the teeth to the cardiac orifice of the stomach is about 
50 cm. To get the distance from the mouth to the cardiac orifice 
of the stomach, in any individual case, one may measure from the 
spinous process of the eleventh dorsal vertebra to that of the ver- 
tebra prominens, and thence across the shoulder to the mouth. 

The lumen of the oesophagus is narrowest at its commencement 
behind the cricoid cartilage, again narrow opposite the third or 
fourth dorsal vertebra and again as it passes through the diaphragm. 
At its narrowest part the caliber of the oesophagus has a diameter 
of 14 mm., but it is capable of much distension beyond this. 

Eelations of the OEsophagus. In the Neck the oesophagus lies 
upon the front of the spinal column and immediately behind the 
trachea, to the posterior non-cartilaginous wall of which it is united 
by loose connective tissue. The oesophagus, situated behind the 
trachea, protrudes a considerable distance beyond the left border of 
the latter, and is therefore in closer relation with the common 
carotid artery, internal jugular vein, etc., upon the left side of the 
neck than upon the right side. In the recess between the trachea 
in front and the oesophagus behind, upon either side, the recurrent 
laryngeal nerve ascends to enter the lower part of the larynx. Above, 
where the lateral lobes of the thyroid gland rest upon the sides of 
the trachea, they reach backward so as to get into close proximity 
with the oesophagus. 

Within the Chest. — In the upper part of the chest the oesophagus 
is still situated in front of the spinal column close behind the trachea, 
protruding somewhat beyond the left border of the latter. Opposite 
the third dorsal vertebra it is placed, together with the trachea, be- 
hind the transverse part of the arch of the aorta. Opposite the 
fourth dorsal vertebra the descending part of the arch of the aorta 
lies to the left side of the oesophagus, pushing it (the oesophagus) a 



MEDIASTINUM AND CONTENTS. 187 

little over toward the right; but immediately below this the azygos 
vein, appearing upon the right side of the oesophagus, forces it again 
to the left, and here at this level the oesophagus is found behind the 
root of the left lung, to which it is loosely attached by connective 
tissue. As the oesophagus descends it remains in close relation with 
the aorta, which vessel gradually passes behind it in order to reach 
the middle line in front of the vertebral column. Opposite the eighth 
dorsal vertebra the oesophagus lies in front of the aorta, and opposite 
the tenth, as it pierces the diaphragm to terminate in the stomach, 
it lies in front and to the left of the aorta and spinal column. 

In the space behind the heart, between it and the vertebral 
column, in the lower back part of the mediastinum, the oesophagus 
lies in close proximity, anteriorly, with the left auricle, which is 
enveloped in the pericardial sac. In this space, upon the right side 
of the vertebral column, is the azygos vein; upon the left, the 
hemiazygos; and in front of the vertebral column, the thoracic duct; 
the aorta is situated behind the oesophagus. The mediastinal portion 
of the pleura, as it passes forward to the root of the lung, is reflected 
upon either side of the oesophagus. Descending upon the anterior 
wall of the oesophagus is the left pneumogastric, and, upon its poste- 
rior wall, the right pneumogastric nerve. These nerves accompany 
the oesophagus through the oesophageal opening in the diaphragm 
and are distributed to the stomach. 

The Thoracic Aorta. — This is the continuation of the arch. It 
lies at first upon the left side of the bodies of vertebra?, but as it 
descends it approaches the middle line, and finally, as it passes into 
the abdomen behind the diaphragm, it lies in front of the body of 
the last dorsal vertebra. Throughout its course the thoracic aorta 
is closely related to the oesophagus; at first it lies to the left side 
of the oesophagus, but as it descends it gets behind it, between it and 
the vertebral column; below, the oesophagus is placed in front of 
and to the left of the aorta, the latter (aorta) as it passes into the 
abdomen being situated upon the front of the spinal column. The 
thoracic aorta gives off the intercostal branches: one for each inter- 
costal space from the third downward. 

The Vena Azygos.- — This vein ascends upon the right side of the 
spinal column; it is made up of branches from the lumbar region 
and receives the intercostals in its course. About the level of the 
fourth dorsal vertebra it passes forward over the root of the right 
lung, and enters the vena cava superior through its posterior wall. 



188 THORAX. 

The Vena Hemiazygos. — The origin and course of this vessel 
are analogous to those of the azygos. It ascends upon the left side 
of the vertebral column. Opposite the eighth dorsal vertebra it 
passes across the front of the spinal column behind the aorta and 
thoracic duct, and upon the right side of the vertebral column joins 
the vena azygos. 

The Thoracic Duct passes into the thorax behind the diaphragm 
in company with the aorta, between this vessel and the front of the 
spinal column. As it ascends through the thorax it lies upon the 
bodies of the dorsal vertebraa. In the upper part of the chest it 
arches forward and outward toward the left, and, passing over the 
subclavian artery and across the front of the tendon of the scalenus 
anticus, it enters the left subclavian vein where this vessel joins the 
left internal jugular. 

The Innominate Artery has a caliber corresponding to the thick- 
ness of the little finger. It springs from the right end of the upper 
border of the transverse part of the arch of the aorta, and is about 
5 cm. long. At its origin it lies in front of the trachea; it terminates 
by dividing into the subclavian and common carotid behind the 
right sterno-clavicular joint. 

Situated in front of this vessel are the sternal attachments of 
the sterno-hyoid and sterno-thyroid muscles, the manubrium of the 
sternum, and the remains of the thymus gland. The left innominate 
vein passes across the front of the root of the innominate artery, and 
upon its outer (right) side joins with the right innominate vein to 
form the vena cava superior. The right inferior thyroid vein, as it 
descends from the lower part of the thyroid gland to enter the right 
innominate vein, also passes across the front of the innominate 
artery. To the outer side of the innominate artery lie the right pneu- 
mogastric and the right phrenic nerves and the pleura and apex of 
the right lung. To the inner side of the innominate is the left 
common carotid, the distance between the two vessels varying. 

The Left Common Carotid and Left Subclavian Arteries arise 
from the upper border of the transverse part of the arch. They lie 
deep within the chest, and are, in this region, not subject to surgical 
interference. 

THE PLEURA. 

The pleura of each side is a completely closed fibro-serous sac. 
It lines the entire inner surface of the cavity, within which the lung 



PLEURA. 189 

is contained, and, besides, as a thin, serous layer, invests the whole 
surface of the lung. 

That 'portion of the pleura which is applied to the surface of 
the lung is called the visceral layer, and that which lines the whole 
inner surface of the cavity in which the lung is contained is called 
the parietal layer. That part of the parietal pleura which lines the 
inner surface of the wall of the chest, sternum, costal cartilage, ribs, 
etc., is spoken of as the pleura sterno-costalis; that portion which 
is spread out upon the surface of the diaphragm, the pleura dia- 
phragmatica; and that which limits the mediastinum on each side, 
passing from before backward like a partition and separating the 
mediastinal space from the space which contains the lung, is called 
the pleura mediastinalis. 

The parietal layer, after lining the inner surface of the ribs, 
intercostal muscles, etc., — that is, the whole inner aspect of the 
wall of the thorax, — is found, behind, upon either side of the verte- 
bral column, to leave the posterior wall of the thorax and pass 
forward, forming the posterior part of the mediastinal pleura; that 
of the left side, as it passes forward, covers the adjacent wall of 
the aorta and, lower down, the oesophagus; that of the right side, 
as it passes forward, covers, below, the side of the vena azygos and, 
higher up, the side of the oesophagus. Upon reaching the posterior 
aspect of the root of the lung the pleura is reflected on to the sur- 
face of the lung and as the visceral layer completely invests it, being 
also continued in between the lobes and intimately united with its 
surface; after thus entirely enveloping the lung it reaches the ante- 
rior aspect of the root of the lung, whence it is reflected forward 
toward the sternum as the anterior portion of the mediastinal pleura; 
upon reaching the posterior surface of the sternum it becomes con- 
tinuous with that part of the parietal pleura which lines the inner 
surface of the wall of the chest: the pleura sterno-costalis. Above 
and below the level of the root of the lung the mediastinal pleura 
passes all the way as an uninterrupted layer from behind forward, 
from either side of the spinal column to the posterior surface of the 
sternum. 

Limits of the Pleura as Indicated by Lines upon the Chest Wall. 
The Anterior Edge or the Pleura. — The line which indicates 
the anterior edge of the right pleural sac commences, above, behind 
the right sterno-clavicular articulation; from this point it passes 
downward and inward behind the sternum, and at the junction of 



190 THORAX. 

the manubrium with the hody of the sternum it lies close to the 
middle line; it is then continued downward behind the middle of 
the body of the sternum, and opposite the articulation of the fourth 
costal cartilage it curves outward, as it descends, to reach a point 
corresponding to the lower border of the sternal end of the sixth 
costal cartilage, whence it may be traced farther downward and 
backward as the lower edge of the pleura. 

The line which marks the anterior edge of the left pleural sac 
is somewhat different. It commences above, behind the left sterno- 
clavicular articulation, from which point it curves downward and 
inward toward the middle line and may then be traced downward 
behind the body of the sternum parallel with the anterior edge of 
the right pleural sac to a point upon a level with the junction of the 
fourth costal cartilage with the sternum; here it curves outward, 
but more obliquely than upon the right side, and reaches the sternal 
end of the sixth costal cartilage at its upper border, whence it is con- 
tinued obliquely downward and backward as the lower edge of the 
pleura. 

According to Merkel, the anterior edge of the left pleural sac, 
upon a level with the fourth costal cartilage, passes still more 
obliquely outward than has been described above so as to strike the 
sixth costal cartilage, not at its junction with the sternum, but some 
little distance beyond this articulation, thus leaving a space between 
the anterior edge of the left pleural sac and the left border of the 
sternum, corresponding to the fifth costal cartilage, fifth intercostal 
space, and sixth costal cartilage, which is not covered by the pleura. 
If this condition were present, one might introduce an aspirating 
needle into the pericardial sac through the fifth intercostal space, 
close to the left border of the sternum, without encountering the 
pleura. 

Without doubt the anterior edge of the left pleural sac is sub- 
ject to considerable variation. I have found the first description to 
hold for most cases. 

The Lower Edge of the Pleura corresponds to a line that 
commences, in front, behind the junction of the sixth costal carti- 
lage with the sternum; it passes downward and backward, crossing 
obliquely the cartilage of the seventh rib in the parasternal line and 
passing into the seventh intercostal space in the mammary line; still 
continued downward and backward it reaches its deepest point, cor- 
responding to the tenth rib or tenth intercostal space, a little behind 




Fig-. 82.— Outline of Pleura, etc. Front view. A, apex of lung and dome of pleura; 
A line of diaphragm; H, outline of heart; L, solid lines show the edges of the lungs; 
P, dotted lines correspond to the edges of the pleura. 



1*5 







r. 












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N\l 




- CO 

O B> 




PLEURA. 



191 



the axillary line, whence it may be traced almost horizontally back- 
ward and inward to the articulation of the twelfth rib with the 
spinal column. Behind, in the scapular line, the lower edge of the 
pleura corresponds to the tenth intercostal space. 

It will be observed that the lower edge of the pleura, as it is 
reflected from the inner surface of the chest wall over on to the 
surface of the diaphragm, does not dip down into the bottom of the 
recess between the costal portion of the diaphragm and the ribs. 
This space varies in depth at different parts. Occasionally the lower 




Fig. 85. — Section through Seventh, Eighth, and Ninth Ribs Anterior to 
the Axillary Line. D, diaphragm; EX, external intercostal muscle; IN, in- 
ternal intercostal muscle; P, pleura covering inner aspect of the chest wall; 
PD, pleura that covers the diaphragm; PE, peritoneum that is reflected upon 
the under surface of the diaphragm; VAN, intercostal vein, artery, and nerve 
situated under lower border of the ribs; 1, 8, 9, cut surface of ribs; * repre- 
sents the space between the diaphragm and chest wall into which the pleura 
does not descend, as it is reflected from the chest wall on to the upper sur- 
face of the diaphragm. 

edge of the pleura, behind, reaches down between the twelfth rib and 
the diaphragm as far as the lower border of the twelfth rib, or, even 
beyond this, down to the level of the transverse process of the first 
lumbar vertebra. 

The Dome of the pleura is that part of the pleural sac which 
projects upward into the root of the neck above the level of the first 
rib; it reaches to a distance of 5 cm. above the level of the anterior 
part of the first rib, but does not reach above the level of the back 
part of the first rib; the first rib is set very obliquely, its anterior 
portion being upon a much lower level than its posterior part. 



192 THORAX. 

The dome of the pleura reaches from 2 to 4 cm. above the level 
of the clavicle; so that a knife introduced above this bone and passed 
directly backward would pierce both the pleura and the lung. In 
front of the dome is the first rib and the posterior surface of the 
scalenus anticus muscle and the clavicle. Internal to the dome are 
the trachea and the oesophagus. 

The subclavian vessels pass forward and outward across the 
dome, grooving it and the apex of the lung, which lies beneath. Care 
is necessary in ligating the subclavian or innominate arteries not to 
wound the pleura. 

As the internal mammary artery dips down into the chest it is 
crossed by the phrenic nerve and lies in close relation with the dome 
of the pleura. 

The dome of the pleura is re-enforced by the fascia endotho- 
racica, and connected behind, through ligamentous bands, with the 
first rib and the last cervical and the first dorsal vertebras and in 
front with the deep surface of the scaleni muscles. 

The mediastinal portion of the pleura and the pericardium are 
adherent to each other, and between these two serous layers the 
phrenic nerves descend to the diaphragm. 



THE LUNGS. 

The Root, or Pedicle, of the Lung. — The root of the lung is 
located in the back part of the mediastinum behind the ascending 
part of the arch of the aorta and above the base of the heart. That 
of each lung is composed of the bronchus, the pulmonary artery, and 
the pulmonary veins, together with lymphatics (also blood-vessels for 
the supply of lung tissue proper and plexuses of nerves). 

The trachea bifurcates opposite the fifth dorsal vertebra, and 
its divisions, the bronchi, are directed outward and downward toward 
the hilum of either lung. The right bronchus is more horizontal, 
shorter, and of wider caliber than the left, and its lumen is more 
directly continuous with that of the trachea; so that foreign bodies 
dropped into the trachea are more apt to enter the right than the 
left'bronchus. 

The pulmonary artery springs from the upper part of the right 
ventricle, and at its origin lies in front of the root of the aorta. It is 
a short trunk, directed upward and backward, and under the trans- 



LUNGS. 193 

verse part of the arch of the aorta divides into the right and left 
pulmonary.. These pass outward, in front of the bronchi, to the hilum 
of either lung. At the hilum the pulmonary arteries are located upon 
a higher level than the bronchi, and may get to lie partly behind 
these as they enter the lung. 

The pulmonary veins are short trunks which, upon leaving the 
hilum of the lung, pass transversely inward and enter the correspond- 
ing side of the left auricle; they lie some little distance below the 
level of the bronchi and the pulmonary arteries. 

There are numerous lymph nodes irregularly arranged about 
the root of the lung, but there is always a well-marked group below 
the bifurcation of the trachea. 

Over the root of the left lung, arching from before backward, 
is the arch of the aorta. The vena azygos passes over the root of 
the right lung, from behind forward, and enters the vena cava supe- 
rior, which lies just in front of the root of the right lung, upon its 
posterior aspect. 

The Lung, suspended by its root, occupies the pleural cavity 
and is entirely enveloped by the visceral layer of the pleura. At the 
root of the lung this visceral layer of the pleura is continuous with 
the mediastinal part of the parietal pleura. The base of the lung 
rests upon the diaphragm; its apex projects into the root of the 
neck for a distance of 4 or 5 cm. above the front end of the first 
rib. In the natural sitting position the apex of the lung reaches to 
a point about 3 cm. above the clavicle. 

The right lung consists of three lobes, the left of two. Each 
lung upon its inner surface shows a depression corresponding to the 
heart, that upon the left lung being deeper than that upon the right 
lung. 

The lung does not entirely fill the pleural cavity except above, 
where the apex occupies all the space corresponding to the dome of 
the pleura. 

Limits of the Lungs. — The posterior border of each lung is 
found alongside the vertebral column. The anterior border of the 
lung corresponds to the line of the pleura from the sterno-clavicular 
articulation to the level of the fourth costal cartilage. The anterior 
border of the right lung continues to be the same as that of the pleura 
down to the level of the sixth costal cartilage. The anterior border 
of the left lung, at the junction of the fourth costal cartilage with 
the sternum, passes almost transversely outward behind the cartilage 



194 THORAX. 

of the fourth rib, forming the upper border of the incisura cardiaca, 
and then, midway between the border of the sternum and the nipple, 
it turns downward behind the fourth intercostal space and fifth costal 
cartilage, and in the fifth space passes sharply inward, forming the 
lower border of the incisura cardiaca. 

The lower border of either lung is represented by a line which 
commences at the junction of the sixth costal cartilage with the 
sternum; it passes downward and backward, behind the sixth costal 
cartilage, and crosses the seventh rib in the mammary line; from 
this point the line passes backward, almost transversely, crossing the 
eighth and ninth ribs in the axillary line, the tenth rib in the scap- 
ular line, and reaches the vertebral column upon a level with the 
articulation of the eleventh rib. Although the line, after crossing 
the seventh rib in the mammary line, is continued almost trans- 
versely backward, it cuts the eighth, ninth, and succeeding lower 
ribs, owing to tbe obliquity of the ribs. 

The lower edge of the lung does not reach to the bottom of 
the pleural cavity; so that a space is left which is called the sinus 
phrenico-costalis. This space commences in front, and gradually 
becomes deeper; upon the sides it is deepest, and may measure up 
to two inches. In more forcible inspiration this space is partly 
obliterated by the increased expansion of the lung. 

A similar pleural space, unoccupied by the lung (incisura car- 
diaca), is found in front of the pericardium and heart, corresponding 
to the fourth intercostal space and fifth costal cartilage, to the left 
of the sternum. 

In the child the distance between the lower border of the lung 
and the bottom of the pleural cavity is one-half to one space deeper 
than described above. In old age the distance between the lower 
border of the lung and the bottom of the pleural cavity becomes 
one-half to one space shorter. 

Luschka gives the depth of the sinus phrenico-costalis as fol- 
lows: In the sternal, parasternal, and mammary lines, 2 cm.; in the 
axillary line, 6 cm.; and near the vertebra, 2.5 cm. 

OPERATIONS UPON THE CHEST. 

Incisions for Abscess of the Breast. — These should radiate from 
the region of the nipple toward the periphery of the breast in order 
to avoid, as far as possible, cutting across the milk-ducts, which all 



OPERATIONS UPON THE CHEST. 195 

converge toward the nipple. The incisions should he liberal, and 
should he so placed as to allow the discharge to drain through the 
lower, dependent part of the breast, and, if necessary in order to 
accomplish this, one or more counter-openings may be made. Liberal 
incisions should be made through the skin and fat, and the abscess 
cavity penetrated with closed artery forceps, which are spread apart 
as they are withdrawn. 

Extirpation of Tumors Out of the Substance of the Mammary 
Gland (Fibroids, for Example). — An incision is made corresponding 
in length to the size of the tumor and radiating from the areola 
toward the periphery of the breast. 

These tumors are usually encapsulated and well defined, and 
can be dissected out with blunt-pointed scissors or may at times be 
enucleated by blunt dissection with the finger. 

Amputation of the Breast. — The patient lies upon the back with 
the arm abducted. The incision depends upon the size of the tumor 
and the condition of the skin. If the skin is involved in the patho- 
logical process, the diseased portion should be sterilized and packed 
or covered with gauze, and the incision placed at least two inches 
outside of the affected area of the skin. 

The incision should be so arranged that the edges of the wound 
may be brought together with sutures, after the breast has been 
removed, for the purpose of obtaining primary union; yet one should 
not hesitate to sacrifice all suspicious integument, since any defect 
that remains may be covered by skin grafting. 

The usual incision is one which includes an elliptical area of the 
skin and the nipple, set obliquely so as to run parallel with the fibers 
of the pectoralis major, the upper end of the ellipse being continued 
along the border of the pectoralis major into the upper arm in order 
to empty the axilla. The edge of the skin, on the inner side of the 
ellipse, is seized with the fingers or a thumb forceps, and, including 
little or none of the subcutaneous fat, is separated from the under- 
lying tumor and breast beyond its farthest limits and down to and 
exposing the surface of the pectoralis major muscle. 

If the breast (tumor) is not adherent to the pectoralis major it 
may be readily detached from the surface of this muscle with the 
fingers, and then, after separating the skin which covers the outer 
part of the breast it may be turned out of the wound ; as the fascia, 
however, which covers the pectoralis major is often involved in the 
disease even when apparently healthy (Volkmann), it is better, in 



196 THORAX. 

all cases, to remove this fascia, together with the superficial portion 
of the muscle, along with the breast, all in one mass. 

At times, portions of the mammary gland, partially disconnected 
from the main mass of the gland and lying in the adjacent fat, are 
difficult to recognize, or the gland itself may be flattened out and 
difficult to identify, or a portion of the gland, almost completely 
detached from the main gland, may be found externally under the 
outer border of the pectoralis major. Care must be exercised to 
include all these parts, and this can only be accomplished by ex- 
cising the entire gland and the fat in which it is imbedded, together 
with the fascia which covers the pectoralis major and the superficial 
portion of this muscle and the contents of the axilla, all in one mass. 

If the muscle is deeply involved, the whole muscle down to the 
ribs should be sacrificed, and it may even be necessary, at times, to 
remove the surface of the ribs; but these are rather hopeless cases 
at best. 

After the breast (tumor) has been entirely freed from the skin 
and pectoralis muscle, but not yet detached, cut away, at its axillary 
end, the axilla is opened and its entire contents — glands, connective 
tissue, fat, etc. — excised in one mass, which still remains continuous 
with the breast (tumor). 

In this way the whole axillary space is completely cleaned out, 
working close along the course of the axillary vessels and adjoining 
nerves and ligating all vascular branches as they are encountered. 
The glands that are involved often extend high up into the axilla 
under the clavicle, and there may be some difficulty in removing 
these. 

The axillary vein should be exposed early during this part of 
the operation. It rests upon the tendon of the latissimus dorsi, 
which is the guide to the vessel, below and to the inner side of the 
axillary artery. The axillary vessels are accompanied by large nerve 
trunks and, these, together with the vessels, are located, all in a 
bunch, close to the humerus, resting upon the tendon of the latis- 
simus dorsi, beneath the edge of the coraco-brachialis and the short 
head of the biceps. If the vessels are thus sought for and exposed 
early in the operation they are less liable to be accidentally injured. 
It is also necessary to clean out the space between the pectoralis 
major and the pectoralis minor muscles. 

If the mass already involves the axillary vessels and nerves, and 
this is usually indicated by shooting pains in the arm and oedema 



OPERATIONS UPON THE CHEST. 197 

of the arm, the case is, at best, rather hopeless, and it is questionable 
whether the .operation had not better be left undone. 

In clearing out the axilla some large arteries and veins may be 
severed, but these may be clamped and ligated; they may be often 
seen before they are cut, and can then be tied before they are divided, 
or they may be avoided. 

The long thoracic nerve, which supplies the serratus magnus, 
lies upon the side of the chest, in the posterior part of the axillary 
space; it is usually seen and may be avoided, although it is of but 
little consequence if it is accidentally divided. One should also, if 
possible, avoid the long subscapular nerve which runs in company 
with the subscapular vessels upon the posterior wall of the axilla. 

If the clearing out of the axilla is commenced below, close to 
the under border of the pectoralis major, the long thoracic artery 
and vein and long thoracic nerve are encountered early, and they 
may be avoided or used as guides in seeking the axillary vein. 

During the operation the parts must be well retracted, and, in 
order to minimize the loss of blood as much as possible, each vessel 
should be clamped as it is cut, and that part of the wound which is 
not under immediate consideration compressed with hot pads to 
prevent oozing. The bleeding should be entirely controlled before 
the wound is finally closed. 

With interrupted sutures the edges of the wound are coapted 
as far as possible, and the area which is then still left uncovered 
may be provided with skin grafts. It is wise to place a tube in the 
axilla for the purpose of drainage. 

Amputation of the Breast (Halsted-Meyer) . — The breast, to- 
gether with the pectoralis major and minor muscles and the glands 
and connective tissue of the axilla, must all be removed in one single 
mass and without cutting into the diseased tissue. 

An incision is made through the healthy skin and fat, elliptical 
and circumscribing the tumor; from the upper end of the ellipse 
the incision should be continued along the edge of the pectoralis 
major to a point upon the iipper part of the arm a little beyond 
(below) the attachment of the tendon of this muscle to the humerus. 
Although it is desirable to bring the edges of the wound together 
with sutures at the end of the operation, yet one should not, on this 
account, take any chance in leaving suspicious looking integument, 
because if we are unable to close the wound with sutures we can 
cover any remaining raw space with skin grafts. 



198 



THORAX. 



To this first incision a second is added which runs obliquely 
from the junction of the middle and outer thirds of the clavicle 
down into the upper border of the elliptical incision. The skin flaps 
which are thus marked out, and including little or no fat, are then 
dissected away from the breast (tumor) and well beyond its periph- 
ery. In this way we expose the tendon of the pectoralis major ex- 
ternally, the border of the latissimus dorsi below and externally, 
and above the space or groove between the edge of the deltoid and 
the upper border of the pectoralis major; in this space the cephalic 




Fig. 86.— Amputation of the Breast. Halsted-Meyer incision for amputation 
of the breast and to clean out the axilla. 



vein and the descending branch of the acromio-thoracic artery are 
found. 

The tendon of the pectoralis major is next divided close to its 
attachment to the humerus, and then, following along the upper 
border of this muscle, between it and the edge of the deltoid as far 
as the clavicle, this muscle (pectoralis major) is cut away from its 
attachment to this bone (clavicle) and reflected downward, thus ex- 
posing the next underlying layer, or "etage," which consists of the 
pectoralis minor covered by its fascia and some loose connective 
tissue. The fascia that covers the pectoralis minor is continued 



OPERATIONS UPON THE CHEST. 199 

upward from the inner border of the muscle as the costo-coracoid 
membrane, and is attached to the first rib and under surface of the 
clavicle, thus covering in the structures of the infraclavicular region. 
This fascia, costo-coracoid membrane, which is perforated by the 
cephalic vein and other structures, is now cut away from its attach- 
ment to the clavicle, and we thus uncover the structures of this 
region, namely: the first part of the axillary artery; the axillary 
vein, which lies along the inner, lower side of the artery; and close 
to the vein a chain of lymphatic vessels and nodes, connective tis- 
sue, and fat. The nerve trunks, which are derived from the brachial 
plexus, run parallel with the vessels, but above them. All these 
structures pass upward and inward, under the clavicle and beyond 
the first rib, into the root of the neck. 

Commencing as high up as possible, the space beneath the 
clavicle being made more accessible by elevating the shoulder, all 
the fat and connective tissue are cleaned away from the vessels, 
ligating all branches as they are met with and working outward and 
downward along the course of the vessels. After the space beneath 
and above the clavicle has been thoroughly cleared of all fat and 
connective tissue, the pectoralis minor is cut close to its origin from 
the coracoid process and reflected downward, together with the con- 
nective tissue and fat that lie upon it and also the fat and connective 
tissue that are found underneath it adjacent to the vessels and nerves 
in this part of the axilla. This dissection is continued down along 
the course of the vessels and nerves as far as the attachment of the 
tendon of the pectoralis major to the humerus, and should be thor- 
ough. The tissue which is thus removed should not be taken away 
piecemeal, but dissected free from the vessels, etc., in one continuous 
mass, and allowed to remain connected with the general tumor mass. 

Now, from the posterior wall of the axilla and from the side of 
the chest, all the fat and connective tissue and lymphatic tissue are 
cleared, working from behind forward and laying bare, behind, the 
anterior surface of the latissimus dorsi, subscapularis, and teres ma- 
jor muscles (posterior wall of the axillary space) and, upon the side 
of the thorax, the ribs and serratus magnus muscle. Upon the 
posterior wall of the axilla the subscapular nerve, in company with 
the subscapular vessels, is encountered. This nerve should be saved, 
if possible, and likewise the vessels, if they have not already been 
cut. 

Upon the side of the chest we meet the long thoracic vessels 



200 THORAX. 

and the long thoracic nerve; if the nerve is recognized it may be 
possible to avoid cutting it. 

The whole mass — which consists of the breast (tumor), pectoral 
muscles (major and minor), axillary contents, etc. — is now grasped 
by an assistant and lifted away from the chest wall when the attach- 
ments of the pectoral muscles to the ribs and sternum are cut, and 
then, the mass being gradually turned out of the wound, the extirpa- 
tion is completed and the bare wall of the chest, together with the 
axillary vessels and the nerves which accompany them, is exposed to 
view. When the mass is lifted away from the chest wall, the perfo- 
rating vessels — branches of the intercostals and the internal mam- 
mary — may be seen as they enter the posterior surface of the pec- 
toralis major and care should be taken not to tear these or cut them 
too close to the surface of the chest wall, as it might then be difficult 
to clamp and tie them. They may often be secured with clamps 
before they are cut. 

The edges of the wound are brought together by suture, and 
if too much integument has not been removed the wound may be 
thus closed entirely. The little triangular flap, corresponding to the 
outer edge of the elliptical incision, is turned up into the axilla and 
fixed there. If there is any raw space remaining, it may be covered 
with rubber tissue and skin grafted later, or the grafts may be ap- 
plied at once. A tube may be placed in the axilla for drainage, and 
this may be removed on the sixth or seventh day, when the dressing 
is changed. 

One should minimize the loss of blood as much as possible, 
clamping vessels before or immediately after they are cut. 

Ligation of the Intercostal Artery. — Each intercostal artery is 
situated, together with the intercostal vein and nerve, beneath the 
lower border of the corresponding rib. These vessels may be injured 
in stab wounds, etc. 

At times it becomes necessary to resect a part of the rib sub- 
periosteally in order to get at the bleeding points. It is necessary 
to tie both ends of the vessel. 

Ligation of the Internal Mammary Artery. — To secure this 
vessel one must resect the costal cartilage of the second or third 
rib close to the sternum or the vessel may be ligated through a 
transverse incision placed midway between the contiguous cartilages 
and close to the sternum in the third intercostal space. The vessel 
descends upon the posterior surface of the anterior chest wall, its 



OPERATIONS UPON THE CHEST. 201 

vein alongside of it; it is accompanied also by a chain of lymphatic 
nodes. 

Thoracentesis. — Puncture through the chest wall into the pleu- 
ral cavity. 

This operation may be performed to show the presence and to 
determine the nature of fluid in the pleural cavity or to evacuate 
such fluid. If for diagnosis only, an ordinary hypodermic syringe 
may be used. If necessary to evacuate a considerable quantity of 
fluid, one may use a rather good sized aspirating needle attached 
to a Dieulafoy syringe. The patient should be semirecumbent or 
lying down. The puncture should be made at the point where the 
physical signs locate the fluid. To anaesthetize the skin a spray of 
ethyl chloride may be used. Before the needle is introduced, the 
skin is drawn upward or downward so that the track of the needle 
through the muscles may not be upon the same level as the puncture 
in the skin. The needle is thrust into the chest between the two- 
ribs nearer the lower than the upper one. 

If one may choose the point at which the needle is to be intro- 
duced, either the eighth space, just below the angle of the scapular, 
or the sixth space, in the middle of axilla, just in front of the border 
of the latissimus dorsi, is usually selected. 

The fluid should be evacuated slowly, and, if the quantity is 
great, care should be taken not to remove too much. One should 
stop if persistent cough occurs or if the pulse changes. At times,, 
the needle becomes plugged with pieces of fibrin, which may be 
dislodged by introducing a stylet or by pumping some of the fluid 
back into the pleural cavity. After the fluid has been withdrawn the- 
needle is removed and the small wound in the skin covered with 
collodion, etc. 

One should remember that the lower limits of the pleural cavity 
fall short of the free border of the ribs, and, further, that if the 
needle is inserted straight inward for a considerable distance it may 
pass through the pleura and diaphragm into the abdominal cavity. 

If we find pus in the pleural cavity, in the adult, it is necessary 
to establish drainage, resecting part of a rib. In the child it often 
suffices to simply evacuate the pus with the needle without providing 
drainage. 

Thoracotomy. — This means cutting through the wall of the 
chest, usually with the resection of part of a rib, for the purpose of 
establishing drainage. 



202 THORAX. 

The patient lies upon his well side, and should be anaesthetized. 
The seventh rib, that portion of it which lies anterior to the latis- 
simus dorsi, is usually resected, as this is not covered by muscle and 
is sufficiently low for proper drainage. 

Immediately before proceeding with the operation one should 
insert the exploring needle in order to ascertain positively the loca- 
tion of the pus, and there, where the pus is located, should the 
entrance into the pleural cavity be made. As already mentioned, if 
we have the choice, the seventh rib is the one selected for resection. 

The incision, usually about two inches long, corresponds to the 
course and direction of the rib to be excised; it is carried down 
through the soft parts, including the periosteum, upon the surface 
of the rib. With the elevator the periosteum and all the soft parts 
are peeled off the bone, which is thus laid bare. Care must be ex- 
ercised, in working around the upper and lower borders of the ribs 
to reach its internal surface, not to perforate the pleura nor wound 
the vessels that are lodged in the groove along the lower border of 
the rib. When the length of bone that is to be excised has been 
denuded of its periosteum it is cut through at either end with the 
sharp bone forceps. The opening into the chest cavity is made by 
incising the pleura with the knife. The opening which is thus made 
may be enlarged by introducing an artery forceps, the blades of 
which are spread apart as they are withdrawn so as to make a hole 
large enough to permit exploration of the interior of the chest with 
the finger and the introduction of one or two good-sized tubes. 

If it is discovered, with the finger in the chest, that the opening 
is a considerable distance above the bottom of the pus cavity, one 
may, in order to facilitate the drainage, make a second counter- 
opening at a lower level: through the eighth space, for instance, or 
even lower, depending upon the part of the chest which is involved 
{see limits of lower edge of pleura). The drainage tubes should be 
secured to the edge of the incision in the skin with a silk stitch. 
If the skin wound is unnecessarily large, it may be partially closed 
with one or two silk sutures. The administration of 20 or 30 minims 
of aromatic spirits of ammonia hypodermically, immediately before 
the opening is made into the pleural cavity, will often ward off the 
condition of collapse which sometimes occurs at this time. 

Thoracectomy, Resection of the Chest Wall (Estlander). — An 
oval or U-shaped flap, consisting of the skin and subcutaneous fat, 
with its base behind, at the axillary line, is raised from the side of the 



OPERATIONS UPON THE CHEST. 203 

chest, exposing three or four ribs; or a vertical incision, six inches 
long, may be made in the axillary line over the fifth, sixth, seventh, 
and eighth ribs, with two additional incisions along the course of 
the ribs, the middle of each of these accessory incisions correspond- 
ing to the upper and lower ends of the vertical incision. The two 
flaps which are thus marked out are reflected, one backward and the 
other forward, exposing four to six inches of three or four ribs. 

Each rib is denuded of its periosteum all around, as described 
in the preceding operation, and resected with the bone pliers. A long 
incision is then made in the pleura and the thickened pleura excised. 
The bleeding is controlled by clamps and ligatures. The cavity of 
the pleura may be curetted if thought necessary. The edges of the 
skin flap are brought together with several silk sutures and the 
pleural cavity packed. 

Pleurectomy (Fowler).— Detachment and excision of the thick- 
ened, diseased pleura, visceral and parietal, entire or in part, in old, 
intractable cases of empyema. 

An incision is made along the course of the ribs corresponding 
io the site of the fistula, which is always present (since this operation 
is usually practiced in cases which have already been operated upon 
unsuccessfully), and the location of the disease; to either end of this 
incision there may be added accessory incisions, an anterior and a 
posterior. The flaps that are thus marked out, including all the soft 
parts, are raised so as to expose two or three ribs for four or five 
inches of their length. Instead of the incision as described above 
-one may employ an elliptical or the double flap incision, as described 
in the Estlander operation. 

The periosteum is stripped off two or three ribs with the ele- 
vator, and then from three to five inches of the two or three ribs 
that have been thus denuded are resected with the bone forceps. 
All bleeding points should be clamped and ligated. Cutting from 
the fistula, the parietal (costal) pleura, which is now exposed, is 
opened up with a free incision, and entrance thus gained into the 
suppurating pleural cavity. The pleura which invests the lung 
■(visceral) is incised, and by blunt dissection with the finger or blunt- 
pointed scissors this is peeled off the lung; here and there it will be 
necessary to cut a band with the scissors. In many cases the pleura 
may be separated from the lung with comparative ease, and this 
should be done with care, so as not to tear into the lung tissue 
proper. 



204 THOKAX. 

As the decortication of the lung progresses there may he con- 
siderable oozing from the denuded lung surface, but this may be 
controlled by compression with gauze pads, which are applied to the 
bleeding surface following up the fingers of the operator, or the 
blunt scissors, according as the pleura is detached. 

After the pleura has been peeled off the lung the parietal pleura 
is stripped off the chest wall and then off the diaphragm. In separ 
rating the pleura from the contiguous portion of the pericardial sac 
care should be exercised to avoid any undue pulling or tearing. As 
a rule, the pleura is fairly easily separated and removed. 

At times it is convenient to commence the detachment of the 
pleura by stripping it away from the chest wall; it is then peeled 
off the diaphragm and finally from the surface of the lung. 

Occasionally the conditions that exist preclude the possibility 
of excising all of the diseased pleura, and under these circumstances- 
the operator must content himself with the excision of the visceral 
or parietal (costal and diaphragmatic) pleura in part, or else simply 
incise the visceral pleura and strip it away from the surface of the 
lung without removing it. 

After the pleura has been removed, either entire or in part, the 
cavity in the chest is loosely tamponed with gauze and the edges of 
the skin approximated with silk-worm gut sutures, except for a part 
of its extent, where the tampon emerges. 

As a rule, as the detachment of the pleura from the lung pro- 
gresses, the lung gradually expands more and more. 

This operation has the advantage of removing the pathological 
suppurating membrane, and besides eliminates an obstacle to the 
expansion of the lung. The operation is not advisable in cases of 
diagnosible pulmonary tuberculosis. The discovery, during the 
course of the operation, of tuberculous deposits in the lung would 
warrant the surgeon in discontinuing the operation. 



PART V. 

THE ABDOMEN AND BACK. 



THE ABDOMEN. 

The abdomen corresponds to the lower part of the trunk, and 
consists of a cavity with elastic muscular walls. 

Within the cavity are contained the chief part of the alimentary 
canal and the organs of digestion and the kidneys, etc. These organs 
are all more or less movable, and are provided with a more or less 
complete investment of peritoneum. 

Externally the abdomen is limited above by the free border of 
the costal cartilages and below by the crest of the iliac bone of 
either side and Poupart's ligaments. The walls consist almost en- 
tirely of soft parts, and may be conveniently considered as the poste- 
rior and the antero-lateral. The capacity of the abdominal cavity is 
greater than is indicated by its external limitations. 

The roof of the abdominal cavity is formed by the diaphragm; 
below, the abdominal cavity includes, on either side, the iliac fossa 
and communicates through a wide, heart-shaped opening with the 
cavity of the true pelvis. The margin of the inlet into the pelvic 
cavity is called the pelvic brim. 

The interior of the cavity of the abdomen is lined by the parietal 
layer of the peritoneum, and is entirely shut off from communica- 
tion with the exterior of the body except in the female, where a 
communication exists through the vagina, uterus, and Fallopian 
tubes, and this is frequently the channel through which infection 
is carried to the peritoneum from without. 

The Diaphragm, which forms the roof of the abdominal cavity, 
is a musculo-aponeurotic structure that separates the cavity of the 
chest from that of the abdomen. It is dome-shaped, bulging into 
the cavity of the thorax and presenting its lower concave surface to 
the abdominal cavity. 

It arises by muscular fibers, which vary in length, from the inner 
surface of the ensiform process of the sternum and from the inner* 
surfaces of the cartilages of the lower ribs. Behind, it arises from 
the ligamentum arcuatum externum and ligamentum arcuatum in- 

(205) 



206 ABDOMEN AND BACK. 

ternum and by its two crura from the anterior surface of the bodies 
of the three upper lumbar vertebrae. From these points of origin 
the muscular fibers converge and are continued into a three-leafed 
aponeurotic structure: the central tendon of the diaphragm. Behind 
the diaphragm there is an opening, the aortic, through which the 
aorta passes from the thorax into the abdomen; the posterior bound- 
ary of this opening corresponds to the body of the twelfth dorsal 
vertebra. In the back part of the diaphragm, to the left of the 
middle line, there is an opening which is surrounded by muscular 
fibers and through which the oesophagus passes to the cardiac end 
of the stomach. To the right of the middle line, toward the front, 
at the junction of the right and middle segments of the central 
tendon, there is an opening for the passage of the inferior vena 
cava; the edges of this opening are formed of aponeurotic fibers. 
The heart, wrapped in its pericardial sac, rests upon the upper sur- 
face of the central tendon of the diaphragm. 

In front, close to the sternum, on either side of the bundle of 
fibers which arises from the ensiform process, there is a space where 
the muscular fibers of the diaphragm are absent; so that, in this 
situation, an opening exists through which the contents of one cavity 
may be forced into the other, giving rise to a so-called diaphragmatic 
hernia. 

On the right side, owing to the presence of the liver, the dia- 
phragm reaches higher into the chest than on the left. The thoracic 
surface of the diaphragm is covered by a thin fascia, the fascia endo- 
thoracica; the abdominal surface is likewise covered by a fascia 
which is very thin, the fascia transversalis. 

The Posterior Wall of the Abdomen, the lumbar region of the 
back, corresponds to the five lumbar vertebras and to the several 
muscles which fill in the space between the last rib and the crest 
of the ilium on either side of the spinal column. Externally we find 
the skin and beneath this the subcutaneous fatty layer. Between 
the muscles of the lumbar region are interposed strong layers of 
fascia — which serve to strengthen this region very much. The in- 
ternal or abdominal aspect of the posterior wall of the abdomen is 
lined by that part of the transversalis fascia which covers the psoas 
and quadratus lumborum muscles. 

The kidney, inclosed within its fatty capsule, is located in the 
lumbar region between the transversalis fascia — i.e., the anterior 
layer of the lumbar fascia — and the parietal peritoneum, its ante- 



ABDOMEN. 207 

rior surface only being covered by the peritoneum; so that the organ 
is thus excluded from the peritoneal cavity. 

The Antero-Lateral Wall of the Abdomen is made up of several 
layers of soft parts. It consists of the skin with its underlying fatty 
layer; several broad, flat muscles, the oblique, the transversalis, and 
the recti; and the aponeuroses which correspond to these muscles;, 
the fascia transversalis is found beneath these muscles, and, beneath 
the fascia transversalis, the subperitoneal fat is encountered, and,, 
finally, deepest, most internal of all, is the parietal peritoneum. 

In the female the abdomen is more rounded and contains a con- 
siderable pad of fat; in the male, especially in athletes, the fatty 
layer is less marked or almost entirely absent; so that the markings 
of the muscles show through the skin and give the characteristic 
appearance to the abdomen. 

In the middle line, about midway between the ensiform process- 
and the symphysis pubis, there is a well-marked depression, the navel;, 
this is an important landmark, although its position may vary some- 
what in different individuals, and marks the place where the fcetal 
umbilical vessels and fcetal channels enter and pass out of the abdo- 
men. Above, in the middle line, is the ensiform process of the ster- 
num, and passing downward from this there is a furrow which corre- 
sponds to the space between the rectus muscles, but which does not 
reach downward as far as the symphysis. On either side of the- 
middle line, corresponding to the outer border of the rectus, is the 
location of the linea semilunaris. Below, on either side, the anterior 
superior iliac spines — important surgical landmarks — may be seen,, 
and upon the pubic bones, on either side of and close to the sym- 
physis, the spinous processes of the pubes may be felt. 

Corresponding to Poupart's ligament, which reaches from the 
anterior superior spine to the spine of the pubes, there is a linear 
crease in the skin which separates the abdomen from the front of 
the thigh. 

The whole abdomen is covered by the skin, underneath which 
is the subcutaneous fat; the abdomen is a favorite site for the accu- 
mulation of fat in the obese, and this layer varies much in thickness 
in different individuals; it is continuous with the corresponding 
fatty layer upon the breast and below with the fat of the thighs. 
At the navel the fat is absent, the skin being depressed and fixed, 
to the aponeurosis beneath, so that the depth of the navel corre- 
sponds to the thickness of the abdominal pad of fat. The subcuta- 



208 ABDOMEN AND BACK. 

neous fatty layer is readily separated from the underlying muscle 
and aponeurosis, leaving these structures covered by a thin, loose, 
cellular fascia, the so-called deep layer of the superficial fascia, but 
which is really a part of the subcutaneous connective-tissue layer. 
This fascia is more intimately attached to the linea alba and Pou- 
part's ligament and to the pillars of the external inguinal ring than 
elsewhere. From the pillars of the ring it is prolonged downward 
around the spermatic cord and into the scrotum, where it is con- 
tinuous with the dartos. 

The Superficial Vessels of the Abdominal Wall. — In the subcu- 
taneous fatty layer the superficial arteries and veins ramify. 

Above, branches of the superior epigastric, which perforate the 
rectus and the anterior layer of its sheath, are distributed to the 
integument and subcutaneous tissue. Below, the superficial epi- 
gastric, which is derived from the femoral, curves obliquely upward 
across Poupart's ligament toward the umbilicus and supplies the skin 
and fat in this region. 

Upon the sides of the abdomen branches from the lumbar ar- 
teries pierce the muscles and ramify in the subcutaneous tissue. 

These vessels are all accompanied by their corresponding veins. 
Underneath the skin of the abdomen are seen many large veins which 
communicate with those within the abdomen, and therefore when 
the blood-current is obstructed in the portal vein or the vena cava 
these superficial abdominal veins become swollen and prominent and 
are readily recognized beneath the skin. 

After the skin and subcutaneous fatty layer, including the thin 
deep layer of the superficial fascia, have been removed from the 
front and sides of the abdomen, the broad, strong aponeurosis of the 
external oblique upon the front of the abdomen and the fleshy por- 
tion of this same muscle upon the side of the abdomen are exposed. 

The Muscles of the Antero-Lateral Wall. The External 
Oblique is a broad, flat muscle, the most superficial of the abdom- 
inal muscles, and occupies the side of the abdomen. The muscle 
arises by fleshy slips from the external surface of the eight lower 
ribs, interdigitating with the processes of origin of the pectoralis 
major and the latissimus dorsi. The fibers of this muscle have a 
general oblique direction, downward, forward, and inward, terminat- 
ing in the broad, strong aponeurosis which occupies the front of the 
abdomen. Those fibers which arise from the lowest ribs pass almost 
directly downward and are attached to the anterior half of the outer 



ABDOMEN. 209 

lip of the crest of the ilium. The posterior free horder of the ex- 
ternal oblique muscle forms the anterior border of the triangle of 
Pettit. The posterior border of this triangle is formed by the outer 
free edge of the latissimus dorsi, its base by the crest of the iliac 
bone, its floor by the internal oblique muscle. 

The aponeurosis of the external oblique is a broad, strong, pearly 
white, glistening, fibrous structure which occupies the front of the 
abdomen and is exposed after the integument and underlying fatty 
layer (superficial fascia) have been removed. The fibers of the apo- 
neurosis are, for the most part, directed downward and inward, cov- 
ering in the recti and joining in the middle line, between these 
muscles, to form the linea alba. 

The linea alba is a strong, fibrous band which reaches from the 
ensiform cartilage above to the symphysis pubis below; it marks the 
union of the aponeuroses of either side and separates the recti from 
each other. The linea alba is interrupted by the navel. Above the 
navel the linea alba is broad: in the epigastric region it is 1 to 2 
cm. wide, and below, toward the navel, becomes still broader. Below 
the navel, however, it is not so broad, owing to the closer approxi- 
mation of the edges of the recti. Above, where it is broad, it is thin 
from before backward, and below, where it is narrow, it is thick 
from before backward. Below, at its attachment to the symphysis 
pubis, it spreads out and is known as the adminiculum linege albas. 

Those fibers of the aponeurosis of the external oblique, that 
pass from the anterior superior spine of the ilium downward and 
inward to the spine of the pubes, form Poupart's ligament; where 
this ligament is attached to the pubic spine, the aponeurosis of the 
external oblique splits and leaves a triangular opening which is called 
the external inguinal ring, and through this the spermatic cord in 
the male, and the round ligament in the female, emerge. Below Pou- 
part's, the aponeurosis is continuous with the fascia lata of the front 
of the thigh. 

Along the outer edge of the rectus, at the linea semilunaris, the 
aponeurosis of the external oblique is blended with the aponeuroses 
of the underlying muscles; from the linea semilunaris the aponeu- 
rosis is continued inward, forming the anterior layer of the sheath 
of the rectus, and in the middle line joins with that of the opposite 
side to form the linea alba. 

The Internal Oblique Muscle lies beneath the external 
oblique upon the side of the abdomen, a thin, loose, cellular con- 



210 ABDOMEN AND BACK. 

neetive tissue being interposed between them. The fibers of this 
muscle have a direction the opposite to those of the external oblique. 

This muscle arises below from the anterior two-thirds of the 
middle lip of the crest of the ilium and from the outer half of 
Poupart's ligament. From this origin the fibers pass in a general 
direction upward and forward, some being attached to the lower 
border of the cartilages of the four lower ribs, the others terminat- 
ing in the anterior aponeurosis, at the outer border of the rectus, 
the linea semilunaris. The lowermost fibers, which arise from Pou- 
part's ligament, pass inward and then, curving downward, join with 
a similar process from the transversalis to form the conjoined tendon, 
which is attached to the crest of the os pubis. 

The Transversalis is the deepest of the three broad abdom- 
inal muscles. It occupies the side of the abdomen lying next beneath 
the internal oblique, a thin, loose, cellular connective tissue inter- 
vening between them. Its fibers have a transverse direction. This 
muscle arises behind, through the lumbar fascia, from the transverse 
processes and spines of the lumbar vertebrae; above, from the inner 
surface of the six lower ribs; below, from the crest of the ilium and 
the outer one-third of Poupart's ligament. The fibers pass forward 
and inward, and, at the outer border of the rectus, terminate in the 
anterior aponeurosis. Those fibers of the transversalis which arise 
from Poupart's ligament pass inward, and curving downward join 
with a similar process from the internal oblique to form the con- 
joined tendon, which is attached to the crest of the pubes behind 
the external inguinal ring. Beneath the transversalis muscle, the 
transversalis fascia, which lines the whole inner surface of the ab- 
domen, is found. 

The Pectus is a long, flat muscle occupying the front of the 
abdomen, one on either side of the middle line, the linea alba being 
interposed between them. 

Above, the rectus muscles are broad and attached to the carti- 
lages of the fifth, sixth, seventh, and eighth ribs and to the sides of 
the ensiform cartilage. Below, they become narrow and are attached 
to the symphysis and crest of the pubes. The recti are marked by 
several transverse fibrous intersections, which are united to the ante- 
rior layer of the sheath of this muscle, but not to the posterior; they 
are usually three in number, two above the umbilicus and one below. 

The Aponeuroses of the external and internal oblique and 
transversalis are blended with each other along the outer border of 




Fig. 87. — Transverse Section of the Abdomen Above the Semilunar Fold of Doug-las. 
AA, anterior layer of the split aponeurosis of the oblique and transversalis muscles — 
anterior layer of sheath of the rectus ; C, descending colon ; EO, external oblique 
muscle; ES, erector spina; muscle ; /, intestine suspended by the mesentery; IO. in- 
ternal oblique muscle ; K, kidney ; LD, latissimus dorsi muscle ; LS, linea semilunaris ; 
M, mesentery (suspends small intestine to vertebral column) ; P, psoas muscle : P. P, P, 
peritoneum lining inner aspect of abdominal wall ; PA, posterior layer of split aponeu- 
rosis of the oblique and transverse muscles — posterior layer of sheath of rectus; 
QL, quadratus lumborum muscle ; R, rectus muscle ; T, T, transversalis tascia ; TR, 
transversalis muscle. 




Fig. 88.— Transverse Section of the Abdomen Below the Semilunar Fold of Douglas, 
Showing the Entire Aponeurosis Passing in Front of the Rectus Muscle. A, aponeu- 
rosis of the abdominal muscles (oblique and transversalis), passing undivided in front 
of the rectus. For explanation of letters see Fi.^. 87. 



ABDOMEN. 211 

the rectus muscle. Here, corresponding to the linea semilunaris, 
they form one aponeurotic layer. At the outer border of the rectus 
the conjoined aponeurosis splits into two layers, — an anterior and 
a posterior, — and these include the rectus between them, one pass- 
ing in front of the muscle and the other behind it and both joining 
again with each other, between the recti, in the middle line, to form 
the linea alba. This disposition of the aponeurosis and sheath of 
the rectus is very simple and holds for the upper three-fourths of 
the muscle. Corresponding to the lower fourth of the rectus, the 
whole aponeurotic layer, without splitting, passes in front of the 
muscle; so that this lower fourth of the rectus, upon its posterior 
aspect, is without a proper sheath and is covered only by the general 
fascia transversalis. 

Upon the "posterior aspect of the rectus, where the posterior 
layer of the sheath terminates, it presents a sharp, curved edge: the 
semilunar fold of Douglas. 

The Fascia Transversalis. — Lining the inner surface of the 
transversalis muscle and continued over the whole internal surface 
of the abdomen is a strong fascia, the fascia transversalis. Above, 
this fascia is thin and lines the abdominal surface of the diaphragm; 
below, and in front, especially in the inguinal region, it is thicker. 
Behind, upon the posterior wall of the abdomen, it covers the psoas 
and quadratus lumborum muscles, forming here the anterior layer 
of the lumbar fascia; it is also attached to the crest of the ilium and 
to Poupart's ligament except where the femoral vessels pass under 
Poupart's ligament into the thigh. It covers the psoas and iliacus 
muscles in the iliac fossa, where it is known as the fascia iliaca, and 
dips into the true pelvis, which it lines and is here called the pelvic 
fascia. All these fascia?, although having different names, are simply 
parts of the general transversalis fascia. 

The Parietal Peritoneum. — The whole interior of the abdominal 
cavity is lined by the parietal layer of the peritoneum. Between 
this parietal layer of the peritoneum and the transversalis fascia 
there is a layer of loose connective tissue which contains a consid- 
erable quantity of fat. This is the so-called subperitoneal connective 
tissue. 

Through an incision in the anterior abdominal wall placed just 
to the left of the middle line, we may study the round ligament of 
the liver. This structure is the remains of the foetal umbilical vein 
and reaches from the posterior aspect of the navel upward and to 



212 ABDOMEN AND BACK. 

the right as far as the under surface of the liver. A fold of the 
parietal peritoneum, which is reflected from the anterior abdominal 
wall around the round ligament, is called the falciform ligament. 

The presence of these structures would complicate somewhat 
entrance into the abdomen through an incision placed near the 
middle line upon the right side of the navel, and therefore when it 
is necessary to prolong an incision in the middle line either upward 
or downward beyond the navel one should pass to its left side. 

Accompanying the round ligament of the liver from the region 
of the umbilicus are several veins (one, the largest, enters the portal 
system, and thus establishes a communication between the veins of 
the skin of the abdomen and the portal circulation); in the newborn 
infection may be carried from the region of the navel to the liver 
through this channel. 

Beaching downward, in the middle line from the umbilicus to 
the summit of the bladder, is the urachus. This is a musculo-fibrous 
cord, — the remains of the fcetal allantois, — and may be found more 
or less pervious in the child or adult; so that a communication may 
thus exist between the umbilicus and the bladder. As the parietal 
peritoneum, which lines the posterior surface of the anterior abdom- 
inal wall, passes over the urachus, it is raised in the form of a distinct 
longitudinal fold: the plica vesico-umbilicalis media. 

The Deep Vessels of the Abdominal Wall. — Between the layers 
of the muscles of the abdomen the deep vessels of the abdominal 
wall ramify. Above are found the terminal branches of the internal 
mammary, the superior epigastric, and the musculo-phrenic. The 
superior epigastric is continued from the thorax, through the open- 
ing in the diaphragm, between its costal and sternal portions, and 
then, piercing the posterior layer of the sheath of the rectus, it sup- 
plies this muscle and gives off branches which perforate the muscle 
and the anterior layer of its sheath to supply the subcutaneous tissue 
and skin of the abdomen. It anastomoses with branches of the su- 
perficial epigastric and deep (inferior) epigastric. 

Below, the deep epigastric and the deep circumflex iliac, which 
are derived from the external iliac, are encountered; these are given 
off just before this vessel passes under Poupart's ligament into the 
thigh to become the femoral. 

The deep epigastric is directed upward and inward toward the 
umbilicus, resting upon the posterior surface of the rectus, be- 
tween the transversalis fascia and the parietal peritoneum, and 




Fig. 89. — The Regions of the Abdomen as Indicated bv Two Transverse Lines Drawn through the 
Tips of the Tenth Costal Cartilages and the Anterior Superior Iliac Spines and Two Oblique Lines 
Drawn from the Tips of the Tenth Costal Cartilages down to the Pubic Spines. D, duodenum indicated 
in red (the dotted portion represents that portion of the duodenum which lies beneath the liver, 
transverse colon, and stomach) ; G, gall-bladder ; L, liver; S, stomach ; TC, transverse colon. 



ABDOMEN. 213 

enters the substance of this muscle below the semilunar fold of 
Douglas, supplying it and anastomosing with the end branches of 
the superior epigastric. Some branches from this vessel pierce the 
anterior layer of the sheath of the rectus muscle and ramify in the 
fatty layer beneath the skin. 

The deep circumflex iliac passes upward and outward beneath 
and parallel with Poupart's ligament toward the anterior superior 
iliac spine; it then runs along the crest of the ilium and after 
piercing the transversalis fascia is distributed to the muscles of the 
abdomen. 

From behind come the abdominal branches of the lumbar ar- 
teries: usually four. They pass forward between the muscles and 
anastomose with the branches of the musculo-phrenic, superior epi- 
gastric, the deep epigastric, and the deep circumflex iliac. These 
arteries are all accompanied by their corresponding vein. 

The Regions of the Abdomen. — The surface of the abdomen is 
marked off into areas by several lines which intersect each other. 
Two of these are transverse, the upper passing through the tips of 
the tenth ribs, the lower through the highest points of the iliac 
crests. These are crossed by two lines which pass from the tip of 
the tenth rib of either side downward and inward to the pubic 
spine. 

Above the upper transverse line is the: — 

(a) Eegio epigastrica; 
between the two transverse lines is the 

(b) Eegio mesogastrica; 

and below the lower transverse line is the 

(c) Eegio hypogastrica. 

The regio epigastrica is subdivided into three portions: — 

1. Eegio epigastrica proper. 

2. Eegio hypochondriaca dextra. 

3. Eegio hypochondriaca sinistra. 

The regio mesogastrica is also subdivided into three portions: — ■ 

1. Eegio umbilicalis. 

2. Eegio abdominis lateralis dextra. 

3. Eegio abdominis lateralis sinistra. 

The regio hypogastrica is subdivided into three portions: — 

1. Eegio pubica. 

2. Eegio inguinalis dextra. 

3. Eegio inguinalis sinistra. 



214 ABDOMEN AND BACK. 

THE BACK. 

When we speak of the back we mean the whole posterior part 
of the trunk. The back may be divided into three regions: the 
dorsal, the lumbar, and the sacral. 

It is better to consider the back as a whole, since these regions 
merge directly into each other without any definite dividing line. 

Above the back is limited by the vertebra prominens and below 
by the tip of the coccyx. The dorsal portion corresponds to the 
chest, and includes the dorsal vertebrae and the ribs, the scapulae 
and the muscles of this region. The lumbar portion forms the poste- 
rior wall of the abdominal cavity, and includes the five lumbar ver- 
tebra? and the thick mass of muscle on either side which fills in the 
space between the last rib and crest of the ilium. 

The sacral region corresponds to the posterior wall of the true 
pelvic cavity and includes the sacrum and the coccyx. 

In the middle of the back there is a longitudinal furrow in 
which the spinous processes of the vertebras, from the seventh cer- 
vical, vertebra prominens, above, to the sacrum below, may be dis- 
tinctly felt; those which correspond to the sacrum are less prominent. 

To either side of this median furrow there is a prominent mass 
formed by the longitudinal muscles of the back. These masses ex- 
tend from the sacrum to the occiput, and, the more pronounced they 
are, the deeper is the median groove. 

In the dorsal region, on either side, are the scapulas — shoulder- 
blades. These bones are triangular in shape and are located between 
the first and eighth ribs toward the outer part of the thorax. The 
inner or vertebral border of the scapula is nearly parallel with the 
spinous processes of the vertebras when the arm hangs by the side. 
This bone is freely movable and its position varies according to the 
position of the upper extremity. The spine of the scapula is felt 
beneath the skin and may be traced outward and upward; its outer 
end, which is prolonged outward and flattened from above down- 
ward, is called the acromion process and overhangs the shoulder- 
joint, articulating with the outer end of the clavicle. The lower 
extremity of the scapula, the angle, corresponds to the eighth rib, 
and is a surgical landmark of some value. 

The skin and subcutaneous connective tissue of the back is 
continuous with the corresponding layers of the adjoining parts of 
the trunk. The subcutaneous tissue is rather firm and fibrous and 
contains a varying amount of fatty tissue. The deep fascia of the 



BACK. 215 

back is a strong, dense, fibrous layer which covers in the superficial 
muscles; it . is attached in the middle line to the spinous processes 
of the vertebra? and may be traced upward, upon the trapezius mus- 
cle, as far as the occipital bone, to which it is attached. In the dorsal 
region it is attached to the subcutaneous surface of the spine of the 
scapula. Below it is attached to the crest of the ilium and to the 
sacrum. 

The Muscles of the Back are numerous and may be divided into 
several layers. 

Fikst Layee of Muscles. — Trapezius and latissimus dorsi. 

The Trapezius is a broad, flat muscle, one on either side; to- 
gether they are lozenge-shaped and occupy the dorsal and cervical 
regions. Each muscle arises from the superior curved line of the 
occipital bone, from the ligamentum nucha?, which corresponds to 
the spinous processes of the cervical vertebras, and from the spinous 
processes of all the dorsal vertebrse. From this extensive origin the 
muscle of each side is attached as follows: Those fibers which arise 
from the occipital bone pass downward, outward, and forward, and 
are attached to the upper surface of the outer one-third of the clav- 
icle; those from the dorsal and cervical vertebrae converge and are 
attached to the whole length of the upper border of the spine of 
the scapula. That portion of the muscle which corresponds to the 
lower cervical and upper dorsal vertebra? shows an aponeurotic origin, 
which, together with that of the opposite side, is oval in shape. 

The Latissimus Dorsi is broad, triangle-shaped, and fiat, and 
occupies the lumbar and lower dorsal regions, being partly over- 
lapped by the trapezius. 

It arises by aponeurotic fibers from the spinous processes of the 
five or six lower dorsal and the lumbar vertebra?. Below the aponeu- 
rotic origin of the latissimus dorsi is intimately blended with the 
aponeurosis that covers the erector spina?; the muscle also arises 
from the back part of the outer lip of the crest of the ilium and by 
three or four slips from the external surface of the lower ribs. From 
this extensive origin the fibers all converge, and at the angle of the 
scapula they form a thick, flat, fleshy muscle, which, making a half- 
turn upon itself, passes upward, in front of the teres major, and is 
attached by a narrow, flat, aponeurotic tendon to the inner lip of 
the bicipital groove of the humerus. The tendon of the latissimus 
dorsi and the teres major form the lower border of the posterior 
wall of the axilla. 



216 ABDOMEN AND BACK. 

Secoxd Later of Muscles: 

Levator anguli scapulae. 

Khoniboideus < 

( Minor. 

The Levator Anguli Scapulae is located in the side of the neck 
and the upper dorsal region. It arises by tendinous slips from the 
tubercles on the transverse processes of the four upper cervical ver- 
tebrae; passing down the side of the neck, it is attached to the upper 
part of the inner, or vertebral, border of the scapulae. 

The Rhomboids are two flat muscles placed one above the other, 
both lying upon the same plane and really forming one broad, flat 
muscle. Internally they are attached to the spinous processes of 
the last cervical and four or five upper dorsal vertebrae, and exter- 
nally to the vertebral border of the scapula. 

Third Layer of Muscles. — Splenius; serratus posticus, supe- 
rior and inferior. 

The Splenius is located in the back of the neck and upper dorsal 
region, reaching from the occiput downward as far as the sixth dorsal 
vertebrae below. 

The Serratus Posticus. — The superior and inferior are two thin, 
flat muscles, the superior being located in the upper dorsal region, 
the inferior in the lower dorsal and lumbar regions. 

The Muscles of the Fourth Later are numerous and have 
a longitudinal direction, reaching upward, alongside of the spinal 
column, from the sacrum as far as the occiput. The muscles of this 
group, except the erector spinas, are of but little importance sur- 
gically. 

The Erector Spinae below, in the lumbar region, forms a large 
musculo-tendinous mass, which fills in the space on either side of 
the lumbar part of the spinal column, being superimposed upon the 
quadratus lumborum in this region. From the lumbar region the 
erector spinae is continued upward into the dorsal region. In the 
dorsal region this muscle divides into* a number of processes, each 
of which receives a different name and is described as a separate 
muscle. The erector spinae below, in the lumbar region, is covered 
by a dense aponeurotic structure: the posterior layer of the lumbar 
fascia. The muscle arises from the back part of the iliac crest and, 
through its aponeurosis, from the posterior surface of the sacrum 
and from the spinous processes of the lumbar and two or three lower 



BACK. 217 

dorsal vertebrae. The erector spinas is included between the poste- 
rior and middle layers of the lumbar fascia. The quadratus lum- 
borum lies beneath the erector spinas. 

In the lumbar region the erector spinas forms a well-marked 
muscular mass, and its outer edge is an important guide in cutting 
down upon the kidney. 

The Muscles oe the Fifth Layer are numerous, and are made 
up, for the most part, of longitudinal strips that connect adjoining 
vertebras to each other. They ar,e all more or less continuous with 
each other, but receive different names in different regions. They 
are lodged in the groove upon either side of the spinous processes, 
and extend from the sacrum to the occiput. 

The Quadratus Lumborum is really a muscle of the abdomen, 
forming part of its posterior wall; it is quadrilateral in shape, broad, 
and thick. It fills in the space on either side of the spinal column 
from the last rib to the crest of the ilium. It is broader below at 
its attachment to the crest of the ilium than above at its insertion 
into the last rib. Its outer border is free and lies more external than 
that of the erector spinas, and forms an important surgical guide. 

The muscle arises by aponeurotic fibers from the upper part 
of the ilio-lumbar ligament and from the adjacent part of the crest 
of the ilium for a distance of about two inches. From this origin 
the muscle passes upward and is inserted into the inner half of the 
lower border of the last rib and, by fleshy slips, to the transverse 
processes of the four upper lumbar vertebras. 

The muscle is inclosed between the middle and anterior layers 
of the lumbar fascia, and lies directly beneath the erector spinas, 
from which it is separated by the middle layer of the lumbar fascia. 

The Lumbar Fascia. — In the lumbar region there is a strong 
aponeurotic structure called the lumbar fascia; it is through this 
fascia that the transversalis muscle is connected with the spine. 
The lumbar fascia is usually described as consisting of three layers 
(see Fig. 87). The anterior layer is rather thin, covers the front 
surface of the quadratus lumborum muscle, and is attached inter- 
nally to the anterior aspect of the transverse processes of the lumbar 
vertebras; above, this layer of the fascia is attached to the lower 
border of the last rib, where it constitutes the ligamentum arcuatum 
externum. The middle layer of the lumbar fascia is strong, is at- 
tached to the apices of the transverse processes of the lumbar ver- 
tebras, and is placed between the quadratus lumborum and erector 



218 ABDOMEN AND BACK. 

spinas muscles. The posterior layer of the lumbar fascia is attached 
to the apices of the spinous processes of the lumbar vertebras; it 
forms the posterior aponeurotic covering of the erector spinas, and 
is blended with the aponeurosis of origin of the latissimus dorsi. At 
the outer border of the quadratus lumborum the three layers of the 
lumbar fascia unite to form a single aponeurotic layer, through which 
the transversalis muscle is connected with the spinal column. 

The Psoas and Iliacus Muscles. — In the back of the abdomen, 
lying one upon either side of the spinal column, is the psoas muscle. 
It arises by slips from the transverse processes and bodies of the last 
dorsal and the lumbar vertebras, and passing downward joins with 
the iliacus. 

The iliacus muscle occupies the iliac fossa, taking its origin 
there, and, together with the psoas, passes out of the abdomen under 
Poupart's ligament to be attached to the lesser trochanter of the 
femur and to the surface of the bone immediately below this. 

The psoas and iliacus are covered by a fascia, the iliac fascia. 
This is simply a part of the general transversalis fascia of the ab- 
domen. That part which covers the psoas muscle is thickened above, 
where it is known as the ligamentum arcuatum internum; laterally, 
beyond the edge of the psoas muscle, this fascia is continuous with 
that which covers the quadratus lumborum: the anterior layer of 
the lumbar fascia. The iliac fascia covers the iliacus muscle also, 
and is attached to the crest of the ilium and the brim of the pelvis, 
and to Poupart's ligament except where the femoral vessels pass 
down into the thigh. In this situation the fascia is continued down- 
ward, under Poupart's ligament, behind the vessels into the thigh, 
covering the anterior surface of the psoas-iliacus muscle. 

The parietal peritoneum is spread out over the inner surface 
of the posterior wall of the abdomen. The kidney, incased in its 
capsule of fat, lies between this layer of the peritoneum and the 
fascia which covers the quadratus lumborum muscle. 

The Spinal Column, etc. — The spinal column is made up of the 
vertebras and intervertebral pads, the sacrum, and the coccyx; it is 
located at a considerable depth from the surface of the body. The 
spinal column gives solidity, combined with flexibility, to the trunk, 
and furnishes a canal to contain and protect the spinal cord. 

"We may palpate the body of the first cervical vertebra, the atlas, 
through the mouth, its anterior tubercle lying just behind the soft 
palate; those vertebras which lie below this down as far as the fifth 



BACK. 219 

cervical may also be palpated through the mouth. Lower in the 
neck and in-the dorsal region palpation of the bodies of the vertebras 
is impossible. The bodies of the lumbar vertebra? can be felt through 
the abdomen, especially in thin persons. The sacrum and coccyx 
may be palpated through the rectum. 

The laminae meet behind, in the middle line, to form the spinous 
processes and inclose the canal which contains the spinal cord. 

In the cervical and lumber regions the spaces between the 
laminae are broad, and a knife-blade might easily be introduced 
through these into the spinal canal. This could not be so readily 
done in the dorsal region, however, where the laminae and spines 
overlap each other like the shingles on a roof. 

The spaces between the laminae are occupied by the ligamenta 
subflava, which serve to complete the canal and even it out upon 
its inner aspect. 

The bodies of the vertebrae are joined to each other by the ante- 
rior and posterior common ligaments; the posterior common liga- 
ment, besides connecting the bodies of the vertebrae with each other, 
also serves to even out the irregularities upon the internal aspect of 
the canal. The spines of the vertebrae are connected with each other 
by ligaments: the interspinous and the supraspinous. 

The spinal column presents three curves in the sagittal direc- 
tion, antero-posterior, and one lateral with the concavity toward the 
left (aorta). 

Fractures of the spine usually involve the fifth and sixth cer- 
vical, last dorsal, and first lumbar vertebrae, and are usually caused 
by indirect violence, the curved parts of the spine being bent beyond 
the limit of their elasticity. 

The spinal canal is widest in the neck and triangular upon sec- 
tion; narrower in the dorsal region and circular upon section. It is 
narrowest at the level of the ninth dorsal. From the eleventh dorsal 
it becomes wider again. In the sacrum it is flattened from before 
backward and terminates upon the posterior surface of this bone. 

The spinal canal shows a series of openings — intervertebral — 
upon either side, just behind the bodies, for the passage of nerves 
and vessels to and from the canal. The contents of the canal are 
well protected. It is an uncommon accident for an instrument to 
penetrate into the canal, and unusual force is required to injure the 
cord inclosed within these bony walls. 

Contained within the canal is the spinal cord, which is much 



220 ABDOMEN AND BACK. 

smaller and shorter than the canal; the spinal cord commences at 
the upper border of the posterior arch of the atlas, where it is con- 
tinuous with the medulla, and terminates below in the conus ter- 
minalis on a level with the lower border of the first lumbar vertebra. 
From the conus terminalis the cord is prolonged still farther down- 
ward as the filum terminale. 

The spinal cord, as it lies within the canal, is inclosed by the 
dura and pia mater. The dura mater is continuous with the dura 
mater, periosteum, of the skull, and is adherent to the margin of 
the foramen magnum. Here it splits into two layers, the external 
of which is applied to the inner aspect of the spinal canal as a lining 
membrane, periosteum, whereas the other, the inner layer, forms a 
loose, sack-like envelope for the cord, the dura mater proper, and 
is continued all the way down to the coccyx, where it is blended with 
the periosteum of that bone. Between these two layers there is a 
space in which veins and arteries ramify and into which hemorrhage 
may take place and spread up and down the canal. Each nerve, at 
its exit from the spinal canal, has prolonged upon it a tubular proc- 
ess, which is derived from the dura and pia mater. 

Beneath this dura mater sheath is the pia mater, a reticular 
structure like that which invests the brain; the outer surface of the 
pia is known as the arachnoid, and the inner, which is applied di- 
rectly to the surface of the cord, is known as the pia mater proper 
and carries the vessels which penetrate into the substance of the cord 
to supply it. 

Between the two surfaces of the pia there is a space, which is 
called the subarachnoid space, and which is subdivided, cut up, by 
numerous trabecule into a net-work of small spaces. In the sub- 
arachnoid space, between the two layers of the pia, the cerebro- 
spinal fluid is found. From the pia mater laterally, between the 
roots of the nerves, there arises a longitudinal septum which is at- 
tached to the inner surface of the dura mater by a number of proc- 
esses. The line of origin from the pia is continuous. The line of 
attachment to the dura mater is interrupted. This is known as the 
ligamentum dentatum. 

The surfaces of the dura and the pia mater (arachnoid) are not 
joined to each other except for occasional strands of connective tis- 
sue that unite them here and there. The space between the dura 
and pia mater is known as the subdural space. 



SURGICAL ANATOMY OF THE STOMACH. 221 

Each nerve-root is provided with an envelope consisting of a 
process of the pia and dura. 

Arteries that supply the cord consist of hranch.es from the ver- 
tebral, intercostals, lumbar, and lateral sacral; from above down- 
ward these vessels pass through the intervertebral foramina to sup- 
ply the coverings and the cord. 

Veins, in the form of plexuses, are found on the front and back 
of the cord, within the canal, between the two layers of the dura, 
or, better, between the dura proper and the periosteum. 

THE STOMACH. 

The Surgical Anatomy of the Stomach. — The stomach is a pear- 
shaped, pouched portion of the alimentary canal with a capacity of 
from five to eight pints. It is suspended obliquely in the upper part 
of the abdomen, upon the left side, extending from the oesophagus to 
the duodenum. Its walls are thick, and consist of a serous, a mus- 
cular, a submucous, and a mucous membrane coat. 

The larger end of the stomach, the cardiac, is above and toward 
the left side; the smaller end, the pyloric, is below and toward the 
right side. 

The oesophageal opening is called the cardiac, and the opening 
into the duodenum, the pyloric, orifice. The dilated left end of the 
stomach— i.e., that part to the left of the oesophageal opening — is 
called the fundus; the middle part, the body; and the right, rather 
constricted portion, the pylorus. 

The stomach presents an upper or right border, the lesser curva- 
ture, and a lower or left border, the greater curvature. It has an 
anterior Avail directed forward and upward and a posterior wall 
which is directed backward and downward. 

The adult stomach, moderately distended, measures in its long- 
est diameter from ten to twelve inches; from the greater to the 
lesser curvature, four to five inches; and from the anterior to the 
posterior wall about three and one-half inches. When the stomach 
is empty the first and second diameters are diminished and the third 
disappears, as the walls come into contact with each other. In this 
condition the mucous membrane lining is thrown into numerous 
folds and ruga?. 

The opening between the pylorus and the duodenum is indi- 
cated by a well-marked thickening of the wall of the stomach, which 
may be felt from without; it is made up of circular muscular fibers, 



222 ABDOMEN AND BACK. 

which act as a sphincter and which serve to shut off the cavity of 
the stomach from that of the duodenum. 

The stomach lies in the left hypochondriac and the epigastric re- 
gions; about five-sixths part of the organ lies to the left of the mid- 
dle line, the pyloric end lying to the right of the middle line. The 
cardiac orifice is located one inch below the diaphragm, to the left 
of the eleventh dorsal vertebra, and at a depth of 11 cm. from the 
front wall of the abdomen, on a line directly behind the articulation 
of the seventh left costal cartilage with the sternum. The pyloric 
orifice lies to the right and a little below the ensiform cartilage and 
nearer the anterior wall of the abdomen. The direction of a line 
drawn from the cardiac orifice to the pyloric orifice of the stomach 
would be downward and to the right. The fundus of the stomach 
reaches upward as high as the level of the sixth costal cartilage, and 
is separated from the base of the left lung by the diaphragm. 

The anterior surface of the stomach, toward the left, is in rela- 
tion with the seventh, eighth, and ninth ribs, the diaphragm being 
interposed; toward the right, the pyloric end of the stomach is cov- 
ered by the left lobe of the liver. 

Below the stomach, along its great curvature and attached to 
it by the so-called gastro-colic ligament, is the transverse colon. 

A triangular area of the anterior wall of the stomach — near the 
left free border of the ribs — is in direct relation with the anterior 
abdominal wall, and is here accessible for operation. The base of 
this triangular space is indicated by a transverse line, which corre- 
sponds to the transverse colon and greater curvature of the stomach 
and which is drawn through the tip of the ninth rib (costal carti- 
lages) of either side. The other lines of the triangle are, upon the 
left, the free border of the ribs, and, upon the right side, a line cor- 
responding to the anterior thin edge of the left lobe of the liver, 
which is drawn from the tip of the tenth right costal cartilage to the 
tip of the eighth left costal cartilage. 

Behind the stomach lie the pancreas, with the splenic vessels 
passing along its upper border; the upper part of the left kidney 
and suprarenal capsule; and, toward the left, the spleen. 

Behind the pyloric end of the stomach are the duodenum, portal 
vein and common bile-duct, the head of the pancreas and the first 
lumbar vertebra, the crura of the diaphragm, the aorta with the 
cceliac axis, the solar sympathetic plexus, the thoracic duct, vena cava 
inferior, etc. 



SURGICAL ANATOMY OF THE STOMACH. 



223 



The spleen lies to the left of the stomach and rather behind it. 
The gall-bladder is in relation with the pyloric end of the stomach. 

The stomach is entirely enveloped by the peritoneum, which 
forms its serous coat; above, extending between the transverse fis- 




Fig. 90. — Sagittal Section to Show the Arrangement of the Great and 
Lesser Omenta, etc. GM, great omentum; L, liver; LM, lesser omentum; 
8, stomach; TG, transverse colon; *, situation where the layers of the great 
omentum become fused to that portion of the peritoneum which invests the 
transverse colon, thus joining the latter to the lower border of the stomach. 



sure of the liver and the lesser curvature of the stomach, the two 
layers of the peritoneum join to form the lesser omentum, gastro- 
hepatic ligament, between the layers of which, toward its right edge, 
the hepatic artery, portal vein, and common bile-duct are located. 



224 ABDOMEN AND BACK. 

Below, at the greater curvature, the two layers of peritoneum, 
after enveloping the stomach, again join to form the great omen- 
tum through which- the transverse colon is attached to the greater 
curvature of the stomach. That portion of the great omentum 
which joins the stomach and transverse colon is called the gastro- 
colic ligament. Toward the left, the two layers of peritoneum which 
cover the anterior and posterior surfaces of the stomach are also 
joined — gastro-splenic omentum — and are reflected over upon the 
spleen, inclosing this organ and connecting it with the fundus of 
the stomach. Between the layers of the gastro-splenic omentum 
the vasa brevia pass to the fundus of the stomach. 

The arteries which supply the stomach are derived from the 
cceliac axis, and consist of large branches which course along the 
lesser and greater curvatures; these vessels give off large branches, 
which ramify upon the anterior and posterior walls of the stomach, 
coursing from the periphery toward the middle of each surface; 
along the lesser curvature, the pyloric artery, a branch of the hepatic, 
and the gastric artery anastomose; along the greater curvature, 
anastomosing with each other, are the gastro-epiploica dextra, from 
the hepatic, and the gastro-epiploica sinistra, from the splenic. The 
vasa brevia, from the splenic, ramify upon the left end, fundus, of 
the stomach. 

The stomach may be reached through several incisions: — 

1. In the linea alba, commencing one inch below the ensiform 
cartilage and reaching down to the umbilicus. After cutting through 
the skin, subcutaneous fat, and the strong fibrous layer, the linea 
alba, the parietal peritoneum is reached and incised. If necessary 
to prolong this incision beyond the navel, it should be carried to the 
left of that structure. 

2. Yon Hacker's incision: Through the left rectus muscle, one 
and one-fourth inches to the left of the linea alba, penetrating 
bluntly between the fleshy fibers of the rectus muscle with the handle 
of the knife. 

3. Just to the left of the linea alba, through the inner portion 
of the rectus muscle, thus avoiding an incision through the linea 
alba. 

4. Fenger's incision: One finger's breadth distant from and 
parallel with the free border of the ribs (left side). This incision 
may be two to three inches in length or longer, its upper end being 
placed a short distance from the tip of the ensiform cartilage. 



SURGICAL ANATOMY OF THE STOMACH. 



225 




Fig. 91. — Incisions to Reach Abdominal Viscera, etc. B, Battle incision; C, left 
colostomy; F, Fenger incision for stomach; G, incisions for operations upon gall-blad- 
der (perpendicular and oblique) ; H, von Hacker's incision for gastrostomy (in the mid- 
dle line, alongside of E, is the linea alba incision for operations upon stomach) ; MB, 
McBurney incision for appendicectomy; SC, incision for suprapubic cystotomy. 



226 



ABDOMEN AND BACK. 



Hemorrhage may be controlled by clamping vessels as they are 
met and cut, afterward ligating any that may require it. 

OPERATIONS UPON THE STOMACH. 

Gastroplication. — The folding in of a portion of the wall of the 
stomach in order to diminish the size of the organ. This operation 
was first performed by Bircher, and is especially applicable to cases 
of dilatation without stenosis of the pyloric orifice. 

The abdominal incision, five to six inches in length, may be 




Fig. 92. — Gastroplication. Lower border of the stomach is turned up and 
stitched near the lesser curvature with a single row of sutures (4), method 
of Bircher; with four rows of sutures (1, 2, 3, 4), method of Weir. 



placed a finger's breadth distant from and parallel with the left free 
border of the ribs, commencing above near the tip of the ensiform 
process, or it may be located in the linea alba, reaching from a point 
one inch below the tip of the ensiform process downward as far as 
the umbilicus. 

Through either of these incisions the stomach may be brought 
out upon the abdominal wall. 

According to Bircher, the anterior wall of the stomach is folded 
upon itself; so that the greater curvature may be brought up close 
to the lesser curvature and fixed in this position with a row of inter- 



OPERATIONS UPON THE STOMACH. 



227 



Tirpted silk sutures; these should take a good, broad bite in the wall 
of the stomach, including its serous and muscular coats. Care should 
be exercised that the sutures do not penetrate through the entire 
thickness of the wall of the stomach. Twelve to fourteen sutures are 
usually required. 




93. — Cross Section of the Stomach After Gastroplication 
according to the Method of Bircher. 



According to Weir, the fixation may be made with three or four 
separate tiers of sutures, one superimposed upon the other. After 
the stomach has been brought out through the abdominal incision, 
its anterior wall, corresponding to the long^ 1 diameter of the organ, 




94. — Cross Section of Stomach After Gastroplication; the Turned-Up 
Portion Fixed by Four Rows of Sutures. (Weir.) 



is inverted, and the edges of the furrow thus made in the wall of 
the stomach united with a row of continuous or interrupted silk 
sutures. A second row of sutures is then introduced parallel with 
and about one inch distant from the first. A third and finally a 



228 ABDOMEN AND BACK. 

fourth row may be introduced, the last row joining the greater curva- 
ture to the upper part of the anterior wall of the stomach near its 
lesser curvature. In this way six or eight inches of the stomach 
wall may be reefed in and the organ materially reduced in size. No 
doubt the folding of the stomach wall is made more secure when 
several rows of sutures are used. 

Gastrotomy. — This operation consists in making an incision into 
the stomach for the purpose of extracting a foreign body lodged in 
the stomach or impacted low down in the oesophagus; for explora- 
tion of the interior of the stomach, ulcer, hemorrhage, etc., and to 
treat strictures in the lower part of the oesophagus. 

Immediately preceding any operation upon the stomach the 
organ should be emptied and irrigated, if the conditions permit, with 
the stomach tube. This is best done after the patient has been 
anaesthetized. 

The incision may be made in the middle line through the linea 
alba, three inches long, commencing above about one inch below the 
ensiform process, and extending downward toward the umbilicus; or 
an incision may be made just to the left of the linea alba, passing 
through the inner margin of the left rectus muscle; or the Fenger 
incision, parallel with the free border of the left ribs, may be em- 
ployed. This last incision (Fenger) is probably the best if the ulti- 
mate object is to reach the oesophagus. 

Having carried the incision down to the parietal layer of the 
peritoneum, this is picked up with two toothed forceps and a small 
incision made between them with the knife; through this the finger 
is introduced, and upon the finger, with a blunt-pointed scissors, the 
opening in the peritoneum is enlarged so as to correspond in length 
with the incision in the abdominal wall. Two fingers are then intro- 
duced into the abdomen and the stomach searched for. If there is 
a foreign body in the stomach, this may oftentimes be felt and serves 
as a guide to the stomach. The thin anterior edge of the left lobe 
of the liver may be always readily recognized, and this is a good 
guide to the stomach, as the stomach lies directly underneath this 
organ, being partly covered by it; that part of the anterior surface 
of the stomach which is. not covered by the liver is accessible for 
operation; it is seized with two fingers and drawn out of the ab- 
dominal incision. Pads of dry, sterile gauze are then placed about 
the stomach and tucked into the abdominal incision and the rest 
of the operation done extraperitoneally. If the stomach is dimin- 



OPERATIONS UPON THE STOMACH. 229 

ished in size there may be some difficulty in bringing it out through 
the incision .upon the abdomen. 

One should not mistake the transverse colon for the stomach. 
Tbe transverse colon lies below and close to the greater curvature, 
being connected with the greater curvature by the great omentum 
(gastro-colic ligament); the great omentum is suspended free, apron- 
like, from the transverse colon, and when this part of the intestine 
is drawn out upon the abdomen the great omentum is drawn out 
with it; the colon can be further recognized by its sacculation, by 
the little fatty appendices attached to it, and by the strise which run 
along its length. 

The wall of the stomach is smooth, and the blood-vessels rami- 
fying upon its. surface have a characteristic course, converging from 
the periphery toward the center; the gastro-epiploica dextra and 
sinistra run along the greater curvature from either end of the 
stomach, anastomosing with each other. 

A portion of the stomach wall which has been drawn out through 
the abdominal incision is now incised. When opened, care should 
be taken to catch any escaping contents, especially if the stomach 
has not been previously emptied, washed out, in order to prevent 
these entering the abdominal cavity. 

The stomach is best incised in its long diameter, and the in- 
cision may vary from one to three inches. Bleeding vessels may be 
caught with artery forceps. Venous hemorrhage stops after the 
artery forceps have been applied for a short time, but spurting arte- 
rial branches should be clamped and tied with either fine silk or fine 
catgut. 

After the removal of the foreign body or examination of the 
interior of the stomach, either by the finger introduced or by in- 
spection, bringing, piece by piece, different areas of its inner surface 
into the incision, treatment of ulcer by curette or Paquelin, etc., the 
opening may be closed. 

The closure of the incision in the stomach is best effected by a 
continuous Lembert suture of fine silk, which is applied with a fine 
curved surgeon's needle. This suture includes the serous and mus- 
cular coats and takes a good bite, each loop being drawn fairly tight. 
This line of suture may be reinforced by a second similar row of 
Lembert sutures which bury the first. Before closing the opening 
in the stomach wall its edges should be wiped with a wet bichloride 
pad. After the closure has been accomplished the parts should be 



230 ABDOMEN AND BACK. 

again mopped off with the bichloride pad, followed by salt solution, 
and the stomach then returned into the abdomen. 

The wound in the abdomen is closed first by a continuous catgut 
stitch which approximates the edges of the parietal peritoneum, and 
then a sufficient number of interrupted silk-worm sutures — each in- 
cluding the skin, aponeurosis, and muscle — are introduced. 

If the stomach is opened for the purpose of treating a cicatricial 
stricture of the lower end of the oesophagus, the finger may be intro- 
duced through the incision in the stomach into the oesophageal 
opening; at times it is necessary to make a little steady pressure 
with the finger before this opening yields so as to allow the finger 
to enter. Conical gum bougies of increasing caliber may then be 
introduced into the oesophagus beyond the stricture. If the stricture 
is dense and unyielding, one may, according to the method of Abbe,, 
pass a thin bougie, carrying a strand of braided silk, up into the 
oesophagus, through and beyond the stricture, so that the end of the 
bougie with the silk cord may be felt in the pharynx. The piece of 
silk is then grasped in the back of the pharynx through the mouth 
or through an opening which may be made for that purpose in the 
side of the neck and oesophagus, and the bougie again withdrawn 
through the opening in the stomach. The silk string having been 
thus carried through the oesophagus, a conical bougie is now again 
introduced into the oesophagus from below through the opening in 
the stomach; this bougie should be large enough to become tightly 
engaged in the stricture; the ends of the silk string are then seized, 
and after this has been drawn back and forth several times it will be 
observed that the bougie can be passed farther and farther into the 
stricture; and one may thus use bougies of increasing caliber until 
the stricture is sufficiently relieved. The incision of the stricture 
which is made by the silk string is accomplished with but little 
hemorrhage. The bougie and string are withdrawn and a tube 
permitted to remain in the oesophagus, with its end projecting 
through the opening in the stomach and out through the abdominal 
incision. 

Besides this a second tube is left in the stomach for the pur- 
pose of feeding. The abdominal incision is left partly open. 

One may again repeat the procedures if necessary, after an in- 
terval of a few days. 

The gastric fistula which results either closes spontaneously or 
may be closed by a secondary plastic operation. 



OPERATIONS UPON THE STOMACH. 



231 



Pyloroplasty (Heinecke and Mikulicz). — For cicatricial stricture 
of the pylorus causing obstruction to the emptying of the stomach. 

The stomach is exposed through a median incision and its py- 
loric end drawn out through the incision. Pads are then properly 
placed to protect the peritoneal cavity during the rest of the opera- 
tion. 




Fig. 95. — Pyloroplasty. Horizontal incision into the pylorus. 

The pylorus is incised in its long axis, a clean cut being made 
through all its coats; this incision should be from 4 to 6 cm. long; 
the edges of the incision are then drawn widely apart by tenacula in 
the middle of each edge, and in this way the transverse incision be- 
comes converted into a vertical one. In this position, after sponging 




Fig. 96.— Pyloroplasty. 



Horizontal converted into a vertical Incision 
and sutures placed. 



its margins with a bichloride pad, the opening is closed by a row of 
interrupted Lembert sutures which take a good, deep, and broad bite, 
these being reinforced and buried by a second row of Lembert sutures, 
which may be continuous. All the sutures are of silk. Care should 
be taken to close the opening accurately, especially in the middle: 
the points which correspond to the extremities of the original incision. 



232 ABDOMEN AND BACK. 

The result is a marked widening of the pyloric orifice. The wound 
in the abdomen is closed in the usual way. 

Gastrostomy. — The formation of a permanent gastric fistula for 
the purpose of feeding in cases of simple or malignant stricture of 
the oesophagus. The fistula should permit the introduction of nutri- 
ment and at the same time prevent the escape of stomach contents. 

Von Hacker's Method. — The operation may be done, if nec- 
essary, under cocain ansesthesia. This method is used only in ad-, 
vanced cases, where time presses. 

The incision, three inches long, is made through the left rectus 
muscle; it should be placed about one and one-fourth inches to the 
left of the middle line, commencing above, about one inch below 
the free border of the ribs. After passing through the integument 
the anterior layer of the sheath of the rectus is reached and incised, 
and then, separating between the fibers of this muscle bluntly with 
the handle of the knife, the posterior layer of the sheath of the 
rectus is exposed; after this layer has been incised the parietal peri- 
toneum is exposed; this is picked up with two toothed forceps and 
between these a small incision is made with the knife. Through this 
small opening the finger is introduced into the abdomen and the 
incision further enlarged with blunt-pointed scissors. Now, corre- 
sponding to the middle of the abdominal incision, upon each side, the 
parietal peritoneum is fixed to the edge of tbe muscle with a single 
catgut suture. Two fingers are then introduced into the abdomen 
and the anterior wall of the stomach is seized and drawn out of the 
wound. Two silk sling sutures are introduced into the wall of the 
stomach; these should take a good, broad bite in the wall of the 
stomach, but should not penetrate into its cavity, and should be 
placed about one and one-half inches apart and one above the other; 
they are simply to serve as tractors to steady the stomach in the 
wound, and should not be withdrawn until after the stomach has 
been opened. They are useful guides when the time comes later to 
incise the stomach. 

Now, with a fairly large curved surgeon's needle a silk suture 
is passed through the edges of the upper part of the abdominal in- 
cision; this should include the whole thickness of the abdominal 
wall, care being taken not to omit the parietal peritoneum. This 
suture is not tied. A similar stitch is then passed through the lower 
end of the wound, and this is also left untied. Now, just below the 
upper suture, the first one introduced, another similar suture is 



OPERATIONS UPON THE STOMACH. 233 

passed, but this includes, in addition, the wall of the stomach: one 
should take a good, broad bite in the wall of the stomach, but with- 
out entering its cavity; this suture is placed just above the upper 
of the two sling tractor stitches; again, in the lower part of the 
wound, a stitch is taken similar to the preceding which likewise in- 
cludes the wall of the stomach and lies just below the lower sling 
stitch. These four sutures are then tied and cut short, and the wound 
i« thus partly closed above and below, and the stomach fixed at the 
same time to the edges of the incision by two good, firm sutures. 
The wall of the stomach is now further fixed to the edges of the 
incision by three or four additional silk stitches on each side; thesa 
may be of fine chromicized catgut or of fine silk. 

The wound is then packed and dressed, and after the lapse of 
two days the stomach is opened between the two sling sutures which 
were left in situ. It is better to make this opening in the stomach 
with a sharp knife, clamping any bleeding points, rather than with a 
Paquelin, which causes a sloughy wound which, when it cicatrizes, 
may be larger than desired. The opening in the stomach should be 
one-half inch long, just large enough to admit a tight-fitting tube. 
The sling stitches may then be withdrawn. 

If one should desire to open the stomach immediately, which 
should be avoided if possible, the union of the stomach to the edges 
of the abdominal incision must be made more accurate in order to 
prevent possible leakage and peritoneal infection. 

Method of Ssabanajew and Fkanck. — A very satisfactory 
operation. The incision (Fenger) should be placed parallel wilh the 
left free border of the ribs and should be not more than two inches 
long, commencing above to the side of the ensiform process. The 
middle of the incision should be opposite the tip of the cartilage of 
the eighth rib. The incision is continued down through the muscles 
and parietal peritoneum. The margins of the peritoneum are fixed to 
the edges of the muscles in the abdominal incision with one or two 
silk or catgut stitches on either side, near the middle. The anterior 
wall of the stomach, near the fundus, is then seized with two fingers, 
and drawn out of the wound in a cone-shaped process about one and 
one-half inches long and a silk sling suture passed through its apex 
to serve as a tractor. The base of this process of the stomach wall is- 
fixed all around to the edges of the incision in the abdomen with a 
continuous silk stitch. This stitch should include the serous and mus- 
cular coats of the stomach and the edges of the parietal peritoneum 



234 



ABDOMEN AND BACK. 



and transversalis fascia and deep muscular layer in the abdominal in- 
cision. They do not pass through the skin nor should they pass 
through the entire thickness of the stomach wall. After this step of 
the operation has been completed a second short incision about three- 
fourths inch long is made through the integument, about one inch 
above and parallel with the first incision and just beyond the free 
border of the ribs. The bridge of integument that intervenes between 
this and the first incision is then raised bluntly with the handle of the 





Fig. 97. — Gastrostomy (Ssabanajew- 
Frum-.k). Cone-shaped process of the 
anterior wall of the stomach (8) drawn 
out through abdominal incision with a 
silk tractor passed through its apex, 
its base sutured all around to the edges 
of the parietal peritoneum and trans- 
versalis fascia, etc. 



Fig. 98. — Gastrostomy (Ssabanajew- 
Franck). Apex of cone-shaped process 
(AS) sutured to the edges of second 
incision over the ribs. 



knife, and, with the silk sling as a tractor, the apex of the cone-shaped 
process of the stomach wall is drawn through into the second small 
incision, where it is fixed with about four interupted silk sutures. 
The edges of the skin corresponding to the first incision are finally 
approximated with several interrupted silk-worm gut sutures, the 
conical process of the stomach wall being thus buried underneath the 
bridge of tissue between the two incisions. After the apex of the 
cone-shaped process of the stomach has been sutured to the second 



OPERATIONS UPON THE STOMACH. 235 

small incision, it may be opened and a tube introduced for the pur- 
pose of feeding. A fistulous tract about two inches long, leading into 
the stomach, is the result. 

Witzel's Method, also a very satisfactory operation. An in- 
cision (Fenger) about two inches long is made through the integu- 
ment, aponeurosis, and muscle down to the parietal peritoneum, 
which layer is then picked up with toothed forceps and incised. 

Instead of cutting through the muscles of the abdominal wall 
one may, after the aponeurotic layer (sheath of the rectus) has been 
■exposed and divided, separate bluntly between the fleshy fibers of 
the several muscles, between those of the rectus in a vertical direc- 
tion and those of the transversalis in a transverse direction; the 
muscles, having been thus separated, are drawn apart with broad 
retractors, and the peritoneum incised for a length corresponding 
to the length of the incision in the integument. 

It is probably just as well in most cases to cut the muscles, as 
the separation between the fibers adds to the difficulty of the opera- 
tion and consumes time, all to little or no purpose. 

Instead of the Fenger incision as described above one may make 
a vertical incision (Mikulicz), 4 to 5 cm. long, just to the left of the 
middle line, passing through the inner edge of the rectus muscle and 
located midway between the ensiform process and the umbilicus. 

Whichever incision is employed, after the abdomen has been 
opened the parietal peritoneum is fixed to the edges of the incision 
with one or two catgut stitches on each side to prevent its retrac- 
tion. These stitches fix the parietal peritoneum to the transversalis 
fascia and the deeper layer of muscles, but do not include the skin. 

Two fingers are now introduced into the abdomen, and the ante- 
rior wall of the stomach seized and drawn out of the wound and 
surrounded with aseptic gauze pads, so that the succeeding steps of 
the operation may be done extraperitoneally. 

A No. 25 F. soft rubber catheter is placed upon the surface of 
the stomach so that it is directed obliquely downward and toward 
the left, and in this position it is fixed with four interrupted silk 
sutures, which pick up the wall of the stomach on either side of the 
catheter, each taking a good, broad bite, but not penetrating through 
the entire thickness of the wall of the stomach. In this way the 
stomach wall is raised in a fold, or plait, upon each side of the tube; 
so that when the sutures are tied these two folds meet and completely 
bury the tube. Corresponding to the end of the catheter a very small 



236 



ABDOMEN AND BACK. 



opening is now made in the stomach wall with the point of the knife, 
and through this the end of the catheter is pushed so that about three 
inches of its length is within the stomach. The opening in the stom- 
ach should be so small that the tube will be a tight fit. The free end 
of the tube is closed with a ligature or forceps to prevent the escape 
of stomach contents. The four sutures which have been introduced 
across the tube into the stomach wall are now tied, and thus the tube 
is imbedded between the two folds, which form a canal about two 
inches long containing the tube. A sufficient number of additional 
silk sutures should be introduced to secure the accurate coaptation 





Fig. 99. — Gastrostomy (Witzel). The 
end of the tube is passed through a 
small incision into the stomach, the 
wall of the stomach being raised up 
upon each side of the tube and sutures 
introduced. 



Fig. 100.— Gastrostomy (Witzel). The 
sutures tied, thus uniting the folds cf 
the stomach to each othtr and burying 
the tube. 



of the two folds of the stomach wall over the tube, and at the point 
where the end of the tube enters the stomach the sutures should be 
extended a sufficient distance beyond to insure against leakage from 
the stomach around the tube. That part of the stomach wall under- 
neath which the tube is buried and that immediately adjacent to the 
catheter as it emerges from the canal formed by the plaiting of the 
wall of the stomach should now be joined with interrupted silk 
sutures to the edges of the parietal peritoneum and transversalis 
fascia upon either side of the abdominal incision; these sutures 
should take a good, broad bite in the wall of the stomach, but should 
not pass through its entire thickness; they serve to fix that part of 



OPERATIONS UPON THE STOMACH. 237 

the wall of the stomach which is immediately adjacent to the tube to 
the parietal peritoneum. 

The abdominal incision is then closed, except for a small portion 
above, just sufficient to allow the catheter to emerge, with several 
interrupted silk-worm gut sutures, each passing through all the 
layers of the abdomen, including the parietal peritoneum. 

G-astrorrhaphy. — Suture of the wall of the stomach for perfora- 
tion, stab, or gunshot wound. 

An incision is made in the middle line, through the linea alba, 
and the stomach exposed. 

If the wound in the stomach is small, it may be closed with a 
single row of interrupted Lembert sutures of fine silk. These should 
take a good, broad bite in the wall of the stomach, and should in- 
clude the serous and muscular coats only; they should not pierce 
the entire thickness of the wall of the stomach or enter the mucous 
membrane layer. 

If the wound in the stomach is large, this first row of inter- 
rupted Lembert sutures may be reinforced by a second continuous 
Lembert stitch, which will positively insure the accurate approxi- 
mation of the serous surfaces and bury the first row of sutures. 

Before applying the sutures the surface of the stomach imme- 
diately adjacent to the wound should be swabbed with a wet bichlo- 
ride pad. If the peritoneum has become soiled by escaping stomach 
contents, it is well to thoroughly wash out the abdominal cavity with 
salt solution after the opening in the stomach has been closed. 

Pylorectomy. — Eesection of the pyloric end of the stomach; 
adapted to early cases of malignant disease of this part of the stom- 
ach where the neighboring organs, especially the pancreas and liver, 
are not involved. The stomach, immediately preceding the opera- 
tion and after the patient has been anassthetized, should be washed 
out through a stomach tube. 

The incision is placed in the middle line and should be suffi- 
ciently large, 10 to 15 cm., extending from the ensiform process 
down to the umbilicus or beyond this point. The pyloric end of the 
stomach is drawn into the wound and well surrounded with gauze 
pads so arranged as to protect the abdominal cavity during the op- 
eration, and the left lobe of the liver is held up out of the way by 
an assistant. 

Billroth's Method. — The first step in the operation is the 
isolation of the pylorus (diseased part, which is to be excised) from 



238 



ABDOMEN AND BACK. 



the greater omentum (transverse colon) below and from the lesser 
omentum above. With a blunt-pointed ligature carrier, armed with 
catgut or fine silk, the greater and lesser omenta, corresponding to 
the diseased pylorus, are transfixed and tied off in sections; the greater 




Fig. 101. — Pylorectomy. Anterior edge cf the liver is lifted up; the lesser 
and greater omenta are shown. The lesser and greater omenta, correspond- 
ing to the portion of the stomach that is to be excised, have been ligated in 
sections. The dotted lines indicate the line of section through the stomach 
and omenta. Instead of being applied as represented in this picture, the 
ligatures may be placed double and the line of incision carried between them. 



and lesser omenta are then cut away from the pylorus, cutting with 
the scissors between the ligatures and the pylorus. Each ligature 
should include one to one and one-half inches of the omentum. In- 
stead of a ligature carrier a sharp-nosed artery forceps may be used 



OPERATIONS UPON THE STOMACH. 23£ 

to pass the ligatures. One should be mindful of the location of the' 
common bile-duct and the portal vein in the free edge of the lesser 
omentum. 

After the pylorus (tumor) has been thus entirely freed from it& 
omental attachment above and below, it may be drawn pretty well 
out through the abdominal incision, so that the operation may be- 
continued with more ease. 

Before excising the pylorus (tumor) compression clamps are ap- 
plied about the stomach and duodenum close to the tumor; ordinary 
long-limbed artery forceps will answer for this purpose. Two are- 
applied to the stomach, close to the tumor, one reaching from the 
lesser curvature and one from the greater curvature, and one is 
placed about the duodenum, also rather close to the tumor. The 
stomach is then seized by an assistant, who compresses it between 
the fingers of both hands, grasping it just beyond the place where 
the clamps are applied in order to prevent the escape of the stomach 
contents when it is cut, and then the operator, with a sharp scissors, 
cuts across the stomach from above downward, between the fingers 
of the assistant and the clamps. 

The stump of the pylorus is now enveloped in a compress and 
turned to one side, the clamps preventing any leakage. The hemor- 
rhage from the cut edge of the stomach is controlled by catching 
the bleeding points with forceps; any spurting arterial points should 
be ligated with fine silk; the hemorrhage from the divided veins- 
ceases when the suture is applied. 

The opening in the stomach is closed, commencing above and 
working downward toward the greater curvature, first with a con- 
tinuous stitch of silk, which includes all the coats of the stomach 
and which is applied with a long, straight needle. Each loop of the 
suture is drawn fairly tight. The lower part of the opening in the 
stomach is left unclosed for a sufficient length to allow the inser- 
tion, later, of the stump of the duodenum. A second continuous 
Lembert stitch is then introduced, which inverts and buries the first 
line of suture. Through the opening left below some strips of iodo- 
form gauze are packed into the stomach to prevent leakage, and then,, 
enveloped in a compress, it is temporarily laid aside. 

The attention of the operator is now directed to the duodenum. 
Its contents are stripped along with the finger, and a compressor 
applied, or it may be surrounded by a strip of gauze which is tied 
moderately tight to prevent the escape of its contents when it is. 



24:0 



ABDOMEN AND BACK. 



cut. If the gauze strip is used, it may be carried around the duo- 
denum in the mouth of a sharp-nosed artery forceps, which is thrust 
through its mesentery. Instead of a compressor or strip of gauze the 
duodenum may be compressed between the fingers of an assistant; 
but the assistant's fingers occupy considerable space, and may thus 
interfere with the work of the operator. 

The duodenum is divided a short distance beyond the clamp 
which had been applied to it, and the resection of the pylorus is 
thus accomplished. Any escaping contents from the end of the duo- 
denum should be caught upon a gauze pad, and the edge of the 
duodenum wiped off with a wad of wet bichloride gauze. 




Fig. 102. — Pylorectomy (Billroth). Dotted lines indicate lines of section 
in excising diseased pylorus. XXX represent diseased portion that is to be 
excised. 



The protecting gauze pads are now renewed, the gauze removed 
from the opening remaining in the stomach, and the end of the 
duodenum sutured into this opening. There is first applied, with 
a curved surgeon's needle, a continuous silk suture; this should be 
applied from within the gut so that the raw edges present toward 
the interior of the gut. This line of suture should include all the 
coats, take a good bite, and be drawn fairly tight. When this suture 
is completed, it is reinforced by a second row of outside sutures, 
uninterrupted and of fine silk, which includes only the serous and 
muscular coats and buries the first line of suture. Special care 
should be taken to secure the point where the stomach suture meets 
the suture that unites the stomach and the duodenum. 



OPERATIONS UPON THE STOMACH. 



241 



"With the Mukphy Button. — The junction of the end of the 
duodenum and the stomach may he accomplished hy means of a 
Murphy hutton. The opening left in the end of the stomach, after 
the pylorus has heen cut away, is closed throughout its entire length, 
and a junction then made between the stump of the duodenum and 
a new opening, which is made in the posterior wall of the stomach 
about one inch away from its sutured edge. 

The end of the stomach and the end of the duodenum may he 
both closed completely by inversion and suture, and a regular gastro- 
jejunostomy then performed with or without a Murphy button or 
with McGraw's rubber suture or with the Laplace or O'Hara for- 
ceps, etc. 




Fig. 103. — Pylorectomy (Billroth). Diseased portion has been excised and 
the end of the duodenum sutured to the end of the stomach. 



In excising the diseased pylorus one should not go too far along 
on the duodenum, as the second part of this segment of the gut is 
only partly invested with peritoneum, and is therefore unfavorable 
for union with the stomach. 

Method of Kochek (Eesection" of the Pylorus, with Gastro- 
duodenostomt). — Marked success in Kocher's hands. 

The pyloric tumor is exposed through a long median incision 
and then isolated from its omental attachments as described above. 
After the pyloric tumor has been thus isolated compresses are packed 
about it to protect the abdominal cavity, and clamps applied: ordi- 
nary long-limbed artery clamps. Upon the stomach side of the tu- 
mor — in order to include the whole width of the stomach — two 
clamps are necessary: one reaching from above downward and the 



242 ABDOMEN AND BACK. 

other from below. Upon the duodenum, to the distal side of the 
tumor, a clamp is likewise applied; parallel with this, hut farther 
along, a second clamp is applied to the duodenum. 

The duodenum is now divided with sharp scissors, between the 
two clamps, but not too close to the distal clamp, in order to leave 
room enough for necessary manipulation in suturing, etc. The 
cut edge of the duodenum, protruding between the limbs of the clamp, 
is wiped clean of intestinal contents with a wet bichloride pad and 
then enveloped in sterile gauze, and with the clamp still applied it 
is turned to the right and held against the right edge of the abdom- 
inal incision by an assistant. The clamp which compresses the stump 
of the duodenum should not be too tight, although Kocher says that 
it does not damage the gut, that the gut still bleeds from its edge 
after the clamp is removed. 

We then turn our attention to the stomach. The stomach is 
seized between the fingers of both hands by an assistant, and the 
pyloric portion cut away in a direction from above downward, be- 
tween the clamps and the assistant's fingers, and removed. The 
tumor mass, being tightly clamped at both ends, when cut away does 
not leak. Bleeding, spurting points in the cut edge of the stomach 
are clamped and tied with fine silk; oozing and venous hemorrhage 
stop when the suture is applied. 

The margins of the wound in the stomach are now wiped off 
with a wet bichloride pad and brought together throughout their 
entire length with a continuous silk stitch in a long, straight needle. 
This stitch includes all the coats, and takes a good bite; this sutured 
edge is then again wiped off with a wet bichloride pad and a fine, 
continuous Lembert stitch is applied, inverting the raw edges of the 
stomach wound and completely burying the first suture. 

The protecting abdominal pads are now again renewed, and we 
may proceed with the last step of the operation: the union of the 
stump of the duodenum to the posterior wall of the stomach. 

The assistant, still holding the stomach, directs its sutured end 
forward out of the wound; so that its posterior surface looks toward 
the duodenum, which is held over against the right edge of the 
abdominal incision. The cut end of the duodenum, with the com- 
pressor clamp still applied, is joined to the posterior wall of the 
stomach by a continuous stitch of fine silk, which is applied with 
a cambric needle and which corresponds to the posterior half of the 
circumference of the duodenum as it protrudes from the clamp. This 



OPERATIONS UPON THE STOMACH. 



243 



suture catches the duodenum just beyond its cut edge. This stitch 
does not pass through the entire thickness of the duodenum, but 
catches only the serous and muscular coats of the duodenum and 
the corresponding coats of the stomach. It forms the posterior half 
of the "outside serous ring suture." This needle, still threaded, is 
then laid aside until it is wanted later to complete this "outside 
serous ring suture." The end of the duodenum is sutured to the 
posterior wall of the stomach about one inch distant from the sutured 
edge of the latter. 




Fig. 104. — Pylorectomy (Kocher). The end of the duodenum has been 
sutured to the edge of the opening made in the posterior wall of the stomach 
with a continuous non-penetrating stitch. 



The clamp is now removed from the duodenum, the hemorrhage 
controlled, and any escaping contents sponged away, finally wiping 
the margin with a wet bichloride pad. An opening is then made in 
the stomach of a size to correspond with the end of the duodenum. 
This should be placed one-fourth inch from the line of suture by 
which the duodenum is already joined to the wall of the stomach. 
The edge of the duodenum stump is then sutured all around to the 
edges of the opening in the stomach, with a curved needle and silk, 
this being a continuous stitch applied from within, and including the 
whole thickness of the wall of each organ and taking a good bite, so 
that the raw edges of the parts look inward toward the lumen of the 
gut. When the parts have been thus united all around, the original 
needle is again taken in hand, and the Lembert suture which forms 



244 ABDOMEN AND BACK. 

the anterior half of the "outside serous ring" applied and the union 
is complete. Before joining the serous coats the parts should be 
swabbed with a bichloride pad. 

The protecting pads are now removed and the abdominal incision 
closed. With a continuous catgut stitch the edges of the peritoneum 
are coapted, and with several interrupted silk-worm gut sutures — 
which pass through the skin, muscle, and aponeurosis — the closure 
of the abdominal wound is completed. 

Gastrectomy. — Extirpation of the entire stomach. First case 
by Schlatter, 1897. A healthy heart is essential to the success of 
this operation. The operating room should be kept warm and the 
patient dressed in flannel garments to prevent as much as possible 
loss of body-heat by radiation. The stomach should be washed out 
immediately before the operation is commenced, after the patient has 
been anesthetized. 

The incision is best made in the linea alba, and must be liberal, 
— from six to seven inches in length, — reaching from the ensiform 
process to the umbilicus or even beyond this point. 

After the abdomen has been opened the stomach is recognized 
and examined, and search made for secondary deposits in the liver 
and adjoining lymphatic glands. In many cases the stomach can be 
drawn almost entirely out of the abdomen, and thus the performance 
of the operation is facilitated. 

The first step consists in the isolation of the stomach, freeing 
it from the greater and lesser omenta and from its attachment to 
the spleen: gastro-splenic omentum. 

Commencing at the pyloric end of the stomach, the omenta 
are tied off in sections, — first the lesser and then the greater omen- 
tum, — each ligature being tied double and including about one and 
one-half inches of the omentum. In ligating the lesser omentum 
the liver must be drawn up out of the way and the stomach pulled 
down. The presence of the common bile-duct between the layers of 
the lesser omentum, near its free right border, should not be for- 
gotten. After the lesser and greater omenta have been ligated as 
far as the middle of the stomach and divided, the section may be 
made between the pylorus and duodenum, in order that the stomach 
may the better be drawn down, so as to make the isolation of its 
cardiac end less difficult, or else one may wait until the whole length 
of the lesser and greater omenta has been ligated and cut away from 
the stomach before the division is made at its duodenal end. The 



OPERATIONS UPON THE STOMACH. 245 

division of the omentum should be made between the double ligatures 
with the scissors, cutting from one ligature hole into the next. 

After the stomach has been freed of its omentum, along the 
lesser and greater curvatures, we are ready for the next step of the 
operation: the removal of the stomach. The stomach is divided 
first at its pyloric end, if this has not already been done. An intes- 
tinal clamp is placed about the duodenum, about one and one-half 
inches from the pylorus, and a clamp about the pyloric end of the 
stomach, and between these' the intestine is divided with the scissors. 
Any escaping contents are caught upon a pad, and the end of the 
duodenum, sterilized and wrapped in gauze, and with the compressor 
still applied, is dropped temporarily into the abdomen. 

A ligature is then thrown around the gastro-splenic omentum; 
this is the peritoneal fold that reaches from the fundus of the stom- 
ach to the spleen, and through it the vasa brevia pass to the stomach. 

This ligature is applied double, that we may divide between 
them. Special pains should be taken to secure the vessels in the 
gastro-splenic omentum, leaving the ligature long that the pedicle 
may be drawn forward, so that, if necessary, the vessels may be 
secured with additional ligatures. 

To reach the oesophagus the stomach must be pulled well down- 
ward. An intestinal compressor is placed about the oesophagus a 
short distance below the diaphragm, and a clamp about the oesoph- 
ageal end of the stomach, and then between these the oesophagus is 
divided with the scissors. The stomach is thus removed. 

After the stomach has been excised it becomes necessary to 
restore the continuity of the alimentary canal, either by joining the 
end of the duodenum to the oesophagus, oesophago-duodenostomy, 
or else by inserting the end of the oesophagus into the jejunum, 
oesophago-enterostomy. 

In most cases the oesophagus can be drawn down and the duo- 
denum sufficiently mobilized to allow of its being brought up into 
apposition with the end of the oesophagus without tension. In this 
case the parts may be joined with a Murphy button No. 3 (see 
"End-to-End Anastomosis"). After the button has been inserted 
the compression clamps may be removed from the duodenum and 
oesophagus, and a row of outside Lembert sutures applied to make 
the junction still more secure. These sutures include the serous 
and muscular coats, but do not pass through the mucous membrane. 

If unable to approximate the parts as described, the end of 



246 



ABDOMEN AND BACK. 



the duodenum may be inverted and closed with a double row of 
sutures and an cesophago-enterostomy done, the end of the cesoph- 




Fig. 105.— Gastrectomy. 0E8, stump of oesophagus; D, end of the duo- 
denum. Dotted lines indicate the excised stomach. The small intestine 
(jejunum) has been drawn up into apposition with the stump of the oesoph- 
agus, as in cesophago-enterostomy. 

agus being sutured into an opening which is made in the small in- 
testine. The upper part of the jejunum is sought in the upper back 
part of the abdominal cavity, — to the left of the body of the second 



SURGICAL ANATOMY OF THE SMALL INTESTINE. 247 

lumbar vertebra, — and a coil of gut about eighteen inches beyond 
this point selected. A segment of this coil of gut about six inches 
long is tied off with tapes, first one and then the other, after the 
contents of the segment have been stripped along with the fingers. 
This segment of gut is then brought up, around the transverse colon, 
into apposition with the end of the oesophagus. 

The posterior half of the circumference of the end of the oesoph- 
agus is sutured to the wall of the coil of gut with a row of continuous 
Lembert sutures. These sutures secure the wall of the oesophagus 
about one-fourth inch beyond its cut edge, and include the serous 
and muscular coats, but not the mucous. This needle is then dis- 
carded temporarily, and an incision is made in the gut corresponding 
in length to the size of the opening in the oesophagus. The edge of 
this opening in the gut is sutured to the edge of the oesophagus all 
around with a continuous silk stitch that includes all the layers. 
When this suture has been completed and the end of the oesophagus 
thus securely fixed to the opening in the intestine, the first needle, 
that with which the posterior half of the end of the oesophagus was 
joined to the gut, is again taken in hand and the anterior half of 
the "outside serous ring" suture applied. It is well to use silk ex- 
clusively for both sutures and ligatures in this operation. The ab- 
dominal wound is closed without drainage. 

During the course of the operation the solar plexus may be 
considerably molested, and at the time that the oesophagus is severed 
both pneumogastric nerves are also divided. The shock is therefore 
apt to be marked, and should be counteracted by avoiding as much as 
possible loss of body-heat and by administering proper stimulation. 
The division of the pneumogastrics leads to disturbance of the 
heart's action; it becomes very greatly accelerated, and an attempt 
should be made to regulate this, probably with proper doses of digi- 
talis hypodermically. For the first few days the patient is nourished 
per rectum; after forty-eight hours fluids may be given per mouth, 
first small quantities of water and then broth, milk, etc., may be 
added. At the end of a week a moderate amount of solid food may 
be taken through the mouth. 

THE SMALL INTESTINE. 

The Surgical Anatomy of the Small Intestine. The Duodenum 
is the first part of the small intestine. It is about ten inches long 
and commences at the pyloric end of the stomach and ends at the 



248 ABDOMEN AND BACK. 

jejunum. Its wall is moderately thick. It is usually described as 
consisting of three parts. 

The first, or ascending, part is freely movable, continuous with 
the pylorus, and entirely invested by peritoneum. It passes from 
the pyloric end of the stomach upward and backward toward the 
right as high as the level of the twelfth dorsal vertebra; it reaches 
close to the under surface of the liver, with which it is connected 
by the so-called ligamentum hepatico-duodenale. This ligament is 
simply the free, thickened, right edge of the lesser omentum: liga- 
mentum gastro-hepaticum. Between the layers of this lesser omen- 
tum are the hepatic artery, portal vein, and common bile-duct, the 
artery ascending to the liver, and the duct and vein descending be- 
hind this first part of the duodenum. Between the layers of the 
lesser omentum the artery lies to the left, the duct to the right, 
and the vein between and behind both. 

The duodenum then makes a turn downward along the right 
side of the first and second lumbar vertebrae, lying upon the front 
of the right kidney, with the head of the pancreas to the left (i.e., 
internal to this part of the duodenum). This is called the second 
part of the duodenum. It differs from the first part in being fixed 
to the posterior wall of the abdomen and in not being completely 
surrounded by peritoneum, but simply covered by the peritoneum 
upon its front surface, and therefore when we look for this part 
of the duodenum, after reflecting the transverse colon and the great 
omentum upward, it is not to be seen, and is only exposed to view 
after the peritoneum which covers its anterior surface has been cut 
through. The common bile-duct and the pancreatic duct open into 
the second part of the duodenum, between it and the head of the 
pancreas. These ducts pass obliquely through the wall of the duo- 
denum, and join with each other, before entering the gut, through 
a single common orifice, which is found upon the inner wall of the 
duodenum in the center of a papilla. A sound may be passed from 
this part of the duodenum into the common duct or into the pan- 
creatic duct. 

Between the head of the pancreas and this part of the duo- 
denum in the injected cadaver there may be seen the anastomosis 
between the superior and inferior pancreatico-duodenalis arteries: 
branches derived from the hepatic and superior mesenteric, respect- 
ively. 

At the level of the third lumbar vertebra the duodenum makes 



SURGICAL ANATOMY OF THE SMALL INTESTINE. 249 

another turn, passing across the hody of the third lumhar from the 
right to the left side of this vertebra, and at the same time ascend- 
ing to the level of the second lumhar vertebra. This is known as 
the third part of the duodenum. The aorta, etc., lie behind this part 
of the duodenum, and the head of the pancreas lies above it. 

Upon the left side of the second lumbar vertebra the duodenum 
is fixed to the vertebral column by a thickened portion of perito- 
neum; this fold contains some unstriped muscular fibers, and is 
called the suspensory ligament of the duodenum, the ligament of 
Treitz. This third part of the duodenum is also covered upon its 
anterior surface only by the peritoneum, and is fixed by this layer 
in the back of the abdomen in common with the pancreas. This por- 
tion of the duodenum is not to be seen when we examine this part 
of the abdomen until after the layer of peritoneum which covers its 
anterior surface and conceals it from view has been cut. 

The whole duodenum, in its curved course, resembles a horse- 
shoe in the hollow of which the head of the pancreas is received. 

The second and third parts of the duodenum are rather un- 
favorable parts for operation, on account of their fixedness and 
depth and the incompleteness of their peritoneal covering. 

The Jejunum and Ileum, about twenty feet long, make up 
the rest of the tube of small intestine, and are the direct continua- 
tion of the duodenum, terminating in the caecum in the right iliac 
fossa. 

Upon the left side of the second lumbar vertebra, where the 
duodenum ends and the jejunum begins, the intestinal canal becomes 
again provided with a complete peritoneal investment and a long 
mesentery, and is known as the jejunum. 

The jejunum forms about two-fifths of the length of the small 
intestine, and becomes the ileum where the valvulas conniventes, 
which characterize its inner surface, cease to exist. It is thick walled 
and large in caliber, and therefore resembles somewhat the large 
intestine; still, it is readily distinguished from this part of the gut 
by the absence of the longitudinal stria? and appendices epiploicse and 
in not being sacculated. 

At its commencement, upon the left side of the second lumbar 
vertebra, the jejunum seems to project directly forward, through the 
parietal peritoneum which lines the back of the abdominal cavity. 
This appearance is due to the fact that the portion of the gut, 
duodenum, which immediately precedes the jejunum, is not pro- 



250 ABDOMEN AND BACK. 

vided with a mesentery, lying behind the peritoneum and covered 
by it upon its anterior surface only, whereas the commencement 
of the jejunum and the rest of the small intestine are provided 
with an investment of peritoneum, which completely surrounds them, 
and a mesentery, which suspends them to the back of the abdomen, 
and, therefore, where this arrangement commences, the gut appears 
to project directly forward through the peritoneum from the poste- 
rior wall of the abdomen. The process of peritoneum that incloses 
the first part of the jejunum marks the commencement of the 
mesentery. 

We can locate this first portion of the jejunum by reflecting 
the great omentum, and with it the transverse colon, upward out 
of the way, and then, passing the hand back to the vertebral col- 
umn, this coil of intestine is found lying just to the left of the 
body of the second lumbar vertebra. An attempt to draw this coil 
of gut out of the abdomen will show that it is fixed within the ab- 
domen, and this fact will serve to identify it positively. 

The ileum, which is the continuation of the jejunum, consti- 
tutes three-fifths of the length of the small intestine. It becomes 
progressively smaller in caliber and thinner as we trace it toward its 
termination at the caecum, where its wall is thinnest and its caliber 
narrowest. 

The jejunum and ileum are suspended free in the abdominal 
cavity arranged coil upon coil, and are provided with a complete 
peritoneal envelope and a long mesentery, through which they are 
attached to the vertebral column in the back of the abdomen. 

The Mesentery is a reflection of peritoneum containing some 
unstriped muscular fiber, fat, etc.; it serves to suspend the gut in 
the abdomen and at the same time supports the blood-vessels, lym- 
phatics, nerves, etc., in their course to and from the small intestine. 

The mesentery is fan-shaped. The distal border is very long, 
corresponding to the whole length of the small intestine, to which 
it is attached; the proximal border is short and is fixed to the ante- 
rior surface of the vertebral column, reaching from the left side of the 
second lumbar vertebra, where the duodenum ends and the jejunum 
commences, downward, to the right side of the fifth lumbar vertebra; 
its line of attachment is thus oblique from the left side, above, down- 
ward and to the right. The vertebral edge of the mesentery is 
but six inches long, whereas the distal, intestinal edge is about 
twenty feet long, and in order to accomodate these two borders to 



SURGICAL ANATOMY OF THE SMALL INTESTINE. 251 

each other the intestinal end of the mesentery is folded and folded 
upon itself, making a series of plaits. 

Where the two layers of peritoneum of which the mesentery is 
composed meet the intestine, they diverge and surround the intes- 
tine in a sling-like fashion, the intestine being entirely invested 
except for the small "dead" space which corresponds to the separa- 
tion of the layers of the mesentery at the so-called mesenteric border 
of the intestine. Here the mesentery is not applied directly to the 
surface of the intestine, but is separated from it, leaving a small 
space — "dead space" — where the serous layer does not form part of 
the wall of the intestinal tube. 

The 'Blood-supply of the Small Intestine is furnished by 
the superior mesenteric artery. This vessel is given off from the 
anterior aspect of the aorta, and passes forward between the lower 
border of the pancreas and third part of the duodenum; it is located 
between the layers of the mesentery, and courses, in a curved direc- 
tion downward and to the right, toward the right iliac fossa. The 
superior mesenteric is a short, thick trunk. From its convex side it 
gives off branches to supply the whole length of the small intestine; 
from its concave side it gives off branches to the large intestine, to 
the caecum and vermiform appendix, ascending colon, and transverse 
colon, finally anastomosing with a branch from the inferior mesen- 
teric (see below). The superior mesenteric vein accompanies the 
artery and its branches, and behind the pancreas joins with the 
splenic to form the portal vein. The blood in the portal vein is 
derived from the intestine; before reaching the general circulation 
it passes through the liver; it leaves the liver through the hepatic 
veins, two or three in number, which empty into the inferior vena cava. 

The branches of the superior mesenteric, which supply the 
small intestine, are given off, as already mentioned, from the con- 
vex, left, side of the artery. These branches do not pass direct to 
the intestine, but anastomose with each other, forming a series 
of arches. From this set of arches another series of branches is 
given off, and thus this peculiar anastomotic arch formation con- 
tinues until the intestine is almost reached; finally the individual 
branches from the ultimate arches are distributed to the wall of 
the intestine. They pass to the intestine from between the layers 
of the mesentery, where these separate to envelop the intestine — 
that is, at the mesenteric border — through the so-called "dead 
space." After the ultimate vascular branches reach the wall of the 



252 ABDOMEN AND BACK. 

gut they do not communicate freely with each other, so that each 
segment of gut is dependent almost entirely upon one or two def- 
inite vessels for its nutrition and integrity. The same arrangement 
holds good for the ultimate veins. Therefore, if several of these 
ultimate vascular branches are severed close to the gut or become 
embolized or thrombosed, we are apt to have, as a result, gangrene 
of the corresponding segment of the gut. Wounds of the intestine 
at the mesenteric border are unfavorable for suture on account of 
the absence of the serous, peritoneal covering, at this part. Wounds at 
the mesenteric border of the gut almost of necessity include division 
of the ultimate intestinal arteries and veins, and therefore interfere 
seriously with the blood-supply to the corresponding part of the 
gut. 

OPERATIONS UPON THE SMALL INTESTINE. 

Enterorrhaphy. — Suture of the intestine for gunshot and stab 
wounds and for perforations due to ulceration, etc. 

These injuries are frequently accompanied by hemorrhage from 
wounded vessels in the mesentery. These vessels should be ligated 
with catgut. If large, and especially if divided close to the gut, it is 
well, after ligating the bleeding vessels, to resect the corresponding 
segment of the gut, as such injuries are very apt to be followed by 
gangrene of that part of gut which is dependent for its supply upon 
the injured vessels. 

The incision for injuries of this character is usually made in the 
middle line, four to five inches long, reaching from the umbilicus 
downward toward the symphysis. The incision may be prolonged 
upward toward the ensiform cartilage, passing to the left of the um- 
bilicus. The operator should avoid laying the abdomen open from 
the ensiform cartilage down to the symphysis pubis in the eager- 
ness of his search for wounds in the gut. If it becomes necessary 
to increase the length of the incision very much, that portion of it 
which is not in immediate use may be brought together temporarily 
with a few interrupted silk sutures which pierce the whole thickness 
of the abdominal wall. 

Having opened the abdomen, one should make a systematic ex- 
amination of the intestine from one end to the other, commencing 
at the lowest part of the ileum, where it enters the caecum. This 
part of the gut should be sought and drawn out upon the abdomen, 
and from this point on the small intestine and mesentery should be 



OPERATIONS UPON THE SMALL INTESTINE. 253 

carefully inspected, coil after coil being drawn out and examined 
and then re-placed until the upper end is reached. 

As a rule, penetrating gunshot and stab wounds of the abdomen 
are accompanied by multiple perforations of the gut and mesentery, 
— may be as many as fifteen or twenty, — and, when one perforation 
in the gut is located, usually a second is found in the same segment 
at a corresponding point opposite. Each time a projectile passes 
through the gut it makes two wounds — one of entrance and one of 
exit. 

Where we locate a perforation of the gut we usually find the 
mucous membrane protruding and tending to plug up the opening, 
nature's effort. Here we pause, replace the mucous membrane, wipe 
off the margins of the opening with alcohol followed by a weak bi- 
chloride solution, and close it with two or three interrupted Lembert 
sutures of fine silk; these sutures should be placed about one-eighth 
inch apart, and care should be taken to invert the edges of the wound 
and to bring the serous surfaces into close apposition. 

In suturing these wounds the caliber of the gut should not be 
reduced more than one-third. 

We then continue along in the search for further wounds. 
Wounds involving the mesenteric border of the gut, especially if the 
adjoining mesentery is torn, are unfavorable for suture; in the first 
place, the serous coat on this part of the gut is imperfect, has a 
"dead space"; and, in the second place, if any of the mesenteric 
vessels are divided close to the gut, the corresponding segment of 
the gut is apt to become gangrenous; therefore it is wise, in many 
cases, to resect such a segment of gut at once. 

Bleeding vessels in the mesentery should be clamped and tied 
with plain catgut. 

After the whole length of the small intestine has been explored 
one should examine the whole length of the large intestine, the 
stomach, and the bladder for perforations, and look further for 
hemorrhage, which might indicate wounds of the liver, spleen, kid- 
neys, etc. 

Hemorrhagic oozing from the solid viscera is usually readily 
controlled by the Paquelin cautery or by packing, or the edges of 
a gaping wound may be brought together with several deep catgut 
sutures, although these tend to tear through if any tension exists. 
Any spurting vessels in the solid viscera should be clamped and tied 
with catgut. 



254 ABDOMEN AND BACK. 

Having thus completed the examination of the entire length of 
the alimentary canal, etc., closed all wounds, and controlled the 
hemorrhage, the whole abdominal cavity may be flushed out with 
hot saline solution, using a considerable quantity — best poured from 
a pitcher. 

During the search for wounds, etc., one should replace the gut, 
coil after coil, as fast as it is examined. While the intestine is out- 
side the abdomen it should be carefully protected with hot sterile 
towels, which may be wet in hot saline solution. After a time the 
wet cloths, if not repeatedly wet with hot water, become cooled; there- 
fore some surgeons prefer dry sterile compresses for this purpose. 

If it is necessary to have a considerable portion of the length 
of the gut outside upon the abdomen, it should be supported so that 
it does not drag upon the mesentery; this should be avoided, how- 
ever, as much as possible, as it adds greatly to the shock and there 
may be some difficulty experienced in returning the distended coils 
of gut into the abdomen again. 

If, owing to the distension of the guts with gas, it becomes dif- 
ficult to replace them within the abdomen, it may be necessary to 
make punctures to allow the gas to escape. In doing this it is prob- 
ably better to make a few rather large openings with a fairly large 
aspirating needle or a scalpel to allow gas to escape, closing them 
afterward with a Lembert stitch; this plan is probably better than 
numerous small punctures made with a fine instrument. 

The abdominal incision should be carefully closed, first sewing 
the edges of the parietal peritoneum together with a continuous No. 
2 catgut suture; then, with a sufficient number of interrupted silk- 
worm sutures, the edges of the skin and aponeurosis are brought 
together, each stitch including all the layers of the abdominal wall 
except the parietal peritoneum. 

Enterectomy. — Eesection of a portion of the gut (small intes- 
tine); the length of gut resected may vary from several inches to 
several feet. The operation is performed for wounds which may 
not be safely closed by suture; for those associated with division of 
the mesenteric vessels, especially if they are divided close to the 
intestine; for malignant growths; for gangrene, strangulation; for 
fistula, etc. 

The incision is usually made in the middle line, four or five 
inches long, reaching from the umbilicus downward toward the sym- 
physis. The portion of intestine to be resected should be gently 



OPERATIONS UPOX THE SMALL IXTESTLXE. 055 

freed from adhesions, if there are any, and brought out upon the 
abdomen, together with an adjoining portion of healthy gut, four to 
six inches to either side of the part which is to be resected; the gut 
should be supported upon dry, sterile gauze compresses, some of which 
are also packed into the abdominal incision to protect the peritoneal 
cavity. 

In order to prevent the escape of intestinal contents during 
the operation, two gauze strips may be tied around the gut, one 
beyond each extremity of the segment which is to be excised. An 
assistant may compress the gut between his fingers or temporary 
intestinal clamps may be applied, but the gauze strips are probably 
more convenient. In order to carry the gauze strips around the gut, 
a thin-nosed artery forceps is thrust through the mesentery close 
to the gut, and with this the end of the gauze strip is seized and pulled 
through. One strip is tied and the contents of the gut gently stroked 
along with the fingers beyond the second strip, and then this is tied 
also. TTe have thus a fairly empty coil to operate upon, the strips 



Fig. 106. — Intestine Compressor. 

being tied just tight enough to prevent the re-entrance of contents. 
The strips should be applied to the gut at a sufficient distance beyond 
the portion which is to be excised to allow convenient working space. 
TTe then proceed to separate the portion of gut that is to be ex- 
cised from its mesenteric attachment. This is done by tying the 
mesentery off in segments, each ligature including about one inch 
of the length of the mesentery; the ligatures should be of thin 
catgut (So. 1 or 2). and each tied single about one inch away from 
the mesenteric edge of the gut. These ligatures may be passed either 
with a narrow-bladed artery forceps or a blunt ligature carrier. One 
must be careful not to tie off a greater length of mesentery than 
that which actually corresponds to the segment of gut which is to 
be excised, because gut which has been deprived of its mesentery is 
deprived of its blood-supply and is bound to slough. One should 
rather err in the other direction, tying off a little less mesentery 
than that which corresponds to the length of gut to be excised. 
After the mesentery has been thus tied off the segment of gut that 



256 



ABDOMEN AND BACK. 



is to be excised is cut away from its mesenteric attachment, using the 
straight scissors and cutting between the ligatures and the gut; the 
point of the scissors should be introduced into the openings made 




Fig. 107. — Enterectomy. A loop of intestine has been drawn oi't through 
the abdominal incision and tied off with tapes. The mesentery corresponding 
to the portion of gut that is to be excised has been tied off in sections. The 
dotted lines indicate the lines of section through the mesentery and gut. 



by the ligatures, and the mesentery cut from hole to hole, and thus 
finally through into the last ligature opening. We are now ready to 
sever the gut, and this is done with long, straight scissors that will 
divide the gut in one clean sweep. The gut should be divided 



OPERATIONS UPON THE SMALL INTESTINE. 257 

straight across at right angles to its long axis or, better, somewhat 
obliquely, so- that the segment of gut excised measures rather more 
upon its distal border than upon its mesenteric border. Bleeding 
points on the cut edges of the intestine should be clamped, but, as a 
rule, these do not require ligation, since after a few moments' press- 
ure they usually stop, especially after the ends of the gut have been 
united. Spurting points, however, should be clamped and tied with 
fine catgut. Contents that escape from the ends of the bowel as the 
section is made should be sponged away, and care should be taken 
that the pads of gauze are so arranged as to prevent the entrance of 
any of this material into the abdominal cavity. 

"We are now ready to restore the continuity of the intestinal 
canal. This may be accomplished by: — 

1. End-to-end anastomosis, the most desirable. 

(a) Suture. 

(b) Invagination and suture (Mounsell). 

(c) Murphy button. 

(d) Laplace anastomosis forceps. 

(e) O'Hara anastomosis forceps. 

2. Side-to-side, or lateral, anastomosis; applicable to both small 
and large intestine. 

(a) Suture. 

(b) Murphy button. 

(c) McGraw's rubber ligature. 

(d) Laplace anastomosis forceps. 

(e) O'Hara anastomosis forceps. 

3. End to side; this method is used to join the ileum to the 
large intestine (see "Resection of Csecum") and to join the end of 
the duodenum to the stomach after pylorectomy (see "Pylorectomy, 
Kocher"). 

End-to-End Anastomosis. Sutuee. — The ends of the intestine, 
after being cleansed and swabbed off with a bichloride pad, are joined 
together all around with a continuous suture. This suture commences 
at the mesenteric border of the gut and unites the two segments of 
the gut end to end all around. This suture is continuous, and may 
be of fine silk or catgut (No. 2). It is applied with a curved sur- 
geon's needle, sewing from within, so that the resulting suture line 
presents into the lumen of the gut. This suture includes all the 
layers of the wall of the gut, should take a good, broad bite, and each 
loop should be drawn fairly tight. 



258 ABDOMEN AND BACK. 

In beginning the suture, near the mesenteric border of the gut, 
special care is needed, in passing the first stitch, to include the serous 
coat in the bite of the needle, as it is in this situation that the mesen- 
tery splits to invest the intestine and is here not applied close down 
upon the muscular coat of the intestine; therefore, unless special 
pains are taken to include the serous coat in the stitch, this will be 
a weak spot, slow to heal, and may allow leakage. 

In uniting the two ends of the gut in this manner the last few 
stitches must be applied interrupted, but they should be tied so that 
the joined edges of the gut will be inverted and look inward into the 
lumen of the gut, and the knots present upon the inner aspect of 




Fig. 108. — End-to-End Anastomosis. Gut joined end to end by a contin- 
uous stitch introduced from within the gut and penetrating all the layers 
(Woelfler). Corresponding to the mesenteric border of the gut there may be 
observed the "dead space" left by the diverging layers of the mesentery. 

the united intestine. The knots of the last one or two stitches will, 
of necessity, have to be on the outside of the gut, but this will not 
prevent the edges of the gut being properly inverted. As before 
noted, especial care is required, in applying this stitch to that part 
of the gut immediately adjacent to the mesenteric attachment, to 
include the serous layer of the gut and thus do away with the "dead 
space" which normally exists in this situation between the serous 
and muscular coats of the intestine. 

Having thus completed the junction of the gut end to end, and 
having wiped the parts immediately adjacent to the line of suture 
with a wet bichloride pad, we may proceed to apply a second con- 



OPERATIONS UPON THE SMALL INTESTINE. 259 

tinuous Lembert suture of fine black silk. This Lembert stitch is 
introduced with a straight cambric needle, and includes only the 
serous and muscular coats; it should completely bury the preceding 
penetrating stitch, special caution being used to appose serous sur- 
face to serous surface, especially near the mesenteric attachment. 

The hole which is left in the mesentery, after the segment of 
gut has been resected and the ends sutured, should be closed with 
a continuous catgut stitch, again using special care to bring the 
edges of the opening close together near the surface of the gut. 

The strips which were placed around the gut are now removed 
and the sutured segment of bowel returned into the abdomen, and 
placed in the immediate neighborhood of the abdominal incision. 

The incision in the abdomen is closed, either with a single series 
of interrupted silk-worm gut sutures which include the whole thick- 
ness of the abdominal wall, and especially the edges of the parietal 
peritoneum, or, better, the edges of the parietal peritoneum may be 
brought together, first with a continuous catgut stitch, and then, 
in addition to this, the other layers of the abdominal wall may be 
united with a sufficient number of interrupted silk-worm gut sutures. 

Mounseli/s Method. — After having excised the segment of 
gut as above described, the cut ends are placed close together, edge 
to edge, supported upon gauze pads outside the abdomen. With a 
moderately large, straight needle and fairly thick silk the edges of 
the cut ends of the gut are fixed to each other at four different points 
of their circumference equidistant from one another. These sutures 
are to serve simply as tractors. The first is applied at a point 
corresponding to the mesenteric attachment, the second at a point 
directly opposite this, and the other two at points midway between 
these. Each of these sutures should include all the coats of the gut, 
special care being taken to catch the mucous membrane and the 
serous coats; the suture at the mesenteric border, particularly, 
should take a good hold of the serous coat to insure its inversion 
at this point. Each suture should be applied from within the gut, 
so that, when tied, the knot will be upon the inner, mucous mem- 
brane aspect of the gut. As each of these four tractor sutures is 
passed, it is immediately tied and one end cut short, leaving the 
other end long. In tying, the suture should not be tied right down 
upon the edges of the gut, but rather loosely, so that afterward they 
may be readily removed. 

In one or the other segment of the gut, a longitudinal incision 



260 



ABDOMEN AND BACK. 




Fig. 109.— End-to-End Anastomosis (MounseU). The ends of the two seg- 
ments have been joined by four tractor sutures, the ends of which are drawn 
out of an opening made in the gut. 




Fig 110 —Segment of the Wall of the Gut Removed to Show the Invagina- 
tion of One Coil of Gut into the Other which is Caused by Pulling upon the 
Tractors. 




Fig. HI.— The Two Coils of Gut, One Invaginated within the Other, have 
been Drawn through the Incision in the Gut and their Edges United all 
Around with a Continuous Penetrating Suture. 



OPERATIONS UPON THE SMALL INTESTINE. 261 

is now made. This incision is placed opposite the mesenteric bor- 
der, should he about one inch long, and commences about one and 
one-half inches distant from the cut edge of the gut. It is best made 
by picking up the wall of the gut with two toothed forceps, and be- 
tween these, with a sharp, straight scissors, a clean-cut incision is 
made through the whole thickness of the wall of the gut. Through 
this incision a narrow artery forceps is passed' into the gut and the 
tails of the four tractor sutures seized and pulled through, thus 
drawing the ends of the gut after them, with the result that the one 
segment of gut is invaginated into the other, their serous surfaces 
lying in contact with each other and their corresponding edges in 
apposition all around. The four tractor sutures are held by assist- 
ants and put somewhat upon the stretch, and then the corresponding 
edges of both segments of the gut are ready to be joined by suture. 
The edges are sewed together with an overhand stitch with a straight 
needle and fine silk. This suture, at each puncture, should take a 
good bite and include a margin of rather more than one-eighth inch, 
should be fairly close (intervals of about one-eighth inch between 
needle punctures), and should be drawn fairly tight. The stitch 
should include all the coats of the gut, special pains being taken to 
include the serous coat, particularly at the mesenteric border of the 
gut. Catgut may be used for this stitch, but silk is probably better. 

Having united the edges of the segments of the gut as above 
described, the temporary tractor sutures are removed and the gut 
restored to its natural position by reducing the invagination; the 
incision in the gut is then closed with a continuous Lembert stitch. 

All around the circular junction of the segments, after swabbing 
with a pad moistened with alcohol, followed by one wet with a weak 
bichloride solution, a continuous Lembert stitch of fine silk is ap- 
plied; this 'inverts the edges of the gut and buries completely the 
penetrating through and through suture. 

The opening which is left in the mesentery, after the segment 
of gut has been excised, is closed with a continuous catgut suture, 
special care being taken to make the union accurate close to the 
intestine. The gut is then returned to the abdominal cavity, being 
placed near the abdominal incision, and the opening in the abdomen 
closed. 

Mukpht Button. — Having resected the gut as above described, 
a running string is placed in the edge of each segment of the gut 
which, when drawn tight and tied, puckers the end of the gut and 



262 ABDOMEN AND BACK. 

grasps the button about its shank, leaving the flange, or cup, of the 
button within the gut. This running stitch, or purse-string, is ap- 
plied in overhand fashion, is of fine silk, and carried upon two long 
straight needles. This stitch should include all the layers of the gut, ' 
especially the serous and the mucous membrane; it should not in- 
clude too wide a margin of the gut, since the amount of tissue which 
is grasped between the flanges, or cups, of the button may be too 
bulky to allow exact coaptation; a margin rather less than one-fourth 
inch is sufficient. For the running stitch we require a single strand 
of fine silk with a straight cambric needle at each end. The running 
stitch is commenced by piercing the mesentery close to the surface 
of the gut, and then, carrying the same needle back over the edge of 
the mesentery, it is again thrust through, so that we thus have a 
loop around the cut edge of the mesentery close to the surface of 
the gut. Now, with this same needle, the running suture is applied 
to the corresponding half of the circumference of the cut edge of 
the gut; each puncture of the needle should be made from within 
the lumen of the gut from its mucous membrane aspect, and the 
punctures should be about one-third inch apart. When a point is 
reached directly opposite the mesenteric border of the gut, this 
needle is discarded; the second needle is then taken in hand and the 
second half of the circumference of the gut treated in exactly the 
same manner. 

In this way the whole circumference of the gut is included, 
leaving the two free tails of the suture, which emerge upon the 
serous surface of the gut opposite its mesenteric attachment, ready 
for tying. 

The object in catching the edge of the mesentery in the loop 
of the purse-string suture is to insure the turning in of a serous 
surface at this point and at the same time to do away with the "dead" 
mesenteric space; besides, it gives a fixed point to the suture. Be- 
fore introducing the button the first double loop of a surgeon's knot 
should be taken with the ends of the purse-string. 

One-half of the button, grasped with a thumb forceps by the 
edge of its tubal part, is now introduced into the end of the gut, 
turning the button a little on the side to facilitate its introduction, 
and while it is thus held the purse-string is tied around its shank, 
leaving the flange within the intestine. The ends of the purse- 
string are cut short so that they will not protrude between the flanges 
of the button when this is closed. This procedure is repeated upon 



OPERATIONS UPON THE SMALL INTESTINE. 



263 



the other segment of gut. The two halves of the button are then delib- 
erately pressed home, and in doing this one should note that the corre- 
sponding mesenteric attachments of either segment of gut are opposite 
each other. 

When the two halves of the button are locked there should be 




Fig. 112. — End-to-End Anastomosis (Murphy Button). 
With the purse-string suture a loop is taken through 
the layers of the mesentery, close to the wall of the 
gut, in order to obliterate the "dead space." 



Fig. 113.— Murphy But- 
ton, the Two Halves 
Separated. 



presented between them a clean, smooth line with no raw mucous 
membrane edge protruding, and at the mesenteric attachment the ap- 
position of serous surfaces should also be assured. Should there be 
any protruding edge of mucous membrane between the flanges of the 
button after this has been locked, it may be seized with a thumb 



264 ABDOMEN AND BACK. 

forceps and trimmed off short with the scissors. Any doubtful points 
should be made secure by adding several Lembert sutures. 

Although it is probably not necessary in all cases to use a layer 
of Lembert sutures in addition to the Murphy button to secure ac- 
curate apposition, nevertheless it is wise in many cases to place a 
continuous Lembert stitch outside of the button after the halves 
have been pressed home, especially as the presence of the button 
makes the application of this stitch rather an easy matter. 

After the hole in the mesentery has been closed as described in 
the preceding operation the abdominal wound is sutured. 

The Murphy button causes a pressure atrophy of the edges of 
the gut which are caught between its flanges. When this atrophy 
is complete, the button is liberated, taking the atrophied ring of tissue 
with it, and thus an opening is left, at the site of the anastomosis, 
which corresponds in size to the full diameter of the flanges of the 
button. 

With Laplace Anastomosis Fokceps. — The Laplace anasto- 
mosis forceps resembles two pair of haemostatic forceps, the blades 
of each being bent to form half a ring. When the two forceps are 
united side by side, their blades together form a complete ring. The 
two parts of the instrument when joined are held securely together 
by means of a clamp that is applied at the rivet. When clamped 
the two halves of the forceps work in harmony, and may be opened 
and closed like a single instrument. The handles are provided with 
a ratchet, like an ordinary hasmostatic forceps, so that when the blades 
are closed they remain locked. The instruments are supplied in five 
sizes. The McLean anastomosis forceps is a modification of the 
Laplace instrument, and is more simple in its construction. 

After the diseased portion of the gut has been resected the ends 
of the bowel are united to each other fairly close with four pene- 
trating sutures of catgut placed equidistant apart, taking care, at the 
same time, that the mesenteric portions of both segments are placed 
opposite each other. The ring-blades of the anastomosis forceps are 
then introduced, closed, between two of the four sutures, and then 
spread apart so that one ring-blade passes into each end of the gut. 
In order to facilitate the turning in, inversion, of the edges of the 
gut so that they may be grasped all around when the blades of the 
forceps are closed, a strand of silk may be thrown around the four 
stitches that unite the edges of the gut so as to encircle these 
stitches. By tightening this thread the edges of both segments are 



OPERATIONS UPON THE SMALL INTESTINE. 265 




Fig. 114.— Laplace Anastomosis Forceps Separated into its Component Parts. 




Fig. 115. — Laplace Anastomosis Forceps Joined Together, its Blades Slightly 
Open. B, ring blades; C, clamp; H, handle; S, shank. 




Fig. 116.— Laplace Anastomosis Forceps Joined Together, its Blades Closed. 



266 ABDOMEN AND BACK. 

turned inward toward the axis of the intestine, with the result that 
when the ring-blades of the forceps are closed they grasp the mar- 
gins of each segment of the gut all around, serous surface to serous 
surface. The margin of each segment, for its entire circumference, 
should he grasped between the closed ring-blades of the forceps. 
The strand of silk is then withdrawn. 

The two ends of the gut are united to each other, all around the 
circumference of the ring-blades of the forceps, with a continuous, 
non-penetrating Lembert suture of silk except at the point where 
the shank of the forceps emerges. After this suture has been ap- 
I^lied the clamp is removed from the forceps, which is then sepa- 
rated into its two component parts; the blades of each portion rep- 
resent but half a ring, and these are withdrawn from within the 
intestine, one at a time. The small opening through which the two 
parts of the forceps were removed is closed with one or two non- 
penetrating Lembert sutures. If desired, a second outside row of 
Lembert sutures may be applied to still further secure the union 
of the two ends of gut. 

With O'Hara Anastomosis Forceps.— O'Hara's anastomosis 
forceps is composed practically of two long, thin-bladed haemostatic 
forceps that may be joined securely to each other, side by side, with 
a clamp. When thus joined together both forceps work in harmony 
as one single instrument. The handles of the instrument are pro- 
vided with a ratchet arrangement like ordinary artery forceps, so 
that when the blades are closed they remain locked until released. 
The edges of the blades are serrated, so that the parts within their 
grasp cannot escape, and they are also graduated with file-marks, so 
that one may accurately estimate the length of tissue that is grasped 
between them. 

The coil of gut that is to be resected is brought out through the 
incision in the abdomen and the corresponding portion of the mesen- 
tery is tied off. One O'Hara forceps is then applied to the gut below 
the seat of disease and locked, and the other forceps secures the 
intestine above the seat of disease and is likewise locked. Each for- 
ceps grasps the gut at right angles to its long axis. The tip of each 
forceps, as it grasps the intestine, should reach just to the mesenteric 
border. The diseased segment of gut is then excised with long, 
straight scissors in the usual way, cutting fairly close to the blades 
of each O'Hara forceps. Before severing the gut ordinary compres- 
sion clamps may be applied to it — one immediately above and an- 



OPERATIONS UPON THE SMALL INTESTINE. 267 




Fig. 117.— O'Hara Anastomosis Forceps Separated into its Component Parts. 




Fig. 118. — O'Hara Anastomosis Forceps Joined Together, its Blades Open. 




Fig. 119. — O'Hara Anastomosis Forceps Joined Together, its Blades Closed. 



26S ABDOMEN AND BACK. 

other immediately below the diseased portion; so that when the gut 
is divided there will not be any escape of the contents of the intes- 
tinal canal. The mesentery corresponding to the diseased segment 
of gut may be tied off before or after the gut has been severed. The 
two O'Hara forceps are now approximated and fixed securely together 
side by side with the clamp. 

Commencing near the rivet and working toward the tip of the 
forceps, the two segments of gut are united with a continuous, non- 
penetrating Lembert suture. This suture catches the wall of each 
segment of gut just beyond the blades of the forceps; so that the 
forceps are thus gradually buried, being invaginated into the lumen of 
the gut as the suture progresses. When the tips of the conjoined for- 
ceps are reached, the gut and forceps are turned over, so as to gain 
access to the other aspect of the gut, and the suture is continued 
along this side of the gut toward the rivet of the forceps until the 
point is reached where the suture commenced. In working around 
the tips of the united forceps at the mesenteric border of the gut 
care is needed to include the serous coat in the suture. The clamp 
is now removed, separating the two forceps. First one forceps is 
unlocked and withdrawn, then the second is unlocked and its blades 
passed up and down through the line of junction to show that this 
is patent and that none of the stitches have been carried across the 
lumen of the gut so as to include the opposite wall, and then this is 
likewise withdrawn. The small opening that is left in the line of 
junction after the forceps have been withdrawn is closed with one 
or two interrupted sutures. 

Side-to-Side, or Lateral, Approximation (Lateral Intestinal Anas- 
tomosis). — This is the formation of a fistulous opening between two 
coils of intestine joined side to side. 

This operation is indicated when the ends of gut that are to be 
united differ much in caliber, — for example, to unite the end of the 
ileum to the cascum, — or where the intestinal tube is very narrow, 
as, for example, in children. 

Suture. — The parts are brought well up into the wound or, if 
possible, outside upon the abdomen, and are surrounded with gauze 
pads to protect the peritoneal cavity. Gauze strips are then tied 
around the intestine, and after the diseased portion of the gut has 
been excised the cut end of each segment of the gut for about one 
inch of its length is inverted and closed with a double row of Lem- 
bert sutures, thus converting each end of the gut into a blind pouch. 



OPERATIONS UPON THE SMALL INTESTINE. 269 

Care should be taken to include the invaginated mesentery in the 
suture. One- should commence the invagination of the end of the gut 
at its mesenteric edge, inverting it about one inch of its length, and 
then the rest of the gut is very conveniently inverted and sutured. 
The next step is the union of the two blind ends of the gut to 
each other, side to side, so that the intestinal canal, through the new- 
opening that is to be made, will be continued in a direct line, and 
not reversed in passing from one segment to the other. The ends 




Fig. 120. — Lateral Anastomosis. The end of each coil of gut has been 
closed by suture. The two coils have been placed side by side and joined 
by a continuous non-penetrating suture. An opening has been made in each 
coil of gut. 

of the gut should be so placed that they overlap each other for a 
distance of four to five inches; their apposed surfaces are then united 
to each other, for a distance of from three to four inches, by a single 
row of continuous Lembert sutures of fine silk. After this row of 
Lembert sutures, which forms the posterior half of the "outside 
serous ring," has been applied, this needle, still carrying the fine silk, 
is laid aside until required later to complete this "outside serous 
ring." This line of Lembert sutures should be one inch longer than 



270 



ABDOMEN AND BACK. 



the proposed openings in the gut, and each stitch should he rather 
less than one-fourth inch distant from its neighbor and should be 
drawn tight. 

Each segment of the bowel is now opened with the scissors, the 
incisions being placed about one-fourth inch distant from the line 
of the Lembert suture; the openings in the bowel should be large 
so as to allow for subsequent contraction, — three inches long and 
at least one inch shorter than the line of the Lembert suture. 

Bleeding from the edges of the incisions in the bowel is con- 
trolled with clamps, which may be removed after a few minutes' 
pressure, as the hemorrhage usually ceases. The edges of the open- 




Fig. 121.— A Cross Section of the Apposed Coils of Gut After the Anasto- 
mosis has been Completed. A, A, the outer, non-penetrating suture, the 
"outside serous" suture; B, B, the buried suture that penetrates all the 
layers of the wall of the gut, joining the contiguous edges of the opening 
in each segment all around. *, the "dead space" corresponding to the mesen- 
teric border of the gut where the layers of the mesentery separate to invest 
the gut. 

ings in the gut are wiped with alcohol followed by a weak bichloride 
solution, and then, with a continuous silk suture, which at the same 
time controls the hemorrhage, the edges of the opening in each seg- 
ment of the bowel are united with each other all around. 

Having thus united the edges of the openings all around, we 
again take up the needle carrying the original fine silk suture and 
complete the anastomosis by making the anterior half of the Lem- 
bert suture, the "outside serous ring." 

The line of Lembert suture serves to bury the suture by which 
the margins of the openings in the gut are joined to each other. 

In making the lateral anastomosis one should not have the blind 
ends of the overlapped gut too long, and, further, the blind ends 



OPERATIONS UPON THE SMALL INTESTINE. 271 

should be anchored to the adjoining portion of the intestine by sev- 
eral Lembert stitches. 

It may be necessary to tear the mesentery somewhat in order 
to allow sufficient overlapping of the ends of the bowel. After the 
anastomosis has been made the adjoining overlapping layers of the 
mesentery may be united with a continuous catgut stitch. The parts 
should then be returned to the abdomen and the wound closed up. 

Murphy Button. — A lateral intestinal anastomosis may be 
made with the Murphy button. After the ends of the gut have 
been inverted and closed with a suture as described in the preceding 
operation, the two ends are placed side by side and a purse-string 
suture placed in each segment; the incisions are then made and the 
buttons inserted in the usual way. This is rather an unsatisfactory 
method of doing a primary lateral intestinal anastomosis, because 
the opening left by the Murphy button is too small to allow for the 
subsequent contraction that always takes place. We may use the 
Murphy button with satisfactory result in making a lateral anasto- 
mosis in connection with a primary gastro-enterostomy (see Fig. 
125; also "Cholecysto-duodenostomy" for description of the purse- 
string suture and the method of its introduction). 

McGraw's Eubber Suture. — With the rubber suture a lateral 
intestinal anastomosis may be made in a manner analogous to that 
described for the gastro-enterostomy. The surfaces of the two seg- 
ments of gut that are to be joined are placed side by side and united 
for a distance of about two and one-half inches with a continuous 
Lembert stitch of silk as described in the previous operation, and 
then the needle carrying this stitch is temporarily laid aside. The 
rubber suture, 2 to 3 mm. thick, is now introduced with a straight 
needle, so as to include both segments of the gut in its grasp, is 
drawn tight, and tied. A silk ligature is tied around the knot in the 
rubber suture so as to secure the latter from slipping. About two 
inches of the wall of each segment of the gut should be included in 
the constricting rubber suture; so that, when this cuts through, the 
opening left between the two coils of gut will be two inches in 
length (see "Gastro-enterostomy with McGraw's Eubber Suture"). 

The needle carrying the silk Lembert suture is now again taken 
up, and with this the two coils of gut are still further united along 
a line just outside of the rubber suture. This forms the second half 
of the "outside serous ring" suture, and buries the rubber suture 
beneath it out of sight. 



272 ABDOMEN AND BACK. 

With Laplace Forceps. — Lateral anastomosis with Laplace 
forceps is accomplished in a manner analogous to that described for 
gastroenterostomy. 

With O'Hara Anastomosis Forceps. — Lateral anastomosis 
with the O'Hara forceps is done in a manner similar to that de- 
scribed for gastroenterostomy. 

Gastroenterostomy. — Gastroenterostomy is the formation of a 
fistulous communication between the stomach and the small intes- 
tine. 

The operation is indicated where the pyloric orifice is con- 
stricted, either simple, following ulcer, etc., or malignant. The 
operation was first performed by Woelfler in 1881. The loop of 
small intestine may be fixed to either the anterior or the posterior 
wall of the stomach. 

The Anterior Operation (Woelfler). — This consists in 
bringing a coil of the small intestine — jejunum — up in front of the 
great omentum and transverse colon and fixing it to the anterior 
wall of the stomach. 

The stomach should be washed out while the patient is anaes- 
thetized, immediately before the operation. 

An incision is made in the middle line through the linea alba 
from a point one inch below the ensiform cartilage down to the 
umbilicus, or even beyond this point if necessary. The incision is 
usually about four inches long (10 to 15 cm.). 

Through this opening the stomach is sought and examined. A 
portion of the wall of the stomach which is not involved in the dis- 
ease should be selected. The stomach is partly covered by the liver, 
the anterior thin edge of the left lobe of the liver being a good 
guide to the stomach. Lying below and close to the greater curva- 
ture of the stomach is the transverse colon, and from this the great 
omentum, apron-like, is suspended, hanging down free in the abdom- 
inal cavity in front of the small intestine. 

After the stomach has been recognized the transverse colon, and 
with it the great omentum, are drawn upward out of the wound, 
and search is then made for the commencement of the jejunum. 
This part of the gut lies in the back of the abdominal cavity, to the 
left of the vertebral column, upon a level with the second lumbar 
vertebra, its mesentery being very short and serving to anchor it in 
this position. To secure this coil of gut the hand is introduced into 
the abdomen and carried backward, along the under surface of the 



OPERATIONS UPON THE SMALL INTESTINE. 



273 



transverse mesocolon, as far as the posterior abdominal wall; just be- 
low the attachment of the transverse mesocolon to the vertebral 
column, at the place indicated upon the left of the column, this coil 
of gut is found. 

This part of the small intestine is readily identified by the fact 
that it is fixed within, as is shown when an effort is made to draw it 
out of the abdomen; any other part of the small intestine may be 




Fig. 122. — Gastroenterostomy. The jejunum has been fixed to the stom- 
ach and an opening made between them. Arrows (1, 1) show the proper 
course of the stomach contents into the long arm of the gut. Arrows (2, 2) 
show the course of stomach contents into the short arm of the gut, through 
which they may again enter the stomach, "vicious circle." 



drawn through the fingers in either direction, and may be readily 
drawn out upon the abdomen. 

We select a loop of gut for attachment to the stomach from 
eighteen to twenty inches distant from this fixed part of the jeju- 
num. A loop of gut about eight inches long is drawn out upon 
the abdominal wall and surrounded and constricted by two thin 
strips of sterile gauze. A sharp-nosed artery forceps is thrust through 
the mesentery near its attachment to the intestine, and with this 
the end of each gauze strip is seized and drawn through. The one 

18 



274 ABDOMEN AND BACK. 

strip is tied and the segment of gut emptied of its contents, to a 
point beyond the second piece of gauze, by gently stripping it be- 
tween the fingers, and then the second gauze strip is tied. The 
gauze strips should be tied sufficiently tight to prevent the re- 
entrance of the intestinal contents into this segment of the gut. 
The transverse colon and great omentum are now pushed back into 
the abdomen again, and the anterior surface of the stomach seized 
and drawn out of the abdomen. Dry, sterile, gauze pads are placed 
about the stomach and intestine and tucked partly into the in- 
cision for the purpose of retaining the parts outside of the ab- 
domen and to prevent the entrance of escaping intestinal contents 
into the peritoneal cavity. The rest of the operation is done extra- 
peritoneally. 

The coil of intestine and the stomach are steadied, side by side, 
and united by a continuous Lembert suture of fine black silk, using 
a straight cambric needle. This suture line, which includes the 
serous and muscular coats, forms the posterior half of the "outside 
serous ring." It should not penetrate into the cavity of the stomach 
or intestine. The suture should be applied in a straight line, about 
two and one-half to three inches long, each puncture of the needle 
being about one-eighth inch distant from its neighbor, and should 
take a good, broad bite. Each stitch should be drawn fairly tight. It 
is probably more convenient for the operator, in applying this suture, 
to commence at the far end and sew toward himself, steadying the 
parts with the thumb and index finger of left hand. The tail of the 
suture should be left long, and may be held by the assistant as a 
tractor. After this line of suture has been completed, the needle, 
carrying this thread, is laid aside until needed later to complete the 
operation by making the anterior half of the "outside serous ring" 
suture. 

The openings in the intestine and stomach are next made. 
These incisions should be one and one-half to two inches long. They 
should be shorter than the line of the Lembert suture, and should 
be placed about one-fourth inch distant from this. The intestine 
should be incised first, the incision being placed opposite its mesen- 
teric border and any escaping contents carefully swabbed away. 
These incisions should be straight and clean cut. The wall of the 
gut is caught up with two toothed forceps, and a small opening made 
between these with a straight, sharp scissors, and then this opening 
is sufficiently enlarged. The stomach is then treated in a similar 



OPERATIONS UPON THE SMALL INTESTINE. 275 

manner. Hemorrhage from the edges of these incisions stops after 
they have been sutured; any spurting points may be clamped and 
tied with fine silk or catgut. 

The adjoining edges of the incisions in the intestine and stom- 
ach are now sewed to each other with catgut or silk in a medium- 
sized, straight needle, each stitch taking a good bite and passing 
through all the coats, including the mucous membrane, and drawn 
fairly tight; the needle punctures should be rather less than one- 
fourth inch apart. This suture is continued uninterrupted all 
around, uniting the corresponding edges of the incisions in the 
stomach and intestine to each other until these openings are entirely 
closed in and the anastomosis made. Before beginning this stitch 
the margins of the openings should be wiped off with alcohol fol- 
lowed by a weak bichloride solution on a swab. 

We now again take up the needle with which the posterior half 
of the Lembert suture — "outside serous ring" — was made, and com- 
plete the operation by making the anterior half of the "outside 
serous ring" suture. 

Thus we have the openings in the intestine and stomach, one 
and one-half to two inches long, united, edge to edge, by a con- 
tinuous stitch which passes through the entire thickness of the mar- 
gins of the contiguous openings, and this surrounded, reinforced, 
by a continuous Lembert suture which passes through the serous 
and muscular coats only and which serves the purpose of burying the 
penetrating mucous stitch. Should there be any doubtful points 
where the mucous penetrating stitch is not certainly buried, one or 
more supplementary interrupted Lembert stitches may be taken to 
remedy this. 

The coil of intestine should be joined to the stomach near its 
greater curvature and about three inches from its pyloric opening. 
The incision in the intestine should be made opposite its mesenteric 
attachment. The intestine should be joined to the stomach in such 
a way that the current of food in the stomach and in the loop of 
intestine will be in the same direction — the distal limb of the loop 
of gut toward the right or pyloric end of the stomach; this is accom- 
plished by taking care not to twist the loop of intestine upon itself 
when drawing it up into apposition with the stomach. 

The transverse colon and great omentum rolled upon itself 
lie together behind the junction formed between the jejunum and 
the stomach. 



276 ABDOMEN AND BACK. 

The tapes are now removed from the intestine and the parts 
replaced within the abdomen. 

The opening in the abdomen is closed with several silk-worm 
gut sutures, which pass through the whole thickness of the abdominal 
wall, care being taken to include the edges of the parietal perito- 
neum. These stitches should be about one-half inch apart. It is 
probably better to suture the edges of the peritoneum first with a 
continuous catgut stitch and after this the silk-worm stitches are 
applied so as to include the other layers of the abdominal wall. 

Posteeioe Operation (von Hacker). — The jejunum is sutured 
to the posterior wall of the stomach, which is exposed through an 
opening torn in the transverse mesocolon. 

This operation is preferred by many surgeons to the anterior. 
The position of the parts is more natural and the transverse colon is 
not displaced, and cannot drag upon the coil of jejunum that is fixed 
to the stomach. 

The technique of this operation is no more difficult than that 
of the anterior; so that the choice between the anterior and poste- 
rior operation will probably depend, in most cases, upon the location 
of the disease. 

An incision is made in the middle line through the linea alba, 
as in the preceding operation. The stomach is recognized and ex- 
amined. The transverse colon and greater omentum are then re- 
flected upward and the stomach drawn out of the incision in the 
abdomen. An opening at right angles to the long axis of the trans- 
verse colon is now cut, or, better, torn, in the transverse mesocolon, 
penetrating from its inferior aspect, in order to expose a sufficient 
area of the posterior wall of the stomach. 

The posterior wall of the stomach is then drawn partly through 
the opening torn in the transverse mesocolon, the edges of the open- 
ing in the mesocolon being fixed at once to the posterior wall of the 
stomach by several fine silk sutures (which do not, of course, pierce 
the entire thickness of the stomach wall). The exposed area of the 
stomach is then brought up into the incision in the abdomen and out 
upon the abdominal wall, where it is retained by an assistant. 

As in the preceding operation, the commencement of the jeju- 
num is sought for and found in the back of the abdomen to the left 
of the body of the second lumbar vertebra, just below the vertebral 
attachment of the transverse mesocolon. A coil of intestine about 
twenty inches farther along is selected, and this is also brought out 



OPERATIONS UPON THE SMALL INTESTINE. 



277 




Pig. 123.— Posterior Gastroenterostomy. Great omentum (GO) and trans- 
verse colon (TC) have been drawn out of the incision and turned upward. 
An opening has been made in the transverse mesocolon in order to expose a 
portion of the posterior wall of the stomach. A loop of jejunum has been 
fixed to the wall of the stomach with a continuous, non-penetrating stitch 
and openings made in the stomach and the attached coil of gut. The loop 
of gut has been temporarily tied off with tapes. 



278 ABDOMEN AND BACK. 

of the abdominal wound and placed alongside of that portion of the 
posterior wall of the stomach which presents through the opening 
in the transverse mesocolon. Pads of gauze are then tucked about 
the viscera and partly into the abdominal incision to steady the 
parts and to prevent the entrance of infectious material into the 
peritoneal cavity and the gastro-enterostomy is performed as in the 
preceding operation. The intestine is fixed to the posterior wall of 




Fig. 124.— Gastro-enterostomy (Jaboulay-Braun). Compare with Fig. 122. 
Lateral anastomosis has been made between the arms of the attached loop of 
gut; so that if the stomach contents do enter the short arm of the gut (2, 2) 
they may still escape into the proper long arm. This measure prevents the 
occurrence of the "vicious circle." 

the stomach, near the greater curvature, and from three to three and 
one-half inches away from the pylorus. The coil should be fixed so 
that the current of food through the stomach and the intestine are 
in the same direction. 

Jabotjlay and Braun Modification. — In some cases, after the 
anterior or posterior gastro-enterostomy as described above has been 
performed, there occurs an accumulation of food, bile, and pan- 



OPERATIONS UPON THE SMALL INTESTINE. 



279 



creatic juice in the short (proximal) limb of the loop of the intestine 
that is fixed to the stomach, with a consequent regurgitation into the 
stomach, and this is characterized by exhausting and fatal vomiting. 
This regurgitation and vomiting are due to a spur formation in the 
attached coil of gut which directs the stomach contents into the short 
or proximal arm of the gut. In order to avoid the occurrence of this 
vomiting — "vicious circle" — a lateral communication between the 
two limbs of the coil of intestine which has been attached to the 
stomach may be made, and this may be done either at the same time 
that the gastro-enterostomy is performed, or, since this regurgita- 
tion, etc., do not occur in all cases, it may be done later as a sec- 
ondary operation, in this latter case waiting for the appearance of 





Fig. 125. — Lateral Anastomosis (Murphy Button). Running, or purse- 
string, sutures applied and incisions made in two coils of gut preparatory to 
the introduction of the Murphy button. 



symptoms indicating the necessity of the additional operation before 
submitting the patient to the additional risk. It is probably wise, in 
most cases, to do this entero-anastomosis at the same time as the 
primary gastro-enterostomy, as it occupies but a few minutes' addi- 
tional time. This secondary entero-anastomosis may be made with 
suture, Murphy button, or McGraw's rubber suture or with the 
Laplace or O'Hara forceps, etc. The communication between the 
two limbs of the loop of gut should be made at their most dependent 
part, — at least five inches distant from their point of attachment to 
the stomach. 

For description of the running, purse-string stitch and the 
method of its introduction in connection with the Murphy button 
see "Cholecysto-duodenostomy." 



280 ABDOMEN AND BACK. 

Gastko-extekostomy with Muepht Button. — This is simple, 
and much time can he saved by the use of this device. 

The use of the Murphy button is no doubt indicated in many 
eases, especially where a malignant condition exists and the time 
permitted for the performance of the operation is short. The 
medium-size button may be used for the gastroenterostomy, and a 
smaller one for the entero-anastomosis, if this latter operation is 
performed in addition. 

If a posterior gastro-enterostomy is done, the button, when 
liberated, is less likely to fall into the stomach than when the ante- 
rior gastro-enterostomy is done. According to the suggestion of 
Weir, the margin of that half of the button which presents into the 
intestine may be provided with projecting flanges, which should 
hinder the button from falling into the stomach. 

The stomach and intestine are brought out upon the abdomen 
as in the operations above described. A running stitch is introduced 
into the wall of the intestine and the wall of the stomach, penetrat- 
ing through the entire thickness of the wall of each. The space in- 
cluded between the two limbs of this running, or purse-string, suture 
should be about one-half inch (for description of the running, purse- 
string suture and the method of its introduction see "Cholecysto- 
duodenostomy"; as applied in lateral anastomosis, between two coils 
of gut, see Fig. 125). This purse-string suture is applied first to 
the jejunum, and then between the two limbs of the suture line an 
incision is made into the gut; this should be barely large enough 
to permit the introduction of the half button. The half button 
which is provided with the spring is seized with a thumb forceps and 
introduced sidewise through the incision into the gut, and, while it 
is thus steadied, the running string is drawn tight about its shank, 
tied, and the ends cut short. 

In a similar manner, after the purse-string has been applied to 
the wall of the stomach, this is incised, and the other half of the 
button is introduced into this incision and the string tied about its 
neck. The parts adjacent to the openings are then sponged off with 
a wet bichloride pad and the two halves of the button deliberately 
pressed home. They should be applied sufficiently tight to cause a 
gradual pressure necrosis of those parts of the walls of the viscera 
that are included within their grasp. No raw edge of mucous mem- 
brane should protrude between the two halves of the button. If 
any raw edge of mucous membrane should present itself between 



OPERATIONS UPON THE SlIALL INTESTINE. 281 

the flanges of the button, it should be seized with the thumb forceps 
and trimmed close with sharp scissors, and then be still farther 
buried with seyeral additional Lembert stitches. Murphy claims that 
the additional outside Lembert stitch is, as a rule, unnecessary; 
nevertheless, it is well to use it if time permits, and especially if 
there are any doubtful points. The button being within the gut 
makes the application of the Lembert stitch easy. Spurting vessels 
in the edges of the openings in the intestine and stomach may be 
clamped and tied with fine catgut or fine silk. 

Carle applies the Murphy button without using the purse-string. 
A simple clean-cut incision is made in the jejunum and in the stom- 
ach barely large enough to admit the button. After the button has 
been introduced the incision is diminished by a single Lembert stitch 
at each end of the incision; and the two halves of the button then 
pressed home. It is said to be perfectly safe and to give more per- 
fect apposition than with the purse-string and saves much time. 
After the button has been introduced and locked several outside 
Lembert sutures may be introduced, especially if there are any 
doubtful points and if time permits. 

Gastro-enterostomy with McG raw's Eubber Suture. — The 
gut is brought into apposition with the anterior or posterior surface 
of the stomach, as described in the preceding operations, and these 
two portions of the alimentary canal are joined to each other with 
a continuous silk Lembert stitch for a distance of about two and 
one-half inches. The needle carrying this suture is then temporarily 
laid aside. 

The stomach is then united to the intestine with a single suture 
of solid rubber, smooth and round and from 2 to 5 mm. in thickness. 
This suture is carried in the eye of a long straight needle; a large 
worsted needle or Hagedorn needle answers well for this purpose. 
It will be necessary to shave the end of the rubber suture so that 
it may enter the eye of the needle. The point of the needle is passed 
into the stomach and then out again, so that about two inches of the 
wall of the stomach, corresponding to its long diameter, is included 
between the two punctures, and then, with the same needle and 
suture, and in a similar manner, the intestine is secured, entering 
and emerging at points opposite the puncture holes in the stomach. 

The rubber suture is then drawn as tight as possible, thus con- 
stricting the parts included in its grasp, and tied. In order to secure 
the knot in the rubber suture a strand of stout silk may be placed 



282 



ABDOMEN AND BACK. 



underneath the rubber at the place where the knot is to be, and after 
one loop of the knot has been taken in the rubber suture the silk 
ligature is tied over it and then the second, final loop of the knot is 
taken in the rubber suture. 




Fig. 126.— Gastro-enterostomy (McOraw). A loop of intestine has been 
fixed to the wall of the stomach with a continuous, non-penetrating stitch 
{A, A). Rubber ligature (B, B, B), which has been passed through the stom- 
ach and intestine, ready for tying. 

In passing the rubber suture one should make certain that the 
needle pierces the entire thickness of tbe wall of the organ and that 
it does not pick up the mucous membrane on its way; in each viscus 



OPERATIONS UPON THE SMALL INTESTINE. 283 

there should he two punctures only, — one as the needle passes in and 
one as the needle passes out. 

In drawing the ruhher suture after the needle, through the wall 
of the stomach and intestine, it may he stretched so that it becomes 
thinner, and may thus the more readily follow the needle through 
the punctures. When the suture is relaxed it becomes increased in 
diameter so that it more than fills the puncture holes and thus pre- 
vents leakage. 

Finally, to complete the operation, the needle, carrying the silk 
thread with which the 'first half of the Lemhert "outside serous ring" 
suture was applied, is again taken in hand and with it the wall of 
the stomach and intestine are joined with a continuous stitch, which 
is applied along a line just outside the location of the rubber liga- 
ture, and which buries this latter and completes the "outside serous 
ring" suture. 

By this operation corresponding portions of the opposed stom- 
ach and intestine are included in the grasp of a single, tight, elastic 
rubber suture, which gradually cuts its way through the walls of the 
opposed viscera; so that after the lapse of two or three days the 
gastro-enterostomy is established and the liberated rubber suture is 
passed unobserved through the bowel. This method may be em- 
ployed in making a lateral anastomosis between two coils of small 
intestine or between the small and large intestine. 

G-astbo-enteeostomy with Laplace Fokceps. — After the 
stomach and intestine have been brought up into the abdominal in- 
cision an opening is made in each viscus, which opening should be 
rather smaller than the ring of the forceps that is to be used. 

The blades of the forceps, joined together and secured with the 
clamp, are introduced, one into each organ, and then closed, with 
the result that the margins of each opening are securely grasped be- 
tween them, serous surface being apposed to serous surface. Care 
must be exercised to include the entire margin of each opening in 
the grasp of the closed blades, and this is facilitated by using an in- 
strument whose ring is larger in circumference than the correspond- 
ing openings in the stomach and intestine. The wall of the stomach 
and the wall of the intestine are then united all around the circum- 
ference of the ring-blades of the forceps, except for the small space 
through which the shanks of the forceps emerge. This union should 
be made with a continuous, non-penetrating Lembert suture of fine 
silk. The rinsj-blades of the forceps which are within the stomach 



284 ABDOMEN AND BACK. 

and intestine retain the parts in accurate apposition, and make the 
application of the suture a matter of comparative ease. 

After the suture has been applied the clamp is removed from the 
forceps, which is thus separated into its two component parts, the 
blades of each of which form but half a ring; these are then with- 
drawn from the stomach and intestine, first one and then the other. 
Finally the small opening through which the separated forceps were 
withdrawn is closed with one or two interrupted non-penetrating su- 
tures. A second row of outside non-penetrating Lembert sutures 
may be applied all around the first row of sutures if desired, in order 
to make the union of the intestine to the stomach still more secure. 

Gastroenterostomy with O'Hara Foeceps. — After the 
stomach and intestine have been drawn out through the abdominal 
incision the wall of each is picked up with a mouse-tooth forceps 
and securely grasped between the blades of one of the forceps, along 
a line corresponding to the long axis of each organ, in the same 
manner as one would grasp the prepuce with a circumcision clamp. 
The length of the wall of the organ thus secured between the blades 
of the forceps will vary according to the size of the intended open- 
ing. The blades of the forceps are graduated so that there should 
be no difficulty in securing the same amount of each organ, and this 
is desirable. As the wall of the stomach or intestine is grasped the 
tip of the blade should reach exactly to the edge of the process thus 
secured. That part of the wall of the stomach and intestine which 
protrudes beyond the blades of the forceps is cut away with the knife 
or scissors fairly close to the blades. The two forceps are then united 
together and securely locked with the clamp, and we are ready for 
the next step of the operation, the suturing of the wall of the in- 
testine to the wall of the stomach. This is done with a continuous, 
non-penetrating Lembert suture of silk. Commencing near the rivet, 
this suture is carried along the blades of the forceps toward the tip 
and then around the tip of the forceps and back again upon the other 
side to a point near the rivet where the suture was commenced. As 
this suture progresses it serves to bury the blades of the forceps 
beneath it. 

The junction of the stomach and intestine is thus complete 
except for the small space through which the forceps emerge. In 
applying the second half of the suture it will be necessary to turn 
the forceps over and with them the stomach and intestine in order 
to make the parts upon this under side accessible. The clamp is now 



SUEGICAL ANATOMY OF THE LARGE INTESTINE, ETC. 285 

removed from the forceps, which is thus separated into its two com- 
ponent parts.' One forceps is unlocked and withdrawn. The second 
forceps is unlocked, and, after being passed in and out through the 
opening between the stomach and the intestine to make certain that 
this is patent and that none of the stitches have been inadvertently 
carried across to the opposite margin of the orifice, this is likewise 
withdrawn. The small opening that still remains and through which 
the forceps were withdrawn is now closed with one or two non-pene- 
trating Lembert sutures. If desired, an additional row of Lembert 
sutures may be placed outside the first row in order to strengthen 
the union. 

THE LARGE INTESTINE AND VERMIFORM APPENDIX. 

The Surgical Anatomy of the Large Intestine, etc. — The large 
intestine may be distinguished from the small intestine by its large 
caliber and by its sacculation; attached along its whole length is the 
great omentum or the analogues of this structure, the appendices 
epiploicae. The large intestine is also marked by three longitudinal 
bands, which traverse its entire length. These longitudinal bands 
are made up of an aggregation of the longitudinal muscular fibers; 
one of them is found along the mesenteric border of the gut, another 
corresponds to the attachment of the great omentum and the little 
fatty processes, — the appendices epiploicae, — and the third is located 
between these two. 

The large intestine may be divided into three parts: the caecum, 
colon (ascending, transverse, descending, and sigmoid flexure), and 
the rectum. 

The C^cum is the dilated, pouched commencement of the large 
intestine. It is found in the right iliac fossa, near the brim of the 
pelvis, resting upon the psoas or iliacus muscle. 

It is provided with a complete peritoneal investment, is mov- 
able, and has a mesentery which is short and serves to anchor it to 
the posterior abdominal wall. The mesentery is sufficiently long, 
however, to allow this part of the intestinal canal to be drawn out 
upon the abdominal wall. The layers of the mesoeaecum are but 
loosely adherent to each other and may be readily separated. The 
caecum is continued upward into the ascending colon without any 
definite line of separation between them. 

The Veemifokm Appendix is a blind, worm-like process, which 
is given off from the inner posterior aspect of the caecum at the 



286 ABDOMEN AND BACK. 

point where the longitudinal bands meet and from one to one and 
one-half inches below the junction of the small intestine with the 
caecuin. It is found lying more or less free in the abdominal cavity 
or dipping into the pelvis. 

The base of the appendix corresponds to a point on the abdom- 
inal wall called "McBurney's point," which is located two inches to 
the inner side of the anterior superior iliac spine, upon a line drawn 
from the anterior superior iliac spine to the umbilicus. 

The appendix varies much in size; it is usually as thick around 
as a lead pencil and its average length is four inches; it varies from 
two to six inches and may be longer. Usually it is a hollow tube, 
its canal extending as far as its tip; at times, however, the canal 
does not extend to the tip or may be absent entirely. Its inner sur- 
face is lined with mucous membrane. The appendix is an intra- 
peritoneal structure, being completely invested by the peritoneum, 
and in nearly all cases it is provided with a mesentery of its own. 
This mesentery is a little fold derived from the under layer of the 
mesentery of the small intestine where the latter enters the csecum; 
it incloses the appendix between its folds, and usually extends only 
part way down to the tip, leaving the lower third or half of the 
appendix free. This mesentery gives one the impression of being 
too short, causes the appendix to present its curled-up appearance, 
serves to limit its range of movement, and holds it in close relation 
with the caecum. That part of the appendix which is unprovided 
with mesentery is freely movable, and in those cases in which the 
mesentery is nearly or entirely absent the appendix enjoys a con- 
siderable range of motion. In most cases the appendix is more or 
less fixed to the caecum and to the posterior abdominal wall through 
its mesentery. Its position, as regards the caecum, varies in different 
individuals; most commonly it is found lying upon the inner or left 
side of the caecum, with its tip behind the ileum and pointing upward 
in the direction of the spleen. In other cases it lies upon the outer or 
right side of the caecum, rather behind it, its tip pointing upward 
toward the liver; again, it may be found dipping down into the 
pelvis or lying across the front of the caecum. In any of these posi- 
tions it may be more or less fixed either naturally or by adhesions. 

In the female the appendix is connected with the broad ligament 
by a thin band, the so-called appendiculo-ovarian ligament. 

The appendix gets its arterial supply from a single small vessel 
derived from the ileo-colic, which is a branch of the superior mesen- 



SUEGICAL ANATOMY OF THE LARGE INTESTINE, ETC. 287 

teric. The venous return is through a corresponding single venous 
channel which empties into the superior mesenteric vein. These 
vessels run parallel with the appendix in the edge of the mesentery 
between its two layers; when the mesentery is absent they are found 
upon the surface of the appendix, beneath its serous coat. In the 
female the appendix receives an additional vessel through the ap- 
pendiculo-ovarian ligament. The appendix is dependent for its 
nutrition upon this very limited blood-supply, and no doubt this 
arrangement is, at least in part, responsible for the readiness with 
which the wall of the appendix becomes necrotic when its circulation 
is disturbed. 

Occasionally some difficulty may be experienced in finding the 
appendix. If the longitudinal bands upon the csecum are traced 
downward, they will be found to lead directly to the point where the 
appendix is given off, and therefore these bands are good guides to 
tbe root of the appendix. 

Just above the root of the appendix the small intestine ter- 
minates by entering the caecum; it enters the caecum upon its left 
side. The opening between the ileum and caecum is guarded by the 
ileo-caecal valve. This valve consists of two folds of mucous mem- 
brane containing some circular muscular fibers. These folds, pro- 
jecting into the lumen of the gut, allow the contents of the ileum 
to pass freely into the caecum, but prevent the reverse. Fluids in- 
jected through the rectum, into the large intestine, cannot pass into 
the ileum unless this valve is forced, and that requires enough press- 
ure to threaten the rupture of the large intestine. 

The Ascending Colon. — This is the continuation upward of 
the csecum. It lies close to the posterior wall of the abdomen. The 
ascending colon has no mesentery, and is only partly invested by the 
peritoneum, which is absent upon its posterior surface. The ascend- 
ing colon ascends along the outer border of the right kidney, lying 
partly upon the kidney, from which it is separated by some inter- 
posed loose connective tissue and fat only. Continued upward as 
far as the under surface of the liver, it makes a turn — the hepatic 
flexure — and becomes the transverse colon. The under surface of 
the liver shows a shallow depression corresponding to the hepatic 
flexure, and here the colon is attached to the liver by a reflection of 
peritoneum, the ligamentum hepatico-colicum. 

The Transverse Colon stretches from right to left across the 
upper part of the abdominal cavity, lying below the first part of the 



2S8 ABDOMEN AND BACK. 

duodenum and greater curvature of the stomach. Close to the 
spleen, on the left side, the colon makes a second turn, — the splenic 
flexure, — and from this point is continued downward as the descend- 
ing colon. At the splenic flexure the colon is fixed to the diaphragm 
by a fold of peritoneum, the ligamentum phrenico-colicum. 

The transverse colon is completely invested by peritoneum and 
has a long mesentery which suspends it from the posterior wall of 
the abdomen. The transverse colon enjoys considerable freedom of 
movement, but is connected with the greater curvature of the stom- 
ach by the peritoneum. 

In the very young child the connection of the transverse colon 
to the greater curvature of the stomach does not exist, because the 
layers of peritoneum which invest the stomach and unite with each 
other at the greater curvature to form the great omentum have not 
become adherent to the peritoneum which envelops the transverse 
colon; this does not occur until later in life (see Fig. 90). 

The Descending Colon passes downward in the left side of 
the abdominal cavity, lying close to its posterior wall, to which it is 
partly fixed. It has no mesentery, is only partly invested by the 
peritoneum, and cannot be drawn out upon the abdomen. The poste- 
rior wall of the descending colon, which is devoid of peritoneum, 
lies close to the outer border of the left kidney, lying partly upon 
its anterior surface. It is continued below into the sigmoid flexure. 

The Sigmoid Flexure is the last part of the colon; it is a 
redundant loop of gut curved upon itself and lying in the left iliac 
fossa. Its caliber is rather smaller than that of the other parts of 
the colon; it is completely invested by the peritoneum, and has a 
fairly long mesentery, which suspends it to the posterior abdominal 
wall and permits of much freedom of motion. It may be freely 
drawn out upon the abdominal wall. At the sacro-iliac synchondrosis 
it is continued down into the pelvis as the rectum. 

The Blood-supply op the Large Intestine. — The caecum, 
appendix, and ascending and transverse colon are supplied by 
branches which are given off from the- right, or concave, side of the 
superior mesenteric artery. 

The descending colon and sigmoid flexure are supplied by the 
inferior mesenteric, which comes off from the front of the aorta just 
below the origin of the superior mesenteric; after supplying the 
parts mentioned this vessel dips into the pelvis, between the layers 
of the mesorectum, to supply the rectum as far as its lower end. 



OPERATIONS UPON THE LARGE INTESTINE. 289 

The arterial branches which are derived from the superior and 
inferior mesenteric for the supply of the ascending and descending 
colon, as they pass to their destination, lie upon the posterior abdom- 
inal wall covered by the peritoneum which lines the back of the 
abdomen; those which supply the caecum, transverse colon, and sig- 
moid flexure, which parts of the large intestine are provided with a 
mesentery, reach their destination between the layers of the mesen- 
tery corresponding to the part. 

The veins have a course similar to the corresponding arteries. 
The inferior mesenteric joins with the splenic vein, which, in turn, 
unites with the superior mesenteric to form the portal; hence, blood 
from the intestinal tract and rectum 1 must first traverse the portal 
circulation (through the liver) before entering the general circula- 
tion. Poisonous matter from the intestinal tract (colitis, hemor- 
rhoids, etc.) may cause thrombosis in the veins leading from these 
parts or abscess in the liver, etc. 

As is the case with the vessels of the small intestine, the ter- 
minals of the arteries that are distributed to the large intestine do 
not anastomose freely; hence division of a considerable branch will 
often result in gangrene of the corresponding part of the gut. 



OPERATIONS UPON THE LARGE INTESTINE. 

Colostomy. — The formation of a fistulous opening into the large 
intestine, a so-called artificial anus. It is performed for obstruction 
in the large intestine or rectum or as a preliminary to extirpation 
of the rectum. This operation may be done to save life when the 
danger is imminent and the nature of the lesion or the patient's 
general condition precludes the probability of doing a radical opera- 
tion with a reasonable likelihood of success. At times one does not 
decide upon the formation of an artificial anus until after an ex- 
ploratory laparotomy shows its necessity. 

Unless one can previously locate the seat of the obstruction, the 
exploratory incision is best placed in the middle line, between the 
umbilicus and the symphysis, and the artificial anus made by bring- 
ing the most accessible portion of the large intestine into this same 
incision and fixing it there. The bowel above (proximal to) the ob- 



1 Some venous blood from the rectum enters the general circulation direct through 
the middle and inferior hemorrhoidal veins. 

19 



290 ABDOMEN AND BACK. 

struction is found distended, and that below (distal), diminished in 
caliber or collapsed. 

Descending Colon. — If the obstruction can be located in the 
sigmoid flexure or rectum, the abdomen is opened in the left iliac 
region and the lower part of the descending colon is brought up into 
the wound and fixed to its edges. 

An incision about three inches long usually suffices; it is made 
slightly oblique from above downward and inward, corresponding to 
the linea semilunaris, the middle of the incision being upon a line 
drawn from the umbilicus to the anterior superior spinous process. 

The incision is carried through the layers of the abdominal wall 
until the parietal peritoneum is reached. After bleeding points have 
been clamped the peritoneum is caught up with two mouse-toothed 
forceps, and between them a small opening, large enough to admit 
the finger, is made with the knife. This opening is enlarged upon 
the finger with a blunt-pointed scissors so as to correspond in length 
with the incision in the skin. 

The edge of the peritoneum, upon each side, is then fixed to 
the corresponding margin of the skin, near the middle, with two or 
three catgut sutures (E, Fig. 127); this is done to prevent retraction 
of this layer of peritoneum. 

Instead of placing the incision as indicated above it may be made 
nearer the middle line, so as to pass between the fibers of the rectus 
muscles, separating between these bluntly with the handle of the knife. 
This may give an artificial anus which is less difficult to control. 

A silk stitch (A, Fig. 127) is now passed through the edges of 
the upper part of the incision, through all the layers, including the 
skin and the edges of the peritoneum; a second similar suture (D, 
Fig. 127) is passed through the lower part of the incision. These 
two sutures are not tied. The lower part of the descending colon 
is now sought and brought up into the wound. In order to secure 
this two fingers are introduced into the abdomen and carried out- 
ward and backward, along the inner aspect of th*e abdominal wall, 
as far as the lumbar region, where the colon is found; one may 
meet with coils of the small intestine, and these may get in the 
way of the hand, but they may be recognized as being entirely sur- 
rounded by peritoneum and easily pushed aside; the fingers are 
then allowed to glide from the posterior wall of the abdomen on to 
the colon. The sigmoid flexure should not be brought up into the 
wound by mistake for the descending colon, because this part of the 



OPERATIONS UPON THE LARGE INTESTINE. 



291 



gut has such a long mesentery that, if used to form the artificial anus, 
it may after a' time become very much prolapsed, and this is unde- 
sirable. Having secured the descending colon, we select a portion 
sufficiently high up as to just allow of it being conveniently drawn 
into the wound. If it can be readily drawn out upon the abdomen 
we may know that we have the sigmoid flexure, and we should then 
select a portion of the gut above this. 



<S) 




Fig. 127. — Colostomy. The wall of the descending colon drawn into the 
incision and fixed. A, D, stitches which pass through all the layers of the 
abdominal wall, including the peritoneum; B, C, stitches which pass through 
all the layers of the abdominal wall, including the peritoneum, but catch up 
the wall of the gut as well in their course; E, stitches that join the parietal 
peritoneum to the skin. 



While that part of the gut which has been selected is steadied 
in the wound, a silk stitch (B, Fig. 127) in a curved surgeon's needle 
is passed through the upper part of one edge of the incision, through 
all the layers, care being taken to include the peritoneum; it then 
passes superficially through the wall of the gut, picking up its serous 
and muscular coats and taking a good, broad bite, but not penetrat- 



292 ABDOMEN AND BACK. 

ing into its lumen, and finally through the opposite edge of the ab- 
dominal incision. A second stitch (C, Fig. 127) is similarly introduced 
in the lower part of the abdominal wound, and this also catches the 
wall of the bowel on the way. These two stitches (B and C) should 
be about two inches apart; they are now tied, likewise the two 
stitches previously introduced through the edges of the wound, above 
and below, and the bowel is thus partially fixed in the abdominal 
incision. 

The bowel is now still further fixed to the margins of the ab- 
dominal incision by three or four interrupted fine silk sutures on 
either side; each one of these should secure the serous and muscular 
coats of the bowel and the edge of the incision in the abdomen, in- 
cluding the parietal peritoneum and skin. 

If the condition is not very urgent, the bowel had better not be 
opened until after the lapse of forty-eight hours, thus allowing time 
for adhesions to form and shut off the peritoneal cavity. If it is 
necessary to open the bowel at once a few more extra sutures should 
be taken in order to secure as accurate a union as possible between 
the surface of the bowel and edges of the abdominal incision. 

The opening in the bowel may be made with a knife, the bowel 
being held between two forceps, or it may be made with a Paquelin 
cautery; it should be sufficiently large to allow the introduction of 
a fairly thick, snugly-fitting tube. Iodoform gauze is packed well 
about this tube in dressing the wound. 

Matdl Method. — An incision is made as above and two or 
three interrupted catgut sutures are introduced on each side, which 
serve to fix the parietal peritoneum to the skin {E, Fig. 128). " A 
silk suture (A and D, Fig. 128) is also introduced in the upper and 
lower ends of the incision. These are left untied until the coil of 
gut has been secured and are simply for the purpose of diminishing 
the size of the incision. A convenient portion of the gut is then 
seized and drawn out through the abdominal incision and a glass 
cylinder or an artery forceps or a strip of gauze is thrust through its 
mesentery and placed at right angles to the incision in the abdomen, 
so as to retain the loop of gut in situ, outside the abdomen, until 
adhesions have had time to form. The loop of gut may be still 
further secured by fixing it to the edges of the incision with several 
catgut sutures. The gut is then, subsequently, divided completely 
through, down to the glass cylinder or forceps. 

If a portion only of the wall of the bowel is fixed to the opening 



OPERATIONS UPON THE LARGE INTESTINE. 



293 



in the abdomen, as described in the first operation, there is permitted 
ready escape of the contents of the bowel, but, at the same time, the 
possibility of some of the contents passing onward, into the lower 
segment, is not precluded. This condition is easily restored to the 
normal, so that this method of operating is preferable unless we 




Fig. 128.— Colostomy (Maydl). A whole locp of large intestine has been 
drawn out of the abdomen and a glass rod thrust through its mesentery to 
prevent its returning. A, D, sutures that penetrate all the layers of the 
abdominal wall and serve simply to diminish size of the wound. E, E, 
sutures that join the edges of the peritoneum to the skin. 



desire the artificial anus to remain permanently. On the other hand, 
if a whole knuckle of gut is brought out of the wound, as described 
in the second (Maydl) operation, a "spur" is formed which acts as 
a valve, directing the bowel contents out through the opening upon 
the abdomen, and at the same time hindering the passage of any 



294 



ABDOMEN AND BACK. 




Fig. 129.— Colostomy. Antero-posterior section shows the wall of the colon 
drawn into the incision in the abdomen. C, colon; S, symphysis pubis; V, 
umbilicus. 




Fig. 130. — Colostomy (Maydl). An antero-posterior section showing a 
whole loop of intestine drawn out of the incision in the abdomen. The ap- 
posed walls of the loop become joined to each other by adhesion, and thus 
a spur, or partition, is formed which prevents the contents of the upper part 
of the gut entering the lower portion. C, S, U, same as Fig. 129. 



OPERATIONS UPON THE LARGE INTESTINE. 295 

part of the bowel contents onward into the lower segment; it also 
insures the permanency of the artificial anus. 

Ascending Colon. — If the growth — obstruction — involves the 
transverse or descending colon, the operation may be performed in 
a similar manner upon the right side of the body; in this case the 
lower part of the ascending colon is brought into the wound and 
fixed. 

Resection of the Caecum. — This may include, in addition to the 
caecum, the whole or a part of the ascending colon and part of the 
ileum. For malignant disease, tuberculosis, and intussusception. 

If, before operating, the disease can be located in this part of 
the gut or a tumor felt, the incision is probably best placed directly 
over the tumor along the outer border of the right rectus muscle, 
in the linea semilunaris. If the incision is made for the purpose of 
exploration, it is usually placed in the middle line, reaching from 
the umbilicus down, toward the symphysis; through this incision, 
however, the caecum may also be excised if found advisable. In either 
case the incision must be long enough to allow sufficient room for 
work. 

If the incision is made along the outer border of the rectus it 
should commence about one inch above the middle of Poupart's 
ligament and is carried in a direction upward to a point located mid- 
way between the umbilicus and the anterior superior iliac spine or, if 
necessary, it may be continued farther upward toward the tip of the 
tenth rib. It may vary from five to ten inches in length. Having 
penetrated through the abdominal wall down to the parietal perito- 
neum, this layer is picked up with two toothed forceps and incised 
between them. We may then find it necessary to separate some ad- 
hesions before the cascum is exposed. This, together with the ad- 
joining portion of the ileum, is then brought out of the incision upon 
the abdomen. 

If the caecum is the seat of malignant disease and already so 
fixed within the abdomen that it cannot be brought out of the wound, 
it is probably inadvisable to proceed with the extirpation, because, if 
one is not reasonably certain of removing all the diseased tissue, the 
risk is probably out of proportion to the best result that can be 
hoped for. 

The cascum, being steadied outside the abdominal incision, is 
surrounded by gauze pads to protect the abdominal cavity, and two 
strips of gauze are tied about the intestine beyond the part which 



296 ABDOMEN AND BACK. 

is to be excised. Before tying the second piece of gauze the seg- 
ment of gut may be emptied by stripping it between the fingers. The 
gauze strips should be placed well beyond the limits of the part to 
be excised, and may be carried around the gut in the mouth of a 
sharp-nosed artery forceps which is thrust through its mesentery. 

The mesentery, corresponding to the segment of gut which is 
to be excised, is tied off in sections with catgut ligatures. The liga- 
tures may be carried in the eye of a blunt ligature carrier or with 
a pointed-nosed artery forceps. Each ligature should be single and 
placed some distance away from the gut, so as to leave space to cut 
between them and the gut. The segment of gut which is to be ex- 
cised is detached by cutting the mesentery between the ligatures and 
the gut. One should take care to excise all of the gut whose mesen- 
tery has been tied off, because, if an end of the gut which has been 
deprived of its mesentery is left, it is likely to become gangrenous. 
It now remains to divide the gut above and below and remove the 
diseased segment. This is done with a long, straight scissors in one 
sweep, long clamps having been previously placed upon the gut 
close to the diseased segment in order to prevent the escape of its 
contents when it is cut. 

Instead of proceeding as above, one may, after the strips of 
gauze and clamps have been applied about the gut, excise the dis- 
eased segment and then tie off the corresponding part of the mesen- 
tery in sections as already described. 

We are now ready for the final step of the operation, the restora- 
tion of the continuity of the alimentary canal by joining the ileum 
to the colon (ileo-colostomy), and this may be accomplished by: — 

1. End-to-end anastomosis (with suture or Murphy button). 

2. Lateral anastomosis (with suture or McGraw's rubber liga- 
ture or Laplace or O'Hara forceps, etc.). 

3. Lateral implantation (with suture or Murphy button). 
End-to-End Anastomosis. — This method may be employed if 

both ends of the gut which are to be united are of the same caliber; 
this condition at times exists, owing to the fact that the obstruction 
in the caecum or at the ileo-caecal opening may have caused a dilata- 
tion and hypertrophy of the ileum, the large intestine at the same 
time having become more or less diminished in caliber. The anas- 
tomosis is made with a double row of silk sutures, the first row pass- 
ing through all the layers of the wall of the intestine, including the 
mucous membrane and serous layers, and applied in such a manner 



OPERATIONS UPON THE LARGE INTESTINE. 297 

that the sutured edges are inverted inward into the lumen of the 
gut; this first row of sutures may he continuous and applied with 
a medium-sized curved surgeon's needle. The second row of sutures 
(Lemhert) is passed through the serous and muscular coats only, — ■ 
they do not penetrate into the lumen of the bowel, — and serve to 
bury the first row. This second row may also be continuous. In 
applying both of these rows great care should be exercised to include 
the serous coat, especially near the mesenteric attachment. This is 
the weak spot, especially in suturing the large intestine. 

The end-to-end anastomosis may also be made with a Murphy 
button of largest size. 

Lateral Anastomosis. — This is a satisfactory method of re- 
storing the continuity of the intestinal canal, particularly if the ends 
are of unequal size; for example, in joining the ileum to the esecum 
or colon. 

The cut edge of each segment of gut is inverted, a margin of 
three-fourths to one inch being turned in and the opening closed with 
a continuous silk stitch, which passes through the serous and muscu- 
lar coats, always taking special care, particularly at the mesenteric 
border, to appose serous surfaces to each other. A second continuous 
silk suture is then introduced; this second suture also includes only 
the serous and muscular coats and serves to bury the first line of 
suture. The ends of the bowel which have been thus closed up are 
now placed side to side, overlapping each other for a distance of five 
or six inches, and they are then united, surface to surface, for a dis- 
tance of four or five inches with a continuous Lembert suture of fine 
silk. This forms the first half of the "outside serous ring" suture, 
and when completed the needle, with the suture left long, is tem- 
porarily laid aside. 

An incision is then made in each segment of the gut three to 
four inches long, but not so long as the line of the Lembert suture 
(one inch shorter), and at a distance of about one-fourth inch away 
from the line of the Lembert suture. The corresponding edges of 
these incisions are then joined together all around with a continuous 
overhand silk or catgut suture, which includes all the coats of the 
gut and which may be introduced with a large, straight needle. 
After the edges of these openings have been thus united, the needle 
with which the first half of the "outside serous ring" suture was 
made is again taken up and the second half of the "outside serous 
ring," Lembert suture, inserted. The gut may be kept free of con- 



-298 ABDOMEN AND BACK. 

tents during the operation, as usual, by strips of gauze passed around 
each segment of gut beyond the site of the operation. The margins 
of the gut may be wiped off with a moist bichloride pad as often as 
they are soiled by escaping intestinal contents. 

Having completed the union of the two segments of gut, any 
rent or opening which is left in the mesentery may be closed by sev- 
eral catgut sutures and the parts returned to the abdomen. 

The lateral anastomosis may also be made with McGraw's rubber 
ligature in a manner analogous to that described in gastroenteros- 
tomy or with the Laplace or O'Hara forceps. 

End-to-Side, Lateeal Implantation. — Analogous to Kocher's 
gastro-duodenostomy (see "Pylorectomy"). This is probably not as 
satisfactory a procedure as either of the preceding methods. It may 
be done by suture or with a Murphy button. 

After closing the end of the large intestine the end of the ileum 
is united to the edges of a slit which is made in the large intestine 
opposite its mesenteric border, the union being accomplished either 
by suture or with a Murphy button (see "Pylorectomy"). 

By any of these means the ileum may be joined to any part of 
the large intestine. Owing to the frequent imperfections of the 
serous coat at the mesenteric border of the large intestine, the suture 
in all these operations is always somewhat doubtful, and it may be 
wise in many cases to leave a strand of gauze, reaching from the 
sutured gut through the abdominal incision, for drainage in case of 
leakage. 

Ileo-colostomy Without Resection of the Caecum or Colon. — This 
operation may be done in cases of obstruction at the ileo-caecal valve 
when the advisability of a more radical operation — resection — is 
doubtful. An anastomosis may thus be made between the ileum and 
the ascending colon, or, if the obstruction is located in another part 
of the colon, the anastomosis may be made between the ileum and 
the sigmoid flexure. Care should be taken to secure a coil of small 
intestine as low down, near the caecum, as possible; so that the 
nutrition of the patient may not be seriously interfered with. 

Resection of the Sigmoid Flexure. — This operation is usually 
performed for malignant obstruction. This part of the large intes- 
tine is a favorite seat of malignant disease. 

The incision is probably best made analogous to that for ex- 
cision of the cascum, but upon the other side of the abdomen, along 
the outer border of the left rectus, commencing below, about one 



OPERATIONS UPON THE VERMIFORM APPENDIX. 299 

inch above the middle of Poupart's ligament. The sigmoid may also 
be resected through an incision in the linea alba, extending from 
the umbilicus downward to the symphysis pubis if such an incision 
has been already made for the purpose of exploration before the 
growth was definitely located. 

The sigmoid, owing to its long mesentery, may be readily drawn 
out through the abdominal incision. It is surrounded by gauze pads 
to protect the abdominal cavity, and after the mesentery, which is 
usually quite long, has been tied off in sections, that part of the bowel 
which is to be resected is clamped off, cut free from its mesenteric 
-attachment, and finally excised. The ends of the bowel are then 
united, end to end, by suture or with a large Murphy button. The 
.same care, etc., should be exercised in suturing near the mesenteric 
.attachment to include the serous coats. After resection of the sig- 
moid each end of the bowel may be inverted and closed and a lateral 
anastomosis done as already described in connection with resection 
•of the caecum. 

If the sigmoid is fixed and the neighboring parts already infil- 
trated, it may be better to make an artificial anus above the seat of 
•obstruction and omit the radical operation. 

The colon has also been resected at the hepatic and the splenic 
flexures, the incision being made above, along the outer border of 
the corresponding rectus, or in the middle line, from the ensiform 
-cartilage downward to or beyond the umbilicus. The continuity of 
the canal may be restored by any one of the methods described above. 

OPERATIONS UPON THE VERMIFORM APPENDIX. 

Appendicectomy. — Eemoval of the appendix. 

As performed in cases of chronic relapsing catarrhal and re- 
-current appendicitis, there being no abscess present. In these cases 
the incision in the abdomen is closed immediately upon completion 
•of the operation and without drainage. 

The Incision" is oblique from above, downward and inward, and 
should be about three inches long. Some operators use a much 
shorter incision: Morris, one and one-half inches. The incision 
«hould be sufficiently long to allow proper performance of the opera- 
tion. It is well to commence with a short incision, which may be 
lengthened later should it become necessary. 

The incision should be placed about one and one-half inches to 



300 ABDOMEN AND BACK. 

the inner side of the anterior superior iliac spine, crossing, almost 
at a right angle, a line drawn from the anterior superior spine to the 
umbilicus and so arranged that one-third of its length is above the 
line and two-thirds below it. 

All bleeding points should be clamped, but need not be ligated 
immediately, as they usually stop after the forceps have been applied 
for a few minutes. The aponeurosis of the external oblique is ex- 
posed and divided, separating between its fibers along a line corre- 
sponding to the skin incision. The muscular fibers of the internal 
oblique are then exposed and incised, together with those of the 
transversalis, which muscle lies beneath the internal oblique; the 
fibers of these muscles are divided at right angles to their course. 
Finally the incision is carried through the fascia transversalis and 
parietal peritoneum, the latter being picked up with two mouse- 
toothed forceps and divided between these. The gut as it lies be- 
neath the peritoneum may be adherent to the latter, and therefore 
care should be exercised in cutting through the peritoneum not to 
wound the gut. It may not be necessary to divide the muscles for 
the whole length of the skin incision. In many cases, if the mus- 
cular layer is divided for a distance corresponding to the middle half 
of the length of the skin incision, this will suffice, and, if necessary,, 
later the incision in the muscles can be lengthened above and below. 

In closing this incision each layer should be united separately:, 
first, the parietal peritoneum with a continuous catgut stitch; then 
the transversalis fascia and the muscles with a second continuous 
catgut stitch; then the aponeurosis of the external oblique, also 
with a continuous catgut suture; and finally the skin, with a catgut 
stitch. The incision in the skin may be closed with an intracutieular 
suture. 

The McBurney Gridiron Incision. — The cut through the 
skin is the same as that described in the preceding paragraphs; the 
aponeurosis of the external oblique is split by separating between 
its fibers, and then two broad, sharp retractors are introduced, and, 
retracting the skin and aponeurosis, the muscular fibers of the in- 
ternal oblique are exposed; these are not cut, but are separated with 
the handle of the knife in the direction of the fibers, which is nearly 
at a right angle to the direction of the skin incision. The fibers of 
the transversalis muscle are next exposed and treated in a similar 
manner. Two broad, blunt retractors are now introduced and the 
edges of the muscles drawn apart, when the transversalis fascia is. 



OPERATIONS UPON THE VERMIFORM APPENDIX. 301 

exposed and incised, and finally the peritoneum. These last two 
layers are divided in the same direction as the internal oblique; i.e., 
at right angles to skin incision. 

Two sets of retractors are necessary to hold the wound open: 
one set, sharp, for the edges of the skin and aponeurosis of the ex- 
ternal oblique, retracting from side to side; the other set*, blunt, 
for the muscles and deeper layers, retracting from above and from 
below. We have thus a four-sided opening in the abdomen which 
may be enlarged by prolonging the separation and incision in the 
different layers. 

In closing this incision the edges of the peritoneum are first 
brought together with a continuous catgut stitch. The edges of the 
muscles of themselves return to place and are secured by two or 
three interrupted catgut sutures, which include the transversalis 
fascia also in their bite. The aponeurosis of the external oblique is 
sewed with a continuous catgut suture from above downward, and 
the skin then closed with an intracuticular catgut suture. 

There being no muscles or aponeurotic fibers cut, the liability 
to hernia is very much diminished. 

The Battle Incision. — A perpendicular incision, four inches 
in length, which is placed one and one-half inches to the inner side 
of the linea semilunaris, is made through the skin and fat, down to 
the aponeurosis of the external oblique. The lower two-thirds of 
this incision should be below a line which is drawn from the anterior 
superior spine to the umbilicus. The aponeurosis, which really forms 
the anterior layer of the sheath of the rectus, is then divided to cor- 
respond with the skin incision and the fibers of the rectus thus ex- 
posed. The rectus muscle is not cut, but is drawn inward until its 
outer edge is reached, and, while it is thus held with a blunt re- 
tractor, the posterior layer of its sheath is incised for a length corre- 
sponding with the incision in its anterior layer. This incision 
through the posterior layer of the rectus sheath is not placed imme- 
diately behind the incision in the anterior layer, but rather external 
to it. The parts being well retracted, good access is had to the ab- 
dominal cavity. 

In closing this opening each layer is sutured separately: first, 
the peritoneum, and then the opening in the posterior layer of the 
sheath of the rectus. The rectus muscle is allowed to resume its 
normal position, and a suture is placed in the anterior layer of its 
sheath. These sutures are all continuous and of simple catgut; 



302 ABDOMEN AND BACK. 

finally the skin incision is closed. This incision also diminishes the 
liability to hernia. 

After having opened into the abdomen we may proceed with 
the next step of the operation, the search for the appendix. At times 
it may be found presenting at once in the wound, more or less 
changed, thickened, etc., or, occasionally being bound down and 
fixed within the abdomen by adhesions, it does not come into view, 
and then it will be necessary to search for it. 

The appendix may be directed downward and may dip into the 
pelvis, or, with its tip pointed upward, it may lie to the outer or to 
the inner side of the caecum. It may be more or less confined in any 
of these positions by its mesentery or by adhesions. 

If difficulty is experienced in finding the appendix, the caecum 
may be brought out of the wound to serve as a guide. The caecum 
may be identified by its sacculation, by the little fatty processes at- 
tached to it, and by its longitudinal, white striae, two of which can 
usually be seen: if these striae are followed they will be found to lead 
down to the point where the appendix is given off. 

The appendix is gently liberated from its adhesions with the 
fingers, — there is no danger of hemorrhage in this procedure, — and 
gradually it is brought out of the wound, the caecum being at the 
same time returned into the abdomen. 

It is wise, before beginning to free the appendix, to introduce 
into the wound one or more gauze pads to protect the peritoneal 
cavity during the removal of the appendix and in the event of unex- 
pectedly meeting a small collection of pus. 

After the appendix has been sufficiently freed it is held in the 
wound or outside the abdominal incision, and after having properly 
arranged the gauze pads so as to protect the peritoneal cavity, we 
proceed at once to tie off the mesentery of the appendix. This is 
done by transfixing the mesentery close to the appendix and near its 
root with a ligature carrier or with a straight or curved needle carry- 
ing a loop of No. 2 simple catgut. This ligature is tied and the 
appendix then cut away from the mesentery, cutting between the 
appendix and the ligature with the scissors. The appendix being 
thus separated from its mesentery, we are ready to proceed with the 
final step of the operation, — the removal of the appendix. This may 
be done in one of several ways. 

1. Ligatuee Without Inveksion. — After the mesentery has 
been tied off and cut away from the appendix with the scissors, a 



OPERATIONS UPON THE VERMIFORM APPENDIX. 



303 



catgut ligature (jSTo. 2) is tied tightly around the appendix about 
one-fourth inch distant from its root; the ends of this ligature are 
left long to serve as a temporary tractor. The appendix is then 




Fig. 131. — Appendix. Meso-appendix shown. 



seized with an artery clamp upon the distal side of the ligature to 
prevent leakage when it is cut, and with the straight scissors it is 
amputated between the clamp and ligature. While the stump of 




132.— Appendicectomy. Appendix (A) ligated without inversion and 
amputated; M, meso-appendix tied off. 



the appendix is steadied by making traction with the ligature, which 
was left long intentionally for that purpose, the raw end of the stump 
is touched with pure carbolic acid on a very small swab or else it is 
cauterized with a pointed Paquelin. Some aristol may then be 



304 ABDOMEN AND BACK. 

rubbed in, the ligature cut short, and the stump of the appendix 
allowed to drop back into the abdomen. 

2. InVEBSION OF THE STUMP OF THE APPENDIX WITHOUT LlGA- 

titke. — After the mesentery has been tied off and cut away from the 
appendix and without applying a ligature around its root, the ap- 
pendix is seized with an artery clamp and amputated within one-half 
inch of its junction with the caecum. The short stump of the ap- 
pendix that remains is then inverted into the lumen of the caecum 
and the opening into the caecum corresponding to the base of the 
inverted appendix stump closed with a row of fine silk Lembert su- 
tures. There is no bleeding from the stump of the appendix. The 
amputation of the appendix may be done with the scissors or the 



ILEUM 




Fig. 133.— Appendicectomy. A portion of the wall of the ceecum removed in order 
to show the inverted appendix stump (A). M, meso-appendix tied off. 



Paquelin. This is a very simple and satisfactory way of treating 
the appendix. 

3. Inveesion of the Stump of the Appendix with Puese- 
steing (Dawbaen). — After the mesentery has been ligated and cut 
free from the appendix, the latter is steadied and a silk purse-string 
suture introduced into the wall of the caecum so as to surround the 
root of the appendix at a distance of about one-fourth inch all 
around. This stitch should include only the serous and muscular 
coats of the caecum; it should not penetrate into the lumen of the 
bowel. The purse-string suture is not drawn tight or tied, but the 
first double loop of a surgeon's knot is taken. Then, without apply- 
ing any ligature around its root the appendix is seized with an artery 



OPERATIONS UPON THE VERMIFORM APPENDIX. 305 

forceps and cut away with the scissors, leaving a stump about one- 
half inch long. The stump does not bleed. One may amputate the 
appendix with a Paquelin instead of a scissors. 

A thin artery forceps or the ends of a thumb forceps are next 
introduced into the canal of the stump like a glove stretcher, and 
the stump is stretched. The cut end of the stump is then seized 
with the thumb forceps or thin artery forceps and inverted into 
the caecum; it is turned "outside in" like a reversed glove finger. 
The forceps is then withdrawn, and at the same time the purse- 
string drawn tight, thus leaving the inverted stump presenting into 
the caecum and closing the opening in the caecum. If thought nec- 
essary, one may still further secure the opening in the caecum by 
applying two or three Lembert stitches in addition to the purse- 
string. This is a very satisfactory method of dealing with the stump 
of the appendix. 

4. Inversion of the Appendix (Edebohls). — This procedure 
is applicable to cases of catarrhal appendicitis that do not demand 
amputation of the organ. It may also be practiced incidentally dur- 
ing the course of other operations in order to preclude the possibility 
of the appendix becoming a source of trouble at some future time. 
The meso-appendix is first tied off close to the root of the appendix 
and then cut away from the appendix for its whole length. The 
point of a probe is then applied to the tip of the appendix, and with 
this the appendix is turned "outside in" into the lumen of the caecum 
as one would reverse the finger of a glove. After the appendix has 
been inverted into the caecum and while it is thus held by the probe 
one or two stitches of silk are taken so as to close the orifice that 
corresponds to the root of the turned-in appendix. The probe is 
then withdrawn and if necessary another stitch may be taken. 

These stitches that unite the margins of the orifice that corre- 
sponds to the root of the appendix serve to retain the appendix in 
its new inverted condition; they are usually of silk and, of course, 
are non-penetrating. 

In connection with any of these methods the stump of the 
mesentery may, in addition, be sutured over -the site of the inverted 
appendix stump. 

During any of these manipulations it is necessary for an assist- 
ant to steady the caecum, grasping it between the fingers with a gauze 
pad, which gives a better hold and at the same time protects it from 
becoming soiled. 



306 ABDOMEN AND BACK. 

The incision in the abdomen is finally closed, as indicated above, 
without drainage. Proper apposition and primary healing of the 
incision are necessary to secure the patient from the liability to sub- 
sequent ventral hernia. 

Operations for Appendicular Abscess. — Cases that go on to sup- 
puration, resulting in the formation of a localized intraperitoneal 
abscess which is shut off from the general peritoneal cavity by adhe- 
sions between immediately adjacent peritoneal surfaces. 

The abscess is opened and drained, the appendix being removed 
at the same time or left, according to the circumstance of each in- 
dividual case. 

During the opening of the abscess and the removal of the ap- 
pendix care should be exercised not to break through the barrier 
of adhesions, which are the result of nature's effort to protect the 
general peritoneal cavity from infection. 

The location of the abscess differs in different cases: it may be 
located anterior to the caecum within a mass of matted guts and may 
be opened as soon as the incision in the abdominal wall is carried 
through the parietal peritoneum. The abscess may be located be- 
hind and to the outer or right side of the caecum, reaching upward 
toward the kidney and liver or downward into the pelvis, or it may 
be located to the inner or left side of the caecum, or it may lie almost 
entirely within the pelvis and cause symptoms of pressure upon the 
bladder. Occasionally there is more than one collection, and care 
should be exercised that such a condition does' not escape our atten- 
tion at the time of the operation. 

The Incision. — The simple incision described above, cutting 
through the various layers, is usually employed. It should be, as a 
rule, about four inches long, and may be increased if necessary to 
allow proper work. The position of the incision may be somewhat 
changed from that described above in order to better expose the tu- 
mor; thus it may be placed farther away from the iliac spine — nearer 
the middle line, or lower down, nearer Poupart's ligament if the 
position of the tumor should indicate. 

Some surgeons use McBurney's gridiron incision for abscess 
cases as well as for the simple appendicectomies. 

The incision is carried through the abdominal wall, layer by 
layer, until the peritoneum is reached, and then after the hemor- 
rhage has been controlled the peritoneum is incised carefully in order 
to avoid wounding the underlying gut, which may be adherent to the 



OPERATIONS UPON THE VERMIFORM APPENDIX. 307 

parietal peritoneum. This is best done by seizing the peritoneum 
with two mouse-tooth forceps and cutting between them. 

Having incised the parietal peritoneum, we may find ourselves 
at once within the abscess cavity. In such cases the abscess is found 
to be located in front of the caecum. When this condition exists, 
we may often note, in making the incision through the abdominal 
wall, that the deeper layers — subperitoneal tissue, etc. — are cedem- 
atous and infiltrated. 

In most cases, however, after the parietal peritoneum has been 
incised, we come down upon a mass, consisting of the caecum and 
small intestine adherent and matted together, and within this the 
appendix and abscess are inclosed. This mass may be still further 
adherent to the overlying parietal peritoneum, which lines the poste- 
rior surface of the anterior abdominal wall, in which case the general 
peritoneal cavity is excluded from the likelihood of infection from 
the field of operation; on the other hand, this adhesion between the 
mass of matted intestine and the immediately adjoining parietal 
peritoneum may be absent; so that, when the fingers are introduced 
into the abdominal cavity through the incision, they may be passed 
freely in all directions, between the matted mass and the overlying 
parietal peritoneum: inward toward the umbilicus, upward toward 
the liver, and downward into the pelvis. 

Having exposed the mass within which the abscess and appendix 
are inclosed, we are ready to evacuate the abscess. Before doing 
this, however, the parts should be properly protected by gauze pads 
placed around and into the incision in the abdomen, and, if the con- 
dition exists as described above, — i.e., if no adhesions have been 
formed between the mass of intestine which incloses the appendix, 
etc., and the parietal peritoneum, — the pads should also be tucked 
into this space (between the matted mass and the anterior abdominal 
wall), in order to block it, off, so that when the abscess is opened the 
entrance of pus into the general peritoneal cavity will be prevented. 
Later, after the abscess has been evacuated, etc., these pads may be 
removed and replaced by fresh sterile pads or strips of gauze, which 
are allowed to remain, with their ends protruding from the wound, 
in order to obstruct this space and to promote the formation of pro- 
tecting adhesions. 

The abdominal incision is held open with retractors and search 
made for the abscess. The appendix is not to be seen, being adherent 
and buried within the mass of matted guts. We can locate the point 



308 ABDOMEN AND BACK. 

where the appendix comes off from the csecum by following down 
along the course of the longitudinal striae and gently, with the 
fingers, working between the adhesions until the abscess is reached. 

As the abscess is opened the patient may be turned on the right 
side to facilitate the escape of the pus, which is swabbed away as fast 
as it escapes. The abscess cavity may be gently flushed with peroxide 
of hydrogen, which may be preceded and followed by irrigation with 
saline solution. 

If the suppurative process involves the connective tissue behind 
the colon, reaching up toward the kidney, a counter-opening may 
occasionally, with advantage, be made in the loin. 

After the pus has been evacuated and the abscess cavity steril- 
ized we may attempt the removal of the appendix. Too much force, 
however, especially in the hands of inexperienced operators, should 
not be used in this effort, and one may wisely in many cases ter- 
minate the operation at this stage, being content with packing the 
abscess cavity and leaving the appendix to take care of itself, or to 
be removed later after suppuration has ceased, thus giving the patient 
the best chance for relief from immediate danger. 

There is no question as to the desirability of removing the ap- 
pendix at the time that the abscess is opened if the conditions permit, 
and one should make an effort to accomplish this. 

If the appendix lies to the inner side of the csecum, there is 
probably more danger in attempting to remove it than if it is located 
to the outer side or below. The manipulations required to remove 
the appendix where an abscess has been present may cause a break- 
ing through of the adhesions and may be followed by peritonitis, 
under which circumstances the patient's chance of recovery is greatly 
diminished. On the other hand, to leave the diseased appendix in 
the wound subjects the patient to the liability of a fsecal fistula, and 
— of more consequence than this — to a subsequent attack of appen- 
dicitis, which may be fatal. 

At times, after the pus has been evacuated, the appendix is 
fairly accessible, and may be felt or seen in the abscess cavity; so 
that, by farther separating the adhesions with the fingers and with 
the introduction of deep retractors, it may be reached and removed. 
It usually suffices to simply tie a catgut ligature around the appendix 
close to its root — say, one-half inch distant from the csecum — and 
amputate it with the scissors. The stump, which is steadied by the 
ligature, left long for this purpose, may then be sterilized with pure 



OPERATIONS UPON THE VERMIFORM APPENDIX. 309 

carbolic acid or the Paquelin. If conditions permit, instead of 
treating the 'stump in this simple manner it may be inverted into 
the cascum, as described above. 

For drainage the most satisfactory material is iodoform gauze, 
which may be loosely packed in the abscess cavity or else made into 
separate bundles inclosed in perforated casings of oil-silk or gutta- 
percha tissue; in addition to the iodoform gauze it is often advisable 
to use one or more glass or rubber tubes perforated on the sides, 
especially if the abscess cavity reaches down into the pelvis. Some 
surgeons use lamp-wick instead of the gauze for drainage. 

The wound in the abdomen should be closed in part with two or 
three silk-worm sutures which include all the layers, especially the 
parietal peritoneum, and which are introduced with a large curved 
surgeon's needle. Several similar sutures may also be introduced 
through the edges of that part of the wound which is to be left open, 
but these are left untied until after the suppuration has ceased and 
the drains have been removed. 

Operations for Appendicitis Accompanied by Progressive or Gen- 
eral Peritonitis or Peritoneal Infection due to perforation or slough- 
ing of the appendix before adhesions have been formed or to rupture 
or leakage of an appendicular abscess after adhesions have been 
formed. In these cases the appendix should be removed and an at- 
tempt made to prevent or check the general peritoneal infection. 

The incision should be sufficiently long — four to six inches; if 
a tumor has existed in the right iliac region it is probably best to 
place the incision in the right semilunar line, reaching down to Pou- 
part's ligament. The incision in other cases may be better placed 
in the middle line of the abdomen between the umbilicus and the 
symphysis pubis, especially if previously there has been no tumor in 
the right iliac fossa and the onset has been sudden or in cases where 
the diagnosis is somewhat in doubt and signs of a general peritonitis 
are present. 

After the abdomen has been opened the appendix is at once 
sought and removed. The fluids in the immediate neighborhood of 
the appendix are sponged away, and the whole abdominal cavity and 
intestine thoroughly flushed with normal salt solution. The pelvis, 
where fluids are especially apt to collect, should be cleared and 
flushed. This flushing should be thorough, using quarts of water 
poured from a pitcher or thrown into the abdomen through a thick 
glass tube. This washing should be clone, if possible, without re- 



310 ABDOMEN AND BACK. 

moving the intestines from the abdominal cavity, as this adds greatly 
to the shock, and there may be some difficulty in replacing them. 
One may follow the saline irrigation with peroxide of hydrogen, this 
in turn being followed up by a final washing with saline solution. 

If the intestine is coated with flaky exudate and matted with 
fresh adhesions, it may be advisable to break these up with the 
fingers in order to make the flushing satisfactory and thorough. 

A glass or rubber drainage tube with a gauze strip passed 
through it may be introduced into the abdomen, reaching well down 
into the pelvis, and strips of iodoform gauze and drainage tubes may 
be introduced into the abdomen down into the region of the ap- 
pendix, and in other directions also. The incision in the abdomen 
is closed in part with interrupted sutures of silk-worm gut which 
pass through all the layers of the abdominal wall, including the 
parietal peritoneum. 

THE LIVER AND GALL=BLADDER. 

The Surgical Anatomy of the Liver. — The liver is a solid gland- 
ular organ almost completely invested by the peritoneum, suspended 
in the upper right portion of the abdomen (right hypochondrium) 
and extending beyond the middle line into the left side (left hypo- 
chondrium). It is situated under cover of and protected by the ribs, 
except in the epigastric region. Behind and toward the right the 
liver is thick, gradually becoming thin toward the front and left. 
From side to side it measures eleven inches; from before backward, 
eight inches; and its posterior border has a thickness of two and 
one-half inches. 

Above, the diaphragm separates the liver from the pleura and 
pericardium; below it are the gall-bladder, hepatic flexure of the 
colon, the first part of the duodenum, the pylorus and stomach 
(which it overlaps), and the right kidney and suprarenal capsule. 

The siiperior surface of the liver looks forward as well as up- 
ward, and is in relation with the diaphragm and with the ribs and 
costal cartilages from the fifth or sixth to the tenth. The lower 
limit of this surface corresponds to the free border of the ribs (costal 
cartilages). This upper surface of the liver is smooth, and presents 
a fold of peritoneum running from the anterior border backward, 
the suspensory ligament. This serves to suspend the liver to the 
diaphragm, and is the continuation of the falciform fold of perito- 
neum, which is thrown around the round ligament from the anterior 



SURGICAL ANATOMY OF THE LIVER. 311 

abdominal wall and which extends from the umbilicus to the anterior 
edge of the liver. The suspensory ligament divides the upper sur- 
face of the liver into the larger right lobe and the smaller left lobe; 
the latter overlaps the stomach and reaches to the left beyond the 
middle line. Toward the posterior border of the liver the folds of 
the suspensory ligament spread out right and left, and, still passing 
between the liver and the diaphragm, form the anterior layer of the 
coronary ligament. 

The posterior border of the liver, really a surface, is thick, 
gradually becoming thin toward the left, and is not covered by 
peritoneum; the peritoneum which covers the upper surface of the 
liver upon reaching its posterior border is reflected upward to the 
diaphragm as the anterior layer of the coronary ligament, and that 
which covers the under surface upon reaching the posterior border 
of the liver is reflected on to the posterior abdominal wall (dia- 
phragm), forming the posterior layer of the coronary ligament. The 
coronary ligament, at either end, forms the right and left lateral 
ligaments of the liver. The posterior border of the liver, to the left 
of the middle line, presents a notch which corresponds to the oesoph- 
agus and which marks the division of the liver into its right and left 
lobes. The posterior border of the liver is in relation with the dia- 
phragm and lower ribs, with the vertebral column, tenth and elev- 
enth dorsal, the aorta, vena cava inferior, etc. The oesophagus is 
received in the notch above mentioned. 

The anterior border is thin, reaches just below the free border 
of the ribs (costal cartilages), and corresponds to a line drawn from 
the tip of the right tenth to the tip of the left eighth costal carti- 
lage, where this joins the cartilage of the seventh. 

The under surface of the liver is irregular and marked by 
grooves and impressions for the colon, gall-bladder, kidney, etc., and 
is covered by the peritoneum, which is reflected downward at the 
transverse fissure, as the lesser omentum, as far as the lesser curva- 
ture of the stomach, where its folds separate to include the stomach 
between them. 

Besides the right and left lobes, the under surface of the liver 
presents three smaller lobes: the quadrate, caudate, and the lobus 
Spigelii. The large right lobe is marked by the transverse fissure, 
which passes from right to left and is situated rather more than 
half-way back from the anterior border. 

At this fissure, the vessels, ducts, lymphatics, and nerves pass 



312 ABDOMEN AND BACK. 

in and out of the liver. These structures descend in the right free 
horder of the lesser omentum, between its two folds, the common 
bile-duct to the right, the hepatic artery to the left, and the portal 
vein between and behind these two. The hepatic duct, which is 
formed by the junction of the right and left bile-ducts, emerges from 
the right end of the transverse fissure and descends between the 
folds of the lesser omentum, where it is joined by the cystic duct 
to form the common bile-duct, ductus choledochus. 

If we examine the under surface of the liver as this organ lies 
in its normal position in the abdomen, through a vertical incision 
made in the abdomen from the tip of the ninth costal cartilage, we 
note, in sweeping across the surface from right to left, two well- 
marked grooves, or depressions, into which the finger sinks; the 
first, that toward the right, corresponding to the tip of the ninth 
costal cartilage, lodges the gall-bladder; the second, nearer the 
middle line, corresponds to the round ligament (foetal umbilical 
vein). 

The Surgical Anatomy of the Gall-bladder. — The gall-bladder is 
a pear-shaped, hollow receptacle. Its wall is fairly thick and is com- 
posed of muscle and mucous membrane. The serous, coat (perito- 
neum) invests the under surface of the body and all of the fundus 
of this organ, binding it to the under surface of the liver. The gall- 
bladder lies in direct relation with the under surface of the liver, 
in the fossa of the gall-bladder, the apposed surfaces of the gall- 
bladder and liver being joined to each other by loose connective 
tissue. 

The fundus of the gall-bladder is directed downward, forward, 
and to the right, usually appearing below the anterior thin edge of 
the liver, opposite the tip of the ninth costal cartilage. Sometimes 
it does not reach quite as far as the anterior edge of the liver, and 
is then concealed underneath the liver. The edge of the liver, corre- 
sponding to the fundus of the gall-bladder, is sometimes marked by 
a slight notch. 

The gall-bladder is three to four inches long and has a capacity 
of about one and one-half ounces. The fundus rests upon the trans- 
verse colon, and the neck, the posterior narrow part, upon the first 
part of the duodenum. To the outer side of the gall-bladder — i.e., 
to the right — is the hepatic flexure of the colon; to the left is the 
pyloric end of the stomach. The neck of the gall-bladder is con- 
tinned into the cystic duct. The cystic duct is about one-twelfth 



SURGICAL ANATOMY OF THE GALL-BLADDER. 313 

inch in diameter and one to two inches long. Its interior has an 
irregular, spiral, twisted shape, which makes difficult the passage of 
a sound through it. It curves down hehind the first part of the duo- 
denum, and joins with the hepatic duct between the folds of the 
lesser omentum to form the common bile-duct. 

The hepatic duct is one-sixth inch in diameter and two inches 
long; it is formed by the junction of the bile-ducts from the right 
and left lobes of the liver. 

The common bile-duct, ductus communis choledochus, varies 




Fig. 134.— Bile-ducts, etc. C, cystic duct; CB, common duct; OB, 
gall-bladder; H, hepatic ducts; P, pancreatic duct. 

in length: it is usually three inches long and one-fourth inch in 
diameter; it continues the course of the hepatic duct, descending 
between the folds of the lesser omentum, lying near its right free 
edge. In this situation it lies in front of the portal vein with the 
hepatic artery on its left side; continuing downward it passes behind 
the first part of the duodenum, and finally behind and to the inner 
side of the second part of duodenum, between it and the head of the 
pancreas, where it meets the pancreatic duct; these unite and perfo- 
rate the wall of the duodenum (second part) upon its inner, poste- 
rior aspect, running very obliquely in the wall of this part of the 



314 ABDOMEN AND BACK. 

gut for one-half to three-fourths inch; the opening of the duct upon 
the inner surface of the gut is marked by a papilla. This papilla is 
distant about four inches from the pylorus. 



OPERATIONS UPON THE LIVER. 

Hepatotomy. — Incision of the liver for abscess, hydatid cyst, etc. 

The incision, when the disease involves the right lobe, is placed 
along the outer border of the rectus muscle, extending from the tip 
of the ninth costal cartilage downward for a distance of from three 
to five inches. 

At times it may be desirable to place the incision elsewhere in 
order that it may correspond with the prominence of the tumor; 
for example, if the abscess is located in the left lobe of the liver, 
then the incision is better placed in the middle line, linea alba. The 
incision is carried through the integument, fascia, etc., down to the 
peritoneum, and after the hemorrhage has been controlled the 
parietal peritoneum is incised between two mouse-tooth forceps. We 
may find the tumor adherent to the parietal peritoneum, and in this 
case, after aspirating to discover the nature of its contents, we may 
incise the tumor and evacuate. The finger is then introduced into 
the abscess cavity to explore and break up septa, etc. The cavity is 
finally packed with iodoform gauze. Under these circumstances the 
operation is very simple and there is no danger whatever of infecting 
the general peritoneal cavity. 

If, however, after incising the peritoneum we find that the tu- 
mor is not adherent to the parietal peritoneum, — i.e., if we can pass 
the hand freely between the tumor and the parietal peritoneum, — 
we must take measures to prevent infection of the general peritoneal 
cavity while the contents of the cavity are being evacuated, and to 
accomplish this we do the operation in two sittings. 

First, having exposed the tumor, the parietal peritoneum is 
united to the edges of the skin with two or three catgut sutures on 
either side, and then strips of gauze are packed into the wound be- 
tween the tumor and parietal peritoneum for the purpose of shutting 
off the general peritoneal cavity in case of leakage and to stimulate 
the formation of adhesions between the tumor and the parietal peri- 
toneum. One may then aspirate with a fine needle in order to discover 
the nature of the contents and to relieve the tension somewhat. 

The incision in the abdomen is left open and packed down to 



OPERATIONS UPON THE GALL-BLADDER. 3 15 

the surface of the tumor or the incision may be closed in part by 
one or two" sutures of silk-worm gut which pass through all the 
layers of the abdomen, including the parietal peritoneum. 

After an interval of several days, when adhesions have formed, 
etc., the tumor, abscess, or hydatid cyst may be incised either with 
the Paquelin cautery or the knife, and drained. 

Hepatectomy (Excision of Diseased Portion of the Liver). — Por- 
tions of the liver have, in a few instances, been excised when involved 
primarily or by extension from growths of the gall-bladder and ducts 
either by means of the Paquelin cautery or by blunt dissection 
(enucleation) with the finger. Large individual vessels may be 
clamped and tied as they are met with during the operation. The 
space which remains in the liver after the removal of the diseased 
part may be closed by approximation of its edges with sutures of 
catgut; but if there is much tension these may tear through. 

Injuries of the Liver. — The liver may be lacerated by blows 
upon the abdomen, by fractured ribs, or by bodies causing penetrat- 
ing wounds. These injuries may be accompanied by free hemorrhage. 
On account of the solid structure of the liver large venous channels 
cannot collapse, and thus hemorrhage is favored. Hemorrhage may 
be controlled by the cautery or by packing, or by packing combined 
with suture. 

OPERATIONS UPON THE GALL=BLADDER. 

Aspiration of the Gall-bladder. — Drawing off the contents of the 
gall-bladder, usually for purposes of diagnosis. 

Aspiration may be resorted to in order to determine the nature 
of a tumor which can be felt through the abdominal wall. 

The needle is introduced over the most prominent part of the 
tumor, usually below the tip of the ninth costal cartilage, and some 
of the contents withdrawn. The needle should be of small caliber. 

This is a dangerous procedure and one to be condemned, even 
if the needle and skin are made aseptic, because some of the contents 
is very apt to escape through the puncture in the wall of the gall- 
bladder upon withdrawing the needle, especially if the needle used 
is not fine, and if the material is infectious a fatal peritonitis may 
be thus set up. 

Cholecystotomy. — Opening the gall-bladder for the purpose of 
removing stones, etc. 

An incision is made which reaches from the tip of the ninth 



316 ABDOMEN AND BACK. 

costal cartilage vertically downward, in the linea semilunaris, along 
the outer side of the rectus or just exposing the outer edge of this 
muscle, three to four inches long. Having cut through the several 
layers of the wall of the abdomen, the parietal peritoneum is ex- 
posed. Before incising the peritoneum, all bleeding points in the 
abdominal wall are clamped. The parietal peritoneum is then 
caught up with two mouse-tooth forceps and snipped between these 
with the knife, whereupon the finger is introduced and the opening 
enlarged with the scissors, cutting upon the finger as a guide. 

Instead of the vertical incision one may make an oblique in- 
cision, one finger's breadth distant from and parallel with the free 
border of the ribs, the middle of the incision corresponding to the 
tip of the ninth costal cartilage. This incision is usually four to 
five inches long. The vertical incision is probably the preferable 
one. After the parietal peritoneum has been incised the sharp ante- 
rior edge of the liver is exposed in the upper part of the incision and 
the transverse colon in the lower part of the incision. The gall- 
bladder may be seen more or less distended, projecting beneath the 
anterior border of the liver, or it may be small and concealed beneath 
the edge of the liver. 

Occasionally in order to bring the fundus of the gall-bladder 
into the wound it may be necessary to draw the liver well upward or 
to incise the thin layer of liver-tissue that overlies the fundus of 
the gall-bladder, or it may be necessary, with the finger, to break 
up some adhesions that bind down the gall-bladder. 

In the cadaver some difficulty may be experienced in locating 
the gall-bladder and bringing it up into the wound, as the liver, post- 
mortem, sinks backward and away from the anterior abdominal wall 
and upward into the thorax, carrying the gall-bladder with it. The 
gall-bladder is sought in the fossa of the gall-bladder upon the under 
surface of the liver, its fundus corresponding to the tip of the ninth 
costal cartilage. 

When the fundus of the gall-bladder has been located, two silk 
tractors may be introduced into its wall to steady it; these should 
take a good, firm, broad bite, but should not penetrate through the 
entire thickness of its wall. Gauze pads are then tucked into the 
incision and around the gall-bladder in order to shut it off from the 
peritoneal cavity. 

If the gall-bladder is much distended, one may aspirate to dis- 
cover the nature of the contents and to diminish the tension and 



OPERATIONS UPON THE GALL-BLADDER. 317 

size of the tumor, and then, making an incision in its fundus, it is 
emptied of its contents, any remaining fluid being withdrawn with 
sponges on a stick, and the finger introduced for exploration. If 
any stones are present, these may be removed with a scoop or forceps. 
With the hand in the abdominal cavity one should thoroughly pal- 
pate the cystic, hepatic, and common bile-ducts. Stones impacted in 
the cystic duct may be forced back into the gall-bladder and removed. 

Having emptied the gall-bladder and convinced one's self that 
the ducts are patent and if the contents of the gall-bladder were not 
purulent, one may proceed at once to close the opening in the gall- 
bladder and the incision in the abdomen. 

To test the patency of the ducts one may introduce a gum 
catheter through the incision in the gall-bladder into the cystic duct 
and onward through this into the common duct. Owing to the 
twisting and irregularity of the interior of the cystic duct, however, 
the catheter may catch in its wall and fail to pass even when the 
duct is pervious. If not successful with the catheter, Abbe has 
suggested a stream of water introduced into the gall-bladder under 
pressure; if it flows freely it indicates the patency of the ducts. 

The incision in the gall-bladder may be closed with a double 
row of sutures. The first row, which may be of catgut, includes the 
whole thickness of the wall and serves to close the opening; it may 
be continuous or consist of several interrupted stitches. This first 
line of suture is reinforced by a second row of Lembert sutures, 
which should include only the serous and muscular coats of the gall- 
bladder; these serve to bury the first row and bring the adjoining 
serous surfaces into accurate apposition. Unless one is certain that no 
obstruction exists in the bile-ducts, it is advisable to allow the opening 
in the gall-bladder to remain; i.e., to sew the edges of the incision in 
the gall-bladder to the margins of the abdominal incision (chole- 
cystostomy). 

If "the incision in the abdomen is to be closed, this is effected 
by uniting, first, the edges of the parietal peritoneum with a con- 
tinuous catgut suture. The transversalis fascia and muscle (aponeu- 
rosis) are then brought together with a second continuous catgut 
suture, and finally the edges of the skin are united by a catgut suture. 
After the edges of the peritoneum have been sutured we may ap- 
proximate the other layers — skin, aponeurosis, fascia, etc. — with sev- 
eral interrupted sutures of silk-worm gut, each suture including all 
of these layers, but omitting the peritoneum. 



318 ABDOMEN AND BACK. 

Cholecystostomy. — Formation of a fistulous opening in the gall- 
bladder; for the removal of calculi from the gall-bladder. The op- 
eration may be done in one or two sittings. 

An incision as described in the preceding operation, either 
vertical, passing from the tip of the ninth costal cartilage downward, 
or oblique, parallel with the free border of the ribs. Probably the 
vertical incision is preferable in most cases. 

The incision may be located nearer to the middle line if the 
presence of a tumor indicates, so that it may be over the most promi- 
nent part of the tumor. 

Cholecystostomy in one Sitting. — Having opened into the 
abdomen, the gall-bladder is usually found distended and presenting 
beneath the free anterior edge of the liver, and may be more or less 
adherent to neighboring parts — colon, duodenum, etc. These adhe- 
sions may be gently broken down by the fingers in the abdomen and 
the cystic, hepatic, and common bile-ducts palpated for an impacted 
calculus, etc. 

The edge of the parietal peritoneum is fixed to the margin of 
the skin by two interrupted catgut sutures on either side. The 
gall-bladder is then drawn into the incision, and, after pads have 
been arranged so as to protect the peritoneal cavity, two silk tractor 
sutures are introduced into its fundus, care being taken to avoid 
passing entirely through the wall into its cavity. While the bladder 
is steadied by the tractor sutures it is emptied of its contents as 
completely as possible with the aspirator or a trochar, and an in- 
cision then made in the fundus of the bladder and the edges of the 
incision seized with artery forceps. The contents of the gall-bladder 
should be entirely evacuated, any remaining fluid being sponged out 
with pads upon sticks, and stones removed with a scoop or forceps. 
A stone impacted in the cystic duct may be pushed back into the 
bladder and removed. If the cystic duct has been obstructed, as 
soon as the obstruction is relieved there is apt to be a copious flow 
of bile from the cystic duct into the gall-bladder. This bile should 
be prevented from entering the peritoneal cavity. Although bile in 
the peritoneal cavity does not cause a septic peritonitis, still its en- 
trance in any considerable quantity should be avoided. 

After having explored the interior of the gall-bladder, removed 
stones, examined the ducts, and tested their patency, we are ready 
to sew the edges of the opening in the gall-bladder to the edges of 
the incision in the abdominal wall. This is done with a number of 



OPERATIONS UPON THE GALL-BLADDER. 319 

interrupted silk sutures placed fairly close together, the ends being 
left long to facilitate their removal later. The stitches should be 
about one-fourth inch apart. Care should be taken to bring the 
peritoneal surface of the gall-bladder into accurate apposition with 
the parietal peritoneum, which has already been sutured to the skin. 
That part of the abdominal incision which is to be closed should be 
brought together with several silk-worm gut sutures, each passing 
through all the layers and including especially the parietal perito- 
neum. The stitches, above and below, immediately adjacent to the 
fixed gall-bladder, may also include the wall of the gall-bladder in 
their course. 




Fig. 135. — A Purse-string Suture has been Introduced Around the in- 
cision in the Fundus of the Gall-bladder Close to its Edge. When the purse- 
string is drawn tight it tends to invert the edges of the opening around the 
tube, and thus accelerates its closure. 

Finally a drainage tube is introduced into the opening in the 
gall-bladder and the wound loosely packed with iodoform gauze. 

McBumey Modification.— -In order to facilitate the rapid oblit- 
eration of the resulting fistula, the gall-bladder may be united to 
the edge of the abdominal incision by a row of sutures which do 
not include the edge of the incision in the gall-bladder, but which 
catch its wall without passing entirely through it, just external to 
the opening all around; and then, before the drainage tube is intro- 
duced, a purse-string suture which passes through the whole thick- 
ness of the wall of the gall-bladder is introduced around and close 
to the margin of the opening in the gall-bladder, so that when it is 
drawn tight it will grasp the tube and at the same time invert the 



320 



ABDOMEN AND BACK. 



edges of the opening in the gall-bladder closely around it. The 
wound is then packed and dressed in the usual way. After the tube 
is withdrawn the opening in the gall-bladder, with the inverted 
edges, tends to close more rapidly. 




Fig. 136.— Cholecystectomy. Fundus of the gall-bladder ((?) drawn Into 
the incision and fixed; A, D, sutures through all the layers of the abdominal 
wall that serve to diminish size of the incision; B, C, sutures that pass 
through the edges of the incision in the abdomen, but catch up the wall of 
the gall-bladder as they pass across from one edge of the incision to the 
other; E, sutures that join the edges of the peritoneum to the skin. 

Cholecystostomy in two Sittings. — This method is especially 
applicable if the contents of the gall-bladder are purulent. 

Through the vertical incision, about four inches long, in the ab- 



OPERATIONS UPON THE GALL-BLADDER. 321 

dominal wall, the gall-bladder is exposed and the bile-ducts, etc., pal- 
pated. After pads have been arranged so as to protect the peritoneal 
cavity, a fine aspirating needle may be thrust into the bladder and 
some of the contents drawn off. If the contents are purulent, the 
operation had better be done in two sittings. 

The parietal peritoneum is first fixed to the margins of the 
abdominal incision with two interrupted catgut sutures {E, Fig. 136) 
on each side; these join the edge of the peritoneum to the edge of 
the skin. Two tractor sutures which do not penetrate through the 
entire thickness of its wall are then introduced into the fundus of 
the bladder in order to steady it. 

Four silk-worm gut sutures (A, B, C, D, Fig. 136) are now in- 
troduced through the edges of the abdominal incision: two in the 
upper part of the incision and two in the lower part. 

Each of these sutures passes through all the layers of the ab- 
domen; the two middle sutures, marked B and C (Fig. 136), pick up 
the wall of the gall-bladder in their course, but do not pass through its 
entire thickness. They serve to partially fix the bladder in the ab- 
dominal incision. There should be a space of one and one-half to two 
inches intervening between these two sutures. 

The uppermost and lowermost sutures, marked A and D, which 
are simply for the purpose of closing the abdominal incision for part 
of its length, are introduced first, but they are not tied until after 
those which pick up the wall of the gall-bladder have been intro- 
duced. 

The fundus of the gall-bladder is then still further united to the 
edges of that part of the abdominal incision which is to be left open 
— i.e., between the sutures B and C — with several additional catgut 
or silk sutures on either side. These do not pass through the entire 
thickness of the wall of the gall-bladder, and are best introduced 
with a narrow, curved surgeon's needle. It may facilitate the intro- 
duction of these accessory sutures if the sutures B and C are left 
untied until these accessory sutures have been introduced. As a 
result, we have the abdominal wound left open for one and one-half 
to two inches of its length, and the fundus of the gall-bladder fixed 
there. 

The wound is then packed, leaving the tractor sutures in place, 
and after two to five days the gall-bladder may be opened between 
the tractors with a knife or Paquelin cautery and emptied of its 
contents. 



322 ABDOMEN AND BACK. 

Cholecystostomy when the Gall-bladder is Adherent to 
the Parietal Peritoneum, thus Shutting off the Peritoneal 
Cavity. — Having made the incision through the abdominal wall 
as described above, we may find the gall-bladder adherent to the 
parietal peritoneum, thus shutting it off entirely from the general 
peritoneal cavity. In this case one may well avoid breaking down 
the adhesions, and proceed at once to open and empty the gall- 
bladder; a drainage tube is introduced into the bladder and the in- 
cision in the abdomen is left open and packed. 

Cholecystostomy when the Gall-bladder Cannot be 
Brought up into the Incision. — At times it is not possible to draw 
the gall-bladder up into the abdominal incision for the purpose of 
fixing it to the edges of the wound, even after adhesions, that may 
be present, have been broken up. 

Under these circumstances it may be better to extirpate the 
gall-bladder, or else, after emptying it in part with the aspirator, 
it may be freely incised, emptied, and thoroughly disinfected. A 
drainage tube may then be introduced into the bladder and fixed 
with a catgut suture (No. 2) to the edge of the opening in the blad- 
der, and in addition to this a purse-string suture of catgut may be 
placed in the wall of the gall-bladder, close to the margin of the 
opening, which, when drawn tight, grasps the tube, the end of which 
is allowed to project through the incision in the abdomen. Finally, 
gauze is packed into the abdominal incision around the tube, reach- 
ing down to the gall-bladder. 

Cholecystectomy. — Extirpation of the gall-bladder. 

This operation may be done in cases of cholelithiasis when one 
is unable to bring the gall-bladder sufficiently well upward, forward, 
to sew it to the abdominal incision; for rupture of the gall-bladder, 
due to falls, blows, or a run-over. One must always be certain of 
the patency of the common bile-duct before extirpating the gall- 
bladder. 

The incision is vertical, four to six inches long, corresponding 
to the outer border of the rectus muscle and commencing above at 
the tip of the ninth costal cartilage. 

After the abdomen has been opened the gall-bladder is sought. 
It may be distended and present below the edge of the liver, or it 
may be small and concealed beneath the free edge of the liver. 

Adhesions between the gall-bladder and neighboring parts 
should be broken up with the fingers, and the bile-ducts, especially 



OPERATIONS UPON THE GALL-BLADDER. 323 

the common, should be thoroughly palpated, since extirpation of the 
gall-bladder is- naturally counter-indicated if the common duct is 
obstructed. If a stone is found in the common duct it may be 
crushed with padded forceps or forced back into the bladder or 
onward into the duodenum, or it may be removed by one of the 
operations described below. 

After having assured one's self of the patency of the common 
duct one may proceed with the extirpation of the gall-bladder. If 
the gall-bladder is distended, one may aspirate for the purpose 
of relieving the tension and to discover the nature of the con- 
tents. The liver is drawn upward and the pylorus downward out of 
the way. 

The layer of peritoneum which covers the inferior aspect of the 
gall-bladder and binds it to the under surface of the liver is incised 
or torn, and the gall-bladder separated from the under surface of 
the liver subperitoneally, and, as much as possible, bluntly with the 
finger, at the same time making traction upon the gall-bladder, 
which is held in the grasp of a forceps. The separation of the gall- 
bladder is commenced at the fundus, gradually working backward 
toward the neck of the organ. After freeing the neck one continues 
along the cystic duct as far as its junction with the common duct; 
so that the gall-bladder finally hangs free, suspended only by the 
cystic duct. The hemorrhage from the raw surface of the liver is 
usually but slight and may be controlled by a few minutes' com- 
pression with a hot gauze pad or by the Paquelin, if necessary. 
A double silk or catgut ligature is thrown around the cystic duct, 
close to its junction with the common duct and tied, and the cys- 
tic duct then divided between the ligatures, and the gall-bladder 
thus removed. The stump of the cystic duct is drawn into the 
incision by the ligature, which is left long for that purpose, and cau- 
terized; the ligature is then cut short and the stump allowed to drop 
back into the abdomen. The edges of the layer of peritoneum which 
bound the gall-bladder to the under surface of the liver, and which 
was torn to allow the enucleation of the gall-bladder, may be brought 
together with a catgut suture, thus closing in the raw area of the 
liver and the stump of the cystic duct. 

The incision in the abdomen is closed without drainage with 
several interrupted silk-worm gut sutures, the edges of the opening 
in the parietal peritoneum being first brought together in the usual 
way with a continuous catgut suture. 



324 ABDOMEN AND BACK. 

Cholecyst-enterostomy. — The formation of a fistulous opening 
between the gall-bladder and the intestine in case of inoperable ob- 
struction of the common duct. 

A vertical incision four to six inches long is made, correspond- 
ing to the outer border of the right rectus muscle, in the semilunar 
line, commencing above, just below the free border of the ribs at the 
tip of the ninth costal cartilage. 

Having cut through the abdominal wall, the distended gall- 
bladder usually presents. It is aspirated and emptied as nearly as 
possible of its contents and then incised, and, if stones are present, 
these are removed; it is then packed with gauze to prevent further 
escape of its contents. A loop of the jejunum, sixteen to twenty 
inches below the duodenum (see "G-astro-enterostomy"), is secured 
and brought up, in front of the great omentum and transverse colon, 
into the incision in the abdominal wall. 

Gauze pads are then properly placed to prevent soiling of the 
peritoneal cavity, and with a fine, straight needle and fine silk the 
gall-bladder, at a convenient point near its fundus, and the gut, 
opposite its mesenteric border, are united to each other. This 
stitch takes a good, broad bite, including the serous and muscular 
coats, but does not pierce the whole thickness of the wall of either 
organ. The gall-bladder and jejunum are joined together in this 
way for a distance of about one and one-half inches. This needle 
is then temporarily laid aside, and an incision one inch long is made 
in both the gall-bladder and the intestine; these openings are 
placed opposite each other and are shorter than the line of suture 
which has already been applied. "With a curved surgeon's needle 
and silk or catgut the contiguous edges of both these openings are 
joined together all around with a continuous overhand stitch, which 
penetrates all the coats, and thus the communication between the 
two organs is effected. After this the first straight needle carrying 
the fine silk thread, with which the first half of the "outside serous 
suture" was made, is again taken up and the second half of this 
"outside serous suture" is introduced. In this way the gall-bladder 
and the intestine are united by a double line of suture, one joining 
the edges of the openings to each other all around, and the other, 
a non-penetrating suture, which surrounds this first suture and 
buries it. 

Having thus completed this part of the operation, the opening 
which was made in the fundus of the bladder for the purpose of 



OPERATIONS UPON THE GALL-BLADDER. 325 

emptying it and removing stones, etc., may be closed with a Lembert 
suture of fine silk, or else the margins of this opening may be fixed 
to the edges of the abdominal incision in order to insure drainage 
for a day or two (cholecystostomy). The abdominal wound may be 
closed in part, that portion which is left open being packed (see 
"Cholecystostomy"). If the opening in the gall-bladder has been 
closed, then the abdominal incision may be likewise closed. 

The result of this operation is the establishment of a commu- 
nication which allows the bile to flow from the gall-bladder into the 
intestine. The fistula (cholecystostomy) closes readily. The dis- 
advantage of this operation is that the bile enters the intestine rather 
low for digestive purposes. This objection Avould be obviated if the 
communication were made between the gall-bladder and the duo- 
denum. This anastomosis may also be effected by the Murphy button 
or with Laplace forceps, etc. 

Cholecysto-duodenostomy with Murphy Button. — The formation 
of a fistulous opening between the gall-bladder and the duodenum, 
the upper part that adjoins the gall-bladder, for obstruction in the 
common duct. 

A vertical incision four to six inches long is made from the tip 
of the ninth costal cartilage, downward, along the outer border of 
the rectus muscle, in the linea semilunaris, or a vertical incision 
(Murphy) may be employed which commences above, just below the 
free border of the ribs and reaches downward for a distance of three 
or four inches; this incision is placed two inches to the right of and 
parallel with the middle line, penetrating between the fibers of the 
rectus muscle. 

Having cut through the abdominal wall, the gall-bladder is lo- 
cated and drawn into the wound and steadied there; then the duo- 
denum is secured and drawn into the wound. The duodenum is 
cleared of its contents by gentle stripping with the fingers, and a 
compressor applied to prevent the re-entrance of contents. Pads are 
arranged to protect the peritoneal cavity, and with a fine, straight 
needle a silk thread is introduced into the free surface of the gut in 
the fashion of a purse-string. This suture should include about one 
and one-half inches of the length of the gut and be in a straight line; 
it should be made with three punctures of the needle, each bite in- 
cluding about one-third inch and passing through the entire thick- 
ness of the wall of the gut; a second similar suture line is then made 
with the same thread in the reverse direction parallel with the first 



326 ABDOMEN AND BACK. 

and distant from this rather more than one-fourth inch, finally ter- 
minating alongside of where the needle first entered in commencing 
the suture (see Fig. 125). Corresponding to the point where the 
thread turns back to form the second half of the suture a little slack, 
or loop, should be left. With the ends of this running stitch the first 
loop of a surgeon's knot is taken. The gut is then incised between the 
two rows of suture for a distance corresponding to two-thirds the 
length of the diameter of the button to be used (No. 1 or 2 preferable), 
the incision being shorter than the suture line. The male half of the 
button, grasped with a thumb forceps, is then slipped sideways into the 
opening in the gut and the running string drawn tight about it and 
tied. This half of the button is thus fixed in the opening in the intes- 
tine and steadied until the female half has been fixed in the gall- 
bladder. 

If the gall-bladder is distended, one may first empty it with 
the aspirator. A similar running suture and incision are made in 
the gall-bladder at a convenient point near the fundus, and any 
stones that are present may be extracted. After this the female 
half of the button is introduced into the opening and the purse- 
string drawn tight and tied; the two halves of the button are then 
gently and steadily forced home. 

It might be wise in addition to make a fistula by incising the 
gall-bladder and sewing the edges of the opening thus made into the 
abdominal wound, as already described (cholecystostomy). As a 
rule, this is unnecessary, however, and the abdominal wound may 
be closed without drainage. 

The anastomosis between the gall-bladder and duodenum may 
also be accomplished with suture or with the Laplace forceps. 

OPERATIONS UPON THE GALL=DUCTS. 

Choledochotomy.- — Incision into the common bile-duct. 

Choledocho-lithectomy. — Incision into the common duct and 
removal of a stone. A stone may be found impacted in the common 
bile-duct and so fixed that it cannot be forced onward into the duo- 
denum. 

The common bile-duct lies fairly deep in the abdominal cavity 
between the layers of the lesser omentum, passing down behind the 
first part of the duodenum. If it contains a stone, it is usually found 
dilated, pouched, and its wall thickened. In order to reach the 



OPERATIONS UPON THE GALL-DUCTS. 327 

common duct it may be necessary to lengthen the usual gall-bladder 
incision, which passes downward from the tip of the ninth rib, and 
introduce deep abdominal retractors; the liver is drawn upward and 
the pylorus pulled downward out of the way. The hepatic artery 
lies to the left of the duct and the portal vein behind it. It may be 
necessary to separate bluntly with the fingers adhesions between the 
neighboring organs, working in between the pyloric end of the stom- 
ach and the under surface of the liver. 

After the common bile-duct has been recognized and the stone 
felt within it, pads are properly placed to isolate the field of opera- 
tion and protect the rest of the peritoneal cavity. The duct is then 
incised in its long diameter and the stone extracted whole or after 
crushing it, if it is very large. Escaping bile is caught and sponged 
away with gauze pads. After the duct has been sponged out and 
the adjoining parts disinfected with a pad moistened with alcohol, 
the opening may be closed with a single continuous suture of 
silk that includes the whole thickness of the edges of the incision. 
This will usually suffice, but it may be reinforced by an additional 
continuous layer of Lembert sutures of fine silk. If in doubt as to 
the security of the suture, one may introduce a plug of gauze through 
the incision in the abdomen down to the suture line in the duct for 
the purpose of drainage, and this may be removed after forty-eight 
hours. 

Choledocho-lithotripsy. — Crushing a stone within the common 
bile-duct without making an incision into the duct. 

This is not advisable unless the calculus is quite soft. It may 
be done with padded forceps. 

Duodenotomy for Removal of Stone Impacted in the Common 
Duct. — McBurney, and after him others, have removed stones of 
considerable size, which had become impacted low down in the com- 
mon duct, through an opening in the duodenum. This operation is 
especially adapted to the removal of stones impacted low down in 
the common duct near its duodenal end; they may present into the 
duodenum through the mouth of the duct. 

A vertical incision about five inches in length is made in the 
abdomen, commencing above at the tip of the right ninth costal 
cartilage. This incision corresponds to the outer margin of the 
rectus muscle. With the hand in the abdomen, the diagnosis may 
be confirmed by feeling the stone in the common duct. 

The greater omentum and the transverse colon are drawn up- 



328 ABDOMEN AND BACK. 

ward out of the way and the second part of the duodenum made 
accessible. Several gauze pads are arranged in the wound to shut 
off the rest of the abdomen from the field of operation, and deep 
retractors then introduced. 

A vertical incision one to one and one-half inches long is made 
in the middle of the descending part of the duodenum, any escaping 
intestinal contents being wiped away with gauze pads. Within the 
duodenum search is made for the orifice of the conjoined common 
and pancreatic ducts. This is found on the inner posterior wall of 
the second part of the duodenum; i.e., upon that part of the wall 
of the duodenum which is contiguous io the pancreas and about 
four inches distant from the pylorus. 

In the normal subject this orifice is marked by a papilla. If a 
stone is present in the common duct, the orifice may be found en- 
larged, with the stone presenting into it, or a probe may be carried 
through the orifice into the duct and the stone felt. A forceps may 
be introduced through the orifice into the duct, and the stone 
grasped and withdrawn. 

In order to extract the stone it may be necessary to dilate the 
mouth of the duct or to nick it with the knife or scissors. When the 
stone is withdrawn there follows a free flow of bile, which should be 
mopped away as fast as it escapes. 

The opening in the duodenum is closed with a row of silk Lem- 
bert sutures, which are introduced with a small, curved surgeon's 
needle in a holder. 

The incision in the abdomen is closed in the usual way. 

THE SPLEEN. 

The Surgical Anatomy of the Spleen. — The spleen is a solid 
organ located in the upper left part of the abdomen in close relation 
with the fundus of the stomach, to which it is attached by the gastro- 
splenic ligament (omentum), being suspended from the diaphragm 
by the phrenico-splenic ligament, its lower end resting upon the 
phrenico-colic ligament. The spleen is rather ellipsoidal, although 
its shape may vary. It measures usually about 12 cm. in its long 
diameter, 8 cm. in breadth, and 3 cm. in thickness. Its size may vary 
considerably. 

Its outer surface is smooth and rounded, and looks outward, 
upward, and backward toward the diaphragm, which separates it 



OPERATIONS UPON THE SPLEEN. 329 

from the pleura and the edge of the lung and the ninth, tenth, and 
eleventh ribs. Its inner surface consists of two areas: the anterior, 
the gastric surface, which is the broader, looks inward and forward, 
and lies close to the posterior surface of the fundus of the stomach; 
the posterior portion of the inner surface is in contact with the upper 
and outer part of the left kidney and the tail of the pancreas. Be- 
tween these two areas the inner surface presents the hilum, where 
the vessels and nerves pass in and out of the organ. 

The lower end of the spleen is in relation with the splenic flex- 
ure of the colon, and rests upon the phrenico-colic ligament, which 
supports it. The anterior border is rather sharp, and marked by a 
varying number of notches. The posterior border is rounded and 
thick. 

The splenic artery is a branch of the cceliac axis, and in its 
course to the hilum of the spleen runs along the upper border of 
the pancreas, lying above the splenic vein. 

The splenic vein is as large around as one's finger — twice as 
large as the splenic artery. It emerges in several branches from the 
hilum of the spleen, runs along the upper border of the pancreas, 
and after receiving the inferior mesenteric vein joins with the supe- 
rior mesenteric to form the portal vein. 

The spleen is almost completely invested by the peritoneum, 
which is intimately blended with the firm capsule proper of the 
organ. The spleen is fixed to the stomach by the gastro-splenic 
ligament (omentum) and to the diaphragm by the phrenico-splenic 
ligament, the suspensory ligament. Its lower end rests upon the 
phrenico-colic ligament. 

The gastro-splenic ligament, or omentum, is the fold of peri- 
toneum which is reflected from the fundus of the stomach over to the 
spleen, and between its layers the splenic vessels pass to and from the 
hilum of the spleen and the vasa brevia to the fundus of the stom- 
ach. The phrenico-splenic ligament, or suspensory ligament, is the 
fold of peritoneum which is reflected from the diaphragm to the 
spleen. 

OPERATIONS UPON THE SPLEEN. 

Splenotomy. — Incision of the spleen for the purpose of evac- 
uating an abscess or an hydatid cyst. 

The abdominal incision may depend upon the location of the 
tumor, if any is present. Usually the incision is made along the 



330 ABDOMEN AND BACK. 

outer edge of the left rectus, in the semilunar line from the lower 
border of the ribs downward. 

After having cut through the abdominal wall and parietal peri- 
toneum, if the spleen is found adherent to the parietal peritoneum, 
thus shutting off the general peritoneal cavity, one may incise at 
-once with the knife or Paquelin cautery and drain. If adhesions, 
shutting off the general peritoneal cavity, are not present, one may 
pack down to the surface of the spleen, leaving the abdominal incis- 
ion open in part, and only after adhesions which isolate the exposed 
splenic surface from the general peritoneal cavity have formed, after 
from two to five days, is the incision into the organ made. 

Splenectomy. — Extirpation of the spleen; for wandering spleen, 
wounds, rupture, prolapse, hemorrhage, or sarcoma. 

The incision must be liberal — from 10 to 15 cm. or longer. It 
may be placed in the middle line, commencing below the ensiform 
cartilage and passing downward and around the left side of the um- 
bilicus, or it may be conveniently placed along the outer border of 
the left rectus muscle in the linea semilunaris, or, if there is a tumor 
present, the incision may be placed to correspond. 

After the abdomen has been opened and the hemorrhage from 
the edges of the incision controlled, the hand is introduced into the 
abdomen and the spleen seized. If adhesions are present, these may 
be gently broken down with the fingers, or, if vascular, they may be 
tied double with catgut and cut. If the capsule of the spleen is not 
wounded, one should avoid injury to it, as this will save considerable 
hemorrhage. 

After the spleen has been freed it is drawn forward into the 
wound; it is fixed within the abdomen by the peritoneal folds, which 
connect it to the stomach and to the diaphragm. Its pedicle, which 
consists practically of the gastro-splenic omentum (including the 
splenic vessels), may be transfixed, through its middle, with a 
curved, blunt-pointed ligature carrier, provided with a long strand of 
strong silk or catgut. This ligature is then cut so as to make two, and 
tied, one including the upper half of the pedicle and the other the 
lower half. One should avoid including the tail of the pancreas in 
tying these ligatures. These ligatures should be tied tight and left 
long to serve as tractors in order to pull the stump of the pedicle 
into the wound for final inspection after the spleen has been cut 
away. If the phrenico-splenic ligament is not included in the liga- 
tures placed as indicated, this may now be ligated also and in a 



SURGICAL ANATOMY OF THE PANCREAS. 331 

similar manner. The pedicle is then cut through close to the spleen 
and the or-gan removed; the stump of the pedicle may be drawn 
.gently forward and an effort made to isolate and ligate the splenic 
•artery and vein, each separately. If the pedicle is properly secured 
there is little danger of hemorrhage. 

The wound in the abdomen is closed without drainage, first bring- 
ing the edges of the parietal peritoneum together with a continuous 
■catgut suture and then the other layers with interrupted silk-worm gut. 

THE PANCREAS. 

Surgical Anatomy of the Pancreas. — The pancreas is an elon- 
gated glandular organ six inches long, its breadth equal to about 
'one-fourth its length; it is about one-half inch in thickness from 
before backward. 

It is placed transversely in the upper back part of the abdom- 
linal cavity, lying behind the stomach across the body of the second 
lumbar vertebra. 

It consists of a head, body, and tail, the tail abutting against the 
■spleen. 

The head lies to the right of the vertebral column, resting upon 
the inferior vena cava, right crus of the diaphragm, and right renal 
vessels, and separated from the inner border of the right kidney by 
the second part of the duodenum. The common bile-duct is located 
'between the second part of the duodenum and the head of the 
( pancreas. 

The body of the pancreas lies opposite the second lumbar ver- 
tebra upon the crus (left) of the diaphragm, aorta, thoracic duct, etc. 
'To the left of the vertebral column it is in relation with the renal 
•vessels and left kidney. In front of the pancreas are the perito- 
neum, stomach, and transverse colon. 

The splenic artery and vein run along its upper border. Its 
"lower border is in relation with the third part of the duodenum, and 
passing forward between this part of the duodenum and the lower 
"border of the pancreas are the superior mesenteric artery and vein. 

The tail of the pancreas projects to the left as far as the spleen, 
to which it is connected by a fold of peritoneum, ligamentum pan- 
<creatico-lienale. 

The pancreas is covered by the peritoneum upon its anterior 
surface only. The transverse mesocolon passes backward, and upon 



332 ABDOMEN AND BACK. 

reaching the pancreas its layers separate; the upper layer passes- 
upward, covering the front surface of the pancreas, and lines the 
hack wall of the upper part of the abdomen (lesser sac). 

The duct of the pancreas courses through the organ from left to 
right, and opens into the second part of the duodenum, through an 
orifice which it has in common with the common bile-duct (see- 
"Conimon Bile-duct"). 



OPERATIONS UPON THE PANCREAS. 

Injuries of the abdomen involving the pancreas are, from their 
very nature, usually associated with such serious injuries to the 
neighboring organs that death results without special regard to the- 
pancreas. 

Parts of the pancreas may be tied off and excised. Abscess 
and tumor of the pancreas may cause obstruction of the intestine 
through pressure and adhesions. 

Abscess of the pancreas may be opened from in front through 
an incision in the anterior abdominal wall or it may be incised be- 
hind, extraperitoneally. If opened from in front, the contents of 
the sac may be evacuated with an aspirator in part and the envelop- 
ing wall of the abscess or cyst cavity then sewed to the edges of the 
abdominal wound, or, without evacuating, the sac may be fixed to the- 
edges of the incision in the abdomen and opened later after adhe- 
sions have formed. 

A retention cyst may be due to occlusion of the pancreatic duct 
by stone. Hydatid cysts may also be found in the pancreas. These 
are incised and drained through an incision in the middle line above 
the umbilicus; the cyst wall may be sewed to the edges of the incis- 
ion in the abdomen and opened later after adhesions have formed. 

• 

OPERATIONS UPON THE SPINAL COLUMN. 

Laminectomy. — Kesection of the laminge of the vertebras for the 
purpose of relieving compression of the cord due to traumatism or 
disease, depressed or displaced bone, extravasated blood, pus, tuber- 
culous products, Pott's disease, tumors, etc. 

The patient is placed prone upon the table with a shallow cush- 
ion under the ribs to give the back a slight curve. A long incision 
is made, in the middle line, through the soft parts down to the tips- 



OPERATIONS UPON THE SPINAL COLUMN. 333 

of the spinous processes. The middle of this incision should corre- 
spond to the probable location of the injury or disease. 

The soft parts — muscles, etc. — upon either side of the middle 
line are then freely separated with a periosteum elevator so as to 
expose the laminge of from three to five vertebras. 

Hemorrhage should be controlled;, oozing, by temporary press- 
ure of a pad, etc., and spurting points by clamps and ligatures. 
The spinous processes may be snipped off at their bases with the 
cutting bone forceps, the blades of which may be conveniently bent 
at an obtuse angle. 

While the soft parts, detached muscles, etc., are well retracted, 
the laminae, if not already fractured by a traumatism, are divided 
and then removed. 




Pig. 137.— Keen Bone Forceps. The end of the upper blade is fenestrated. 

The laminae that are to be resected should first be stripped 
bare of their periosteum and any remaining soft parts with the 
sharp-edged periosteum elevator, and then divided as close as pos- 
sible to the transverse processes, first on one side and then on the 
other. The laminae may be divided with a Hays saw, chisel, or 
rongeur forceps, or they may be gnawed through with a Keen for- 
ceps. The laminae which correspond to the middle of the wound 
are first resected and then those of the vertebras above and below. 
In this way the spinal canal is opened and in some cases of trauma- 
tism the compression will have been relieved. 

The dura mater proper is exposed by tearing with a blunt 
director through the loose connective tissue that overlies the dura. 
In thus exposing the dura mater, there may be considerable hemor- 
rhage from the venous plexus that is located in the posterior part of 



334 ABDOMEN AND BACK. 

the vertebral canal between the bony wall and the dura, but this is 
readily controlled by a few minutes' compression with a gauze pad. 
As already mentioned, after the spinal canal has been opened, the 
immediate cause of the symptoms may present itself and the con- 
dition may be remedied without opening the dura; for example, 
a dislocated vertebra, tuberculous granulation tissue, extradural 
tumor, etc. Prominent angular deformity of the anterior wall of 
the spinal canal due to fracture, dislocation, Pott's disease, should 
be corrected by reduction or by chiseling or gouging away the offend- 
ing process of bone; carious bone may be curetted and sequestra 
removed. 

In order to reach the anterior wall of the canal, it may be 
necessary to divide several nerve-trunks upon one side and lift the 
cord partly out of its bed. The severed nerves may be reunited 
afterward by suture. 

If the cause of the symptoms is not apparent the dura should 
be laid open. Before opening the dura, its color, degree of bulging, 
pulsation, etc., should be noted. The dura is picked up with a 
toothed forceps and a small opening made in the middle line, and 
through this opening the dura is incised upon a grooved director te 
any requisite length. When the dura is incised there is an escape 
of cerebro-spinal fluid and may be pus or blood. Adhesions 
between the dura mater and the arachnoid should be gently broken 
up. The edges of the dura may be then well retracted and the cord 
carefully examined. A bent probe may be used to investigate the 
sides and anterior aspect of the cord. 

In closing the wound the edges of the dura are brought together 
with interrupted catgut sutures placed about one-eighth inch apart,, 
and the edges of the muscles and skin approximated with inter- 
rupted sutures of silk-worm gut. For the purpose of drainage, a 
narrow strip of gauze is introduced into the bottom of the wound, its 
extremity emerging through the lower end of the skin incision. The 
wound usually heals by first intention. 

The parts should be immobilized by incasing the patient in, 
plaster or by the use of a proper extension apparatus. 

Lumbar Puncture. — J. Leonard Corning, of New York, in 1885 
reported experiments of injecting solutions of cocairi into the spinal 
canal through a puncture in the dorsal region for the purpose of in- 
ducing analgesia, etc. 

Quincke, of Kiel, in 1891, practiced lumbar puncture for the 



OPERATIONS UPON THE SPINAL COLUMN. 335. 

purpose of drawing off fluid to diminish intracranial pressure in 
eases of hydrocephalus. With this object in view he has drawn off 
as much as 100 c.c. in some cases. 

Bier in 1899 reported a number of cases which had heen oper- 
ated upon painlessly under the influence of cocain introduced into 
the subarachnoid space through a lumbar puncture. 

Tuffier in 1899 brought the matter prominently before the gen- 
eral profession, and since then the method has been practiced by 
many operators with varying degrees of satisfaction. 

The necessary instruments consist of a needle and a syringe. 
The needle should be about 10 cm. long, with a diameter of about 
1.1 mm. and with a canal, or bore, of 0.8 mm. The point of the- 
needle should be sharp, but the bevel should be short. The needle 
throughout may be made of steel or its body may be made of a flex- 
ible alloy and its extremity of steel. Such a needle would bend, 
without breaking (Bainbridge). The syringe should have a capacity 
of 30 minims, and be so constructed as to permit of proper ster- 
ilization; a glass barrel with a solid metal piston would answer. 
The nozzle of the syringe and the cap of the needle should form a 
smooth bevel joint, — not a screw thread, — in order to permit of 
their rapid adjustment and to eliminate the use of washers. 

The puncture may be made between the laminae of the fourth 
and fifth lumbar vertebrae or between the third and fourth or the 
fifth and first sacral. The puncture between the laminae of the 
fourth and fifth seems to be preferred by most surgeons. 

The needle is introduced just below and to the right of the tip of 
the spinous process of the fourth lumbar vertebra and is pushed in a 
direction forward and inward and slightly upward into the spinal, 
canal. 

The patient should be seated upon the side of the table with 
his back to the operator, his trunk bent forward, and his elbows 
resting upon the thighs. The tips of the spinous processes should 
form a straight line from above downward, deviating neither to the- 
right nor left. 

To locate the tip of the spinous process of the fourth lumbar 
vertebra, which is the guide in performing the operation, a line may 
be drawn across the back from the highest point of one iliac crest 
to a corresponding point upon the other. The tip of the spinous 
process of the fourth lumbar will be found to correspond to this line. 

The patient being bent forward causes the space between the- 



336 ABDOMEN AND BACK. 

lamina of the fourth and fifth lumbar vertebrae to become wider. 
The index finger of the left hand is placed upon the lower part of 
the tip of the spinous process of the fourth lumbar vertebra, and 
with the right hand the needle is introduced; it is entered just 
below and about 1 cm. to the right of this point (tip of the spine of 




Fig. 138. — Lumbar Puncture. Tip of spinous process of fourth lumbar 
vertebra corresponds to a line drawn across the back touching the highest 
point of each iliac crest. The needle is inserted just below and to right of 
the tip of the spinous process of the fourth lumbar vertebra. 

the fourth lumbar). The skin may be anaesthetized and a small in- 
cision made with the point of the knife in order to permit the 
easy passage of the needle through this structure, which is some- 
times pretty tough and difficult to penetrate. The needle is then 
pushed slowly and deliberately forward and inward through the 
soft parts, entering the spinal canal in the middle line between the 



OPERATIONS UPON THE SPINAL COLUMN. 337 

laminas of the fourth and fifth lumbar vertebras. After the needle 
has passed through the ligament between the laminae, ligamentum 
subflavum, and the dura mater into the subarachnoid space there 
is felt a sense of diminished resistance which is readily appreciated, 
especially by the experienced. The positive proof that the extrem- 
ity of the needle is in the subarachnoid space is the escape of the 
clear cerebro-spinal fluid, which flows from the end of the needle 
drop by drop. Not more than about ten drops of the cerebro-spinal 
fluid should be allowed to escape. The syringe containing the co- 
cam solution which is to be introduced is now adjusted to the needle 
and its contents slowly injected. From 15 to 20 minims of a 2-per- 
cent, solution is the quantity usually injected. 

Unless the escape of cerebro-spinal fluid occurs to indicate pos- 
itively that the end of the needle is in the subarachnoid space the 
injection should not be made. 

If the needle strikes an impediment, bone, on the way, it should 
be partly withdrawn and its direction changed so as to avoid the 
obstruction. One should not attempt to forcibly change the course 
of the needle by bending it without withdrawing it at least in part, 
as it may break off; a sudden movement or jerk on the part of the 
patient may also break the needle. With the flexible needle of 
Bainbridge this danger is eliminated. 



PART VI. 

THE RECTUM. 



Surgical Anatomy of the Rectum. — The rectum is the ter- 
mination of the alimentary canal and is contained within the true 
pelvis, the posterior wall of which is formed hy the sacrum and 
coccyx. 

The Sackum is an irregular, triangular-shaped bone formed 
hy the coalescence of five vertebras. With the coccyx it forms the 
lower part of the vertebral column and the posterior wall of the 
pelvis, where it is wedged in between the ossa innominata. 

It is flattened from before backward and curved upon itself, 
and is placed very obliquely, so that its anterior surface looks down- 
ward as well as forward. Above, it articulates with the fifth lumbar 
vertebra, forming a prominent angle which projects forward and 
forms the back part of the inlet into the true pelvis. Its lower end 
articulates with the base of the coccyx. The lateral borders of the 
sacrum are broad and irregular above, for articulation with the iliac 
bones and for the attachment of the posterior sacro-iliac ligaments. 
The lower part of the lateral border is thin, and gives attachment 
to the greater and lesser sacro-sciatic ligaments and to a portion of 
the gluteus maximus muscle. Its anterior surface is smooth, con- 
cave, looks downward and forward, and presents on either side, one 
below the other, the four anterior sacral foramina, through which 
openings the anterior sacral nerves escape from the sacral canal. 
The branches which emerge from the first, second, and third ante- 
rior sacral foramina are large and go to form the sacral plexus. 
Through the fourth anterior sacral foramina emerge nerves which 
are distributed to the rectum and the bladder. 

The posterior surface of the sacrum is convex, rough, and irreg- 
ular. In the middle line from above downward are three or four 
tubercles, which represent the corresponding spinous processes; 
usually the fourth and always the fifth are absent. External to the 
spinous processes, on either side of the middle line, are the four 
posterior sacral foramina, one below the other. These provide exit 
to the posterior sacral nerves, which are of no importance surgically. 
Between the posterior sacral foramina and the spinous processes the 
(338) 



SURGICAL ANATOMY OF THE RECTUM. 339 

bone is smooth, and corresponds to the laminae of the other verte- 
bra?, forming' the posterior wall of the sacral canal; the laminae of 
the fourth -usually and of the fifth always are absent, thus leav- 
ing the sacral canal open at its lower part. The margins of the 
laminae below, where the canal is open, are prominent, and are called 
the cornua. They articulate with the corresponding cornua of the 
coccyx. The posterior surface of the sacrum is covered by and gives 
attachment to the erector spina? muscle. 

The Coccyx is formed of four rudimentary vertebrae, and con- 
tains no spinal canal. Below, at the tip, the coccyx is pointed and 
gives attachment to the sphincter ani. Above, it presents a base 
with a prominent process on each side, the cornu. Its base artic- 
ulates with the lower end of the sacrum; its cornua articulate with 
those of the sacrum. Its lateral border gives attachment to the 
greater and lesser sacro-sciatic ligaments, to the coccygeus muscle, 
and low down near its tip to a few fibers of the levator ani muscle. 

The Rectum is continuous with the sigmoid flexure and ter- 
minates at the anus. It is about eight inches long, and is located in 
the back part of the true pelvis, surrounded by loose connective 
tissue. It includes that part of the large intestine which reaches 
from the left sacro-iliac synchondrosis to the anus. It is usually 
described as consisting of three parts. 

The first, or upper, part of the rectum extends from the left 
sacro-iliac synchondrosis toward the middle line, and, dipping into 
the pelvis in front of the sacrum, becomes continuous, opposite the 
second sacral vertebra, with the second, or middle part. This upper 
part of the rectum is narrower than the middle portion, and com- 
prises about one-half its entire length. It is provided with a com- 
plete investment of peritoneum, which, as mesorectum, is attached 
to the front of the sacrum, and thus serves to suspend the rectum in 
the pelvis. Dipping down into the pelvis, behind the rectum, be- 
tween the folds of the mesorectum, is the termination of the inferior 
mesenteric artery, which is known as the superior hemorrhoidal. 
This part of the rectum is in relation behind with the left sacro- 
iliac synchondrosis and the front of the sacrum. Interposed be- 
tween it and the sacrum are the pyriformis muscle, the sacral plexus 
of nerves, and the left internal iliac vessels and their branches. 
Anteriorly it is covered by the peritoneum, and is in relation with 
some coils of small intestine. 

The second, or middle, part of the rectum is more roomy than 



340 RECTUM. 

the first part, and is known as the ampulla; it corresponds to the 
front of the sacrum and coccyx, reaching from the second sacral 
vertebra to the tip of the coccyx. It is curved, with its concavity 
forward. This part of the rectum is covered only upon its anterior 
aspect by the peritoneum. In the male the peritoneum is reflected 
from this part of the rectum forward on to the bladder, which it 
reaches just above the seminal vesicles (see Fig. 177). In the female 
the peritoneum reaches lower down upon the front surface of the 
rectum than in the male, and is reflected from this organ forward 
upon the upper fourth of the posterior wall of the vagina and upon 
the uterus, forming the pouch of Douglas. This pouch often con- 
tains coils of small intestine and in the female may contain a dis- 
placed ovary. 

In the male the lower part of this middle portion of the rectum 
is in relation with the base, or trigone, of the bladder, the latter 
lying directly in front of the rectum. Between the base of the 
bladder and this part of the rectum are the seminal vesicles and the 
prostate gland, and here upon either side the ureters enter the 
bladder. In the female the lower portion of this part of the rectum 
is in relation with the posterior wall of the vagina. 

The third, or lowest, part of the rectum is that portion which 
extends from the tip of the coccyx to the anus, and is directed down- 
ward and backward; it has no relation whatever with the peritoneal 
cavity. In the male the perineum separates this third portion of 
the rectum from the urethral canal, and in the female from the 
lower part of the vagina. This part of the rectum is rather narrow, 
and corresponds to the location of the sphincters. Upon either side 
of this part of the rectum, the levator ani, which extends downward 
and inward from its origin along the lateral wall of the true pelvis, 
is attached. 

Besides the antero-posterior curves already described the rec- 
tum presents a lateral curve. The first part of the rectum in dipping 
into the pelvis from the left sacro-iliac synchondrosis reaches a 
little to the right of the middle line, while the lower part lies a 
little to the left of the middle line. 

The lumen of the rectum presents three half-moon folds, or 
plicae sigmoidea, with corresponding constrictions on its outer surface. 
These folds contain muscular fibers. The most marked and constant 
of these folds, plica transversalis recti, is located about half-way up 
upon the right wall, 5 to 6 cm. from the anal orifice and upon a 



SURGICAL ANATOMY OF THE RECTUM. 341 

level with Douglas's fold. The two others are upon the left wall, 
not so constant nor so prominent, and are placed one nearer and the 
other farther away from the anus than the one first mentioned. 
These folds may offer considerable obstruction to the passage on- 
ward of bougies, etc. 

In the lower part of the rectum the mucous membrane is 
thrown into longitudinal folds, — columns Morgagni, — so that upon 
section it would present a star-shaped appearance. About one inch 
above the anal opening the circular muscular fibers are increased 
in number and aggregated into a bundle — the sphincter internus; 
this is composed of unstriped muscular fibers. 

Surrounding the anal orifice and attached behind to the tip of 
the coccyx and in front to the midpoint of the perineum is the col- 
lection of muscular fibers which is known as the sphincter externus; 
this is formed of striped voluntary muscular fibers. 

The skin about the anus is thrown into folds, which radiate 
toward the anus, and often in the form of tags, etc., may become 
hypertrophied, inflamed, and itch — external, or itching, piles; or 
they may present cracks and fissures between them, at the edge of 
the anus — fissure in ano. 

The rectum is supplied by the superior hemorrhoidal artery, 
the termination of the inferior mesenteric. This vessel descends 
behind the rectum between the folds of the mesorectum, and op- 
posite the middle of the rectum divides into two branches; these 
distribute branches upon the sides of the rectum almost to the lower 
end. One may cut into the posterior wall of the rectum (strictures, 
etc.) for a distance of about three inches above the anal orifice with- 
out meeting this vessel. It bifurcates above this point. 

The middle hemorrhoidal branches are derived from the in- 
ternal iliac. The inferior hemorrhoidal, several on each side, are 
derived from the internal pudic (branch of the internal iliac) as it 
courses forward upon the inner aspect of the tuber ischii; they pass 
inward toward the anus and beneath the skin, and supply the in- 
tegument about the anus and the lower end of the rectum; these 
branches are divided when incisions are made in this region in the 
skin or into the ischio-rectal fossa?. The branches from these three 
sets of vessels anastomose freely with each other up and down the 
rectum. 

The veins of the rectum form a plexus of interanastomosiug 
branches upon the wall of the rectum; they terminate above in the 



342 RECTUM. 

superior hemorrhoidal, which empties into the inferior mesenteric, 
which in turn empties into the portal. The middle and inferior 
hemorrhoidal veins empty, the middle into the internal iliac and the 
inferior into the internal pudic. Thus the rectum is liberally sup- 
plied with arterial blood from both the inferior mesenteric and the 
internal iliac arteries, the branches from both freely anastomosing 
with each other; it is drained by venous branches which carry blood 
to both the portal and general circulation, these also freely inter- 
communicating with each other. 

The venous plexus situated in the lower part of the rectum, 
just above the anus and beneath the mucous membrane, is tortuous, 
and in certain conditions — disturbance of the portal circulation, 
habitual constipation, pressure of the gravid uterus, etc. — may be- 
come enlarged, pouched, and varicose, and give rise to the condition 
known as "bleeding piles," or internal hemorrhoids. Through the 
veins which drain the rectum infection may be carried to the liver 
— abscess of the liver, etc. 

The nerves that emerge from the first, second, and third ante- 
rior sacral foramina join with each other to form the sacral plexus. 
The rectum is supplied by nerves that emerge through the fourth 
anterior sacral foramen. Branches from these nerves are also dis- 
tributed to the bladder. 

OPERATIONS UPON THE RECTUM. 

Dilatation of the Sphincter. — This operation is practiced as a 
curative measure for fissure in ano and as a preliminary step in other 
operations upon the anus and rectum. 

The patient is placed in the lithotomy position. Under anaes- 
thesia two fingers or the thumb of each hand are introduced through 
the anus and well up into the rectum beyond the level of the internal 
sphincter, and a gradually increasing steady force is exerted in a 
lateral direction toward either tuber ischii until the sphincter is 
thoroughly relaxed. Considerable force may be employed, but it 
should be applied gradually, and not abruptly. 

Fistula in Ano. — This may be either complete or incomplete. 
The incomplete may be either blind external or blind internal. 

A complete fistula is a tract, or sinus, which opens internally 
into the rectum and externally upon the skin near the margin of 
the anus, and may allow the escape of gas and faeces from the bowel. 



OPERATIONS UPON THE RECTUM. 



343 



The opening into the rectum is usually single, but there may be 
several openings upon the skin. 

If the finger is introduced into the rectum and a probe passed 
into the fistula through the opening in the skin, its point may be 
felt beneath the rectal mucous membrane and may be guided 
through the inner orifice of the fistula into the rectum. This open- 
ing will be found a variable distance above the anal orifice and at 
times may be somewhat difficult to discover; it may be located above 
the internal sphincter or it may be just above the external sphincter 
close to the margin of the anus. 

An incomplete, or blind, fistula is one which presents an orifice 
at only one end. If it opens into the rectum, but not externally 




Fig. 139.— Complete Fist- 
ula in Ano. M, muscular 
layer of the rectum; M.M. 
mucous membrane layer of 
rectum ; SE, cross section 
of external sphincter; 81, 
cross section of internal 
sphincter. 




Fig. 140.— Blind Internal 
Fistula. Arrow indicates 
opening from rectum. For 
letters, see Fig. 139. 




Fig. 141.— Blind External 
Fistula. Arrow shows open- 
ing upon the skin. For 
letters, see Fig. 139. 



upon the skin, it is called a blind internal fistula; if it opens ex- 
ternally upon the skin, but not internally into the rectum, it is called 
a blind external fistula. 

Operation for Complete Fistula. — The anus is first thor- 
oughly stretched. The finger is then introduced 'into the rectum 
and a blunt-pointed grooved director passed into the fistula through 
the opening in the skin. The point of the director, which may be 
recognized by the finger in the rectum beneath the rectal mucous 
membrane, is guided into the bowel through the internal orifice of 
the fistula. It is important to find this opening. The end of the 
director is then brought out through the anus, — the director may 
be bent somewhat in order to do this, — and the bridge of tissue 
upon the director is divided with the knife, carried along the groove 



344 RECTUM. 

of the director; the fistula is thus laid open through its whole 
length into the rectum. If there is more than one external orifice 
upon the skin, the intervening tissue between the separate open- 
ings should be divided. Any secondary sinuses branching off 
from the main fistulous tract should also be laid open. As the in- 
ternal orifice of the fistula is above the external sphincter or may 
be above the internal sphincter, these muscles are naturally divided 
when the fistula is laid open. One may curette the tract of the sinus 
after it has been laid open, but too much force should not be used. 
The whole wound is finally packed with iodoform gauze. This pack- 
ing should not be too tight, but should reach well to the bottom of 
the wound in every direction. The bleeding is usually readily con- 
trolled by the packing. Any spurting vessels should be clamped and 
tied or the clamps may be left on until the first dressing. 

Operation for Incomplete Fistula is practically the same 
as the foregoing. If there is no opening into the rectum, — a blind 
external fistula, — the point of the director, which is passed into the 
fistula through the external orifice and which is felt beneath the 
rectal mucous membrane by the finger within the rectum, may be 
forced into the rectum, the sinus being thus converted into a com- 
plete fistula, and the parts then divided as already described. 

If there is no external opening, — a blind internal fistula, — we 
make one. The skin about the margin of the anus at the point 
corresponding to the blind external extremity of the fistulous tract 
is usually marked by redness, induration, etc. After the skin has 
been incised at this point, thus converting the sinus into a com- 
plete fistula, it is treated as above described. 

Hemorrhoids. External, or Itching, Piles present them- 
selves about the margin of the anal orifice outside, external to the 
sphincter; they consist of cutaneous tags, which may be snipped 
off with the scissors, the edges of the skin being then, if necessary, 
brought together with a single suture. Occasionally they contain 
a varicosed vein, which may be thrombosed; this may be laid open, 
the clot turned out, and the edges of the skin brought together with 
one or two catgut stitches. 

Frequently a fissure is located at the base of one of these ex- 
ternal tags, or piles, and it is therefore wise, in all these cases, to 
stretch the sphincter before removing the pile. 

Internal, or Bleeding, Piles. — These are located entirely 
within the anus, only appearing externally when the patient strains, 



OPEEATIONS UPON THE RECTUM. 



345 



or bears down. They may be caught in the grasp of the sphincter 
and become- strangulated. When the patient strains they may ap- 
pear as one or more fairly well defined bunches. Each mass consists 
of a bunch of dilated, pouched, varicose veins covered over by mu- 
cous membrane which may be normal in appearance or may be more 
or less ulcerated. 

Ligation and Excision. — The sphincter is first stretched and 
the rectum thoroughly irrigated. Each individual hemorrhoidal 
mass is then seized with a clamp, an ordinary artery forceps, and 
while it is pulled down the mucous membrane around its base is cut 
through by snipping with the blunt-pointed scissors. This incision 
should extend through the mucous membrane into the submucous 




Pig. 142. — Hemorrhoids. E, hemorrhoidal mass (internal piles), consist- 
ing of a bunch of tortuous veins covered by mucous membrane protrud.ng 
through the anal orifice; M, muscular layer of the rectum; M.M., mucous 
membrane layer of rectum; SE, cross section of external sphincter muscle; 
81, cross section of internal sphincter muscle; SM, submucous layer in which 
the veins ramify; *, loose connective tissue to either side of lower end of 
rectum in ischio-rectal fossa. 



connective tissue layer, but should not cut into the vessels that go 
to form the hemorrhoidal mass. After this the mucous membrane 
at the base of the pile may be peeled back with the finger-nail or 
the end of the scissors, and the base or pedicle of the pile surrounded 
with a strong catgut ligature; this should be tied very tight so that 
it cannot slip (No. 2 plain catgut). The pile is cut away close to 
the ligature and the ligature then cut short. Each hemorrhoidal 
mass that presents itself is treated in- like manner. They usually 
vary from two to four in number. The edges of each opening may 
be brought together over the stump of the pile with one or two cat- 
gut sutures, but this is probably, in most cases, unnecessary. 

After the operation has been completed strip gauze is packed 



346 RECTUM. 

into the rectum fairly tight. It should reach to a point above the 
level of the site of the operation. Instead of the strip gauze one 
may introduce a tampon in the shape of a square piece of gauze, the 
center of which is seized with a forceps and, pouch-like, pushed into 
the rectum beyond the site of the operation, and then into this gauze 
pouch strips of gauze or a wad of cotton may be packed. The pack- 
ing is to guard against hemorrhage from the slipping of a faulty 
ligature. One should bear in mind that the patient may suffer con- 
siderable hemorrhage into the bowel without any blood appearing 
externally; hence the importance of carefully tamponing. 

Clamp and Cautery. — After the anus has been stretched, etc., 
each pile is seized at its most prominent part with an artery forceps 
and drawn well down and a special clamp — pile clamp — applied to 
its base. The end of the clamp as it grasps the pile should be di- 
rected upward into the rectum; i.e., it should not grasp the hemor- 
rhoidal mass along a line parallel with the margin of the anus, as 
this would result in an annular scar, which is not desirable. The pile 
should be firmly caught between the blades of the clamp and secured 
by turning the screw down tight. The pile is then cut away with 
the scissors, rather close to, but not flush with, the surface of the 
blades of the clamp; a small part of the tissue should be left pro- 
truding beyond the surface of the clamp after the pile is cut away. 
The cautery at a red heat is now applied to the cut edge of the re- 
maining portion of the pile which protrudes beyond the surface of 
the blades of the clamp and this is slowly burned to a crisp down to 
the surface of the blades. The clamp is then removed. Each pile 
is treated in this manner. It is unnecessary to tampon the rectum. 

Excision of a Circumscribed Part of the Rectal Wall. — Before 
proceeding with this operation the bowel should be thoroughly emp- 
tied by a course of laxatives and thorough irrigation of the rectum. 
This preparatory treatment may well occupy several days to a week. 
The ease with which a limited portion of the rectal wall is excised 
depends upon the situation of the disease. 

If the Disease Involves the Lower Part of the Bowel 
situated at or near the anus, the operation is comparatively easy. 
The sphincter is first thoroughly stretched so that it is completely 
relaxed. The tumor or diseased area is seized with a vulsella forceps 
or the fingers and is drawn down and out through the anal orifice, 
and may then be excised, together with that part of the rectal wall 
which forms its base, with the scissors or a sharp knife. The hem- 



OPERATIONS UPON THE RECTUM. 347 

orrhage should be controlled, seizing or tying bleeding points as they 
are encountered, and the edges of the defect in the rectal wall 
brought together by suture step by step as the operation progresses. 
The wound in the rectal wall should be closed in a transverse direc- 
tion, because if sewed in a vertical line we may get a troublesome 
diminution of the caliber of the bowel, and this should be avoided in 
this narrow part. The stitches should be of catgut and interrupted, 
and should pass through the whole thickness of the wall of the bowel; 
the ends of the sutures should be left long to serve as tractors to 
facilitate the placing of the succeeding sutures. After the diseased 
part has been entirely removed additional sutures may be placed 
between those already introduced, but these should pass only through 
the mucous and submucous layers of the bowel, and are for the pur- 
pose of giving a more exact union of the edges of the mucous mem- 
hrane. 

If the Disease is Located Highee up, Beyond the Region 
of the Anus. — The field of operation must be made accessible to 
view and touch, if possible; but this is more difficult than is the case 
when the disease is located lower down, nearer the anus. 

The sphincter should be forcibly dilated, so that it is entirely 
Telaxed. The tumor or diseased area may then be seized with a 
vulsella forceps, and can often be pulled down and out through the 
anal orifice, under which circumstances the operation may be done 
practically as described for disease situated lower down, in the anal 
region. Usually, however, the stretching of the anal orifice does not 
suffice to allow access to the diseased area, and we may find it de- 
sirable to make an incision, from within the bowel, through the 
posterior wall of the rectum, including the anus, back to the coccyx. 
In this way we may make the field of operation accessible. Occa- 
sionally, however, even with this posterior incision, we are still un- 
able to bring the disease within easy reach, or we may wish to avoid 
this posterior incision. Under these circumstances the work must 
be done within the rectum with the aid of retractors. For this pur- 
pose, after the sphincter has been thoroughly dilated, two flat-bladed 
retractors are introduced well up into the rectum, one on either side, 
the mucous membrane that tends to prolapse between the blades of 
the retractors being held back with a pad upon a long sponge holder. 
One should thus be able to see the field of operation, and this is nec- 
essary in order to control the hemorrhage and to suture the edges 
■of the wound which is left in the rectal wall after the diseased por- 



348 RECTUM. 

tion has been extirpated. The retractors being in position, the dis- 
eased area is seized with a vulsella forceps and excised as already de- 
scribed. The portion of the rectum immediately above the anal 
region is roomy, and one may suture the woimd left in this part of 
the rectal wall, after the excision of the disease, in a vertical direc- 
tion without fear of constriction. The sutures should be of simple 
catgut, and the ends of each should be left long t-o serve as tractors 
to facilitate the introduction of the succeeding sutures; when the 
operation is complete they are all cut short. The stitches should be 
interrupted; every second stitch should pass through the whole 
thickness of the rectal wall and the intermediate ones through the 
mucous membrane and submucous layers only. 

If an accessory posterior incision has been made through the 
wall of the rectum back to the coccyx this part of the wall of the 
rectum should also be closed in a similar manner, but the back part 
of this posterior incision which opens through the skin behind the 
anus, between it and the coccyx, should be left partly open for the 
purpose of drainage. The drainage is arranged by inserting a strip 
of gauze, which is packed into the wound behind the rectum and well 
up as far as the site of the suture line. This packing should not be 
tight, but should surely reach to the bottom of the wound. 

Volkmann strongly advises drainage in all cases of excision of a 
portion of the wall of the rectum even where the wall of the rectum 
has not been split by the posterior incision. In those cases where the 
posterior incision through the rectal wall has been made one may 
drain as described above. If the posterior incision has not been 
made, one may make an incision in the skin near the margin of the 
anus, and through this penetrate sufficiently deep to reach the site 
of the suture line in the wall of the rectum when a strip of gauze is- 
introduced. 

Innocent Rectal Polypi. — After the anus has been dilated these 
may be seized with a clamp and twisted off the wall of the rectum 
with great ease or they may be amputated with the cautery. They 
usually do not bleed, but, if they do, the stump may be clamped and 
tied. 

Extirpation of the Rectum, Amputatio Recti (Volkmann).— 
Special pains should be taken to thoroughly empty the bowel, espe- 
cially above the point of constriction, with a course of laxatives and 
copious rectal irrigations. This preparatory treatment may require 
several days or a week. 



OPERATIONS UPON THE RECTUM. 349 

This operation is adapted to those cases in which the disease 
has already -involved the lower part of the rectum, including the 
anus — where the lower end of the bowel (sphincter) cannot be saved. 
The diseased portion, including the anal part, is amputated, and 
after this has been accomplished the upper part of the gut is pulled 
down and sutured to the margin of the skin about the anus. 

The patient is placed in the lithotomy position. A strip of gauze 
may first be introduced into the rectum to prevent leakage, etc., and 
then an incision which encircles the anus is made through the skin. 
This incision is carried down into the loose connective tissue about 
the lower end of the rectum, and, when this part of the bowel has 
been liberated all around, it is seized and drawn down. The levatores 
ani, which are inserted into the sides of the lower part of the rectum, 
are encountered. These are divided with the knife or scissors close 
to the wall of the rectum, and then, gradually working deeper and 
deeper, the rectum is thoroughly separated all around from the loose 
connective tissue which surrounds it, and pulled down more and more 
as this step of the operation progresses. The isolation of the rectum 
is accomplished chiefly by dissecting with the fingers or with blunt- 
pointed scissors. 

If more space is required, accessory incisions may be added. A 
posterior incision which reaches from the circular incision that sur- 
rounds the anus backward to the tip of the coccyx may be made. 
This incision may still farther be extended upward upon the back 
of the coccyx, and, if necessary, this bone may be enucleated, after 
the soft parts which cover it have been separated with a periosteum 
elevator. An anterior incision may also be added; this passes for- 
ward from the circular incision which surrounds the anus as far as 
the bulb of the urethra in the male and the posterior wall of the 
vagina in the female. This anterior incision not only provides more 
room, but allows the operator to keep himself informed of the loca- 
tion of the urethra and vagina, and may thus diminish the liability 
of injuring these parts. A catheter may be introduced into the 
bladder as an additional caution. These accessory incisions should 
not extend through the wall of the rectum, as it is advisable to am- 
putate the rectal tube intact, without cutting into it, in order to 
avoid soiling the wound with its contents. 

In liberating the rectum in the female we have to separate it 
upon its anterior aspect from the posterior wall of the vagina. The 
vagina may also be involved in the disease, and it will then be nee- 



350 RECTUM. 

essary to excise a part of its wall together with the rectum. In this 
case one should pause and close the opening made in the vaginal 
wall before proceeding further with the isolation of the rectum. In 
the male the rectum has to be separated anteriorly from the pros- 
tate and from the base of the bladder. 

As we continue deeper with the isolation of the rectum upon its 
anterior aspect, especially if the disease reaches pretty well up, we 
meet the fold of peritoneum which dips down in front of the rectum: 
in the female between the rectum and the vagina, in the male be- 
tween fne rectum and the bladder. The depth to which this peri- 
toneal fold is reflected upon the front wall of the rectum varies. 
Usually it descends to a level which is just above a point that can 
be reached by the finger introduced into the rectum through the 
anus; i.e., to a point 5 to 6 cm. above the anus. This fold may, 
however, extend down to a point within a short distance of the anus. 
If this fold of peritoneum is not involved in the disease, it may be 
simply stripped away from the front wall of the rectum without 
opening into it. At times, however, it is opened, either intentionally 
when it is diseased or accidentally. This is of no special significance, 
especially if the rectum itself has not been opened. The opening in 
the peritoneum may be closed at once. If small, its edges may be 
caught in an artery clamp and tied with a catgut ligature as one 
ties a bleeding vessel. If larger, its edge may be sewed to the peri- 
toneum that covers the front wall of the rectum with several catgut 
stitches, or it may be left unsutured and packed with gauze. In 
separating the rectum posteriorly there may be considerable hemor- 
rhage. All bleeding vessels should be clamped as they are cut. Dis- 
eased glands which lie behind the rectum may also be enucleated. 

After having separated the rectum beyond the upper limits of 
the disease the whole tube is pulled down and steadied with the 
vulsella forceps, which serve as tractors, grasping the bowel above 
the level of the disease, and then the lower diseased portion is am- 
putated, making a straight cut transversely across the bowel. After 
this has been done the edge of the bowel is sewed to the edges of 
the skin around the anus with alternating superficial and deep 
stitches of silk. Before the edge of the bowel is sewed to the margins 
of the skin about the anus it may be twisted on its long axis through 
a quarter of a circle. This may make the artificial anus somewhat 
more retentive (Gersuny). If twisted to a greater degree, it may re- 
sult in gangrene of the lower part of the bowel. 



OPERATIONS UPON THE RECTUM. 351 

If there have been made accessory posterior and anterior in- 
cisions, thes.e may be closed with several interrupted sutures; but 
this closure should not be complete, as there should be sufficient 
space between the sutures to allow free drainage from the parts about 
the rectum. 

Drainage is made with strips of gauze, which are packed loosely 
into the incision, both in front and behind the rectum. 

Resection of the Rectum in Continuity (Dieffenbach). — This op- 
eration may be performed for excision of cicatricial stricture (Hal- 
sted). 

This operation is applicable to those cases where the disease 
involves the wall of the rectum above the sphincter, the lower portion 
of the tube being free and healthy. 

The diseased portion of the rectum is resected in its continuity 
and the lower, end of the upper healthy segment then sutured to the 
upper end of the lower healthy anal part, which includes the sphinc- 
ter. The Kraske method of resecting the rectum is probably prefer- 
able to this method, especially if the parts outside the rectum are 
involved. 

After the sphincter has been thoroughly dilated the lower, 
healthy part of the rectum is divided into two lateral halves by two 
incisions, one of which, commencing within the rectum, passes back- 
ward, dividing the lower part of the rectum, including the anus, back 
to the coccyx. The second incision divides the front wall of the 
rectum, passing forward through the perineum as far as the bulb of 
the urethra in the male and the posterior wall of the vagina in the 
female. Both these incisions reach upward through the wall of the 
rectum to a point just below the lower limits of the disease. Two 
broad, blunt-pronged retractors are then introduced, one on either 
side, and the wound thus held wide open. 

In either lateral half of the rectum which has been thus split 
and just below the lower limits of the disease a transverse incision 
is now made. This incision passes through the entire thickness of 
the rectal wall, and separates the lower healthy part of the rectum 
from the upper diseased portion. Into these lateral incisions upon 
either side of the rectum the blunt-pronged retractors are intro- 
duced, and, after inserting a strip of gauze into the diseased portion 
to prevent its contents from soiling the wound, the lower cut edge of 
the upper diseased portion of the rectum is secured with vulsella 
forceps or silk tractor sutures, which at the same time close its lower 



352 RECTUM. 

end, and its isolation from the loose connective tissue by which it is 
surrounded upon all sides is commenced. Steadily drawing the dis- 
eased portion of the bowel more and more downward, its separation 
from the adjoining connective tissue is continued until it is entirely 
free and we are able to reach beyond the upper limits of the disease. 
This separation of the rectum is accomplished chiefly by blunt dis- 
section with the finger or the end of the blunt-pointed scissors, work- 
ing all the time fairly close to the rectal wall. Vessels are clamped 
as they are cut during the course of the operation. All spurting 
vessels should be ligated. 

In liberating the rectum anteriorly we may meet the fold of 
peritoneum that projects downward upon its front aspect. If this 
is not involved in the disease it can usually be peeled away from the 
wall of the rectum with the finger without opening into it. If dis- 
eased, or if it cannot be separated from the front wall of the rectum, 
we may cut through it close to the wall of the rectum, and, intro- 
ducing the ringer into the opening thus made, draw the rectum down. 
A pad may be temporarily introduced to prevent the prolapse of in- 
testine through the opening and to protect the peritoneal cavity. 
After the rectum has been drawn down for a sufficient distance the 
opening in the peritoneum may be closed by suturing its edge with 
catgut to the peritoneal layer that covers the anterior wall of the 
rectum, or it may be left unsutured and drained with a strip of gauze, 
which is left protruding through the wound in the perineum in front 
of the anus. The part of the rectum above the disease should not 
be separated from its surrounding parts any more than is absolutely 
necessary to permit its being drawn down to the edge of the lower 
segment of the bowel, and furthermore one should not work too close 
to the wall of the rectum in order not to damage the blood-supply to 
such a degree that the nutrition of the rectum might be seriously 
impaired. 

After the rectum has been liberated to a point beyond the upper 
limits of the disease we may then proceed to excise the diseased por- 
tion. Before doing this two tractors of silk are passed through the 
whole thickness of the wall of the rectum above the diseased area in 
order to steady it and to hold it after the diseased segment has been 
excised. When this has been accomplished the end of the healthy 
bowel is drawn down and sutured to the upper edge of the lower seg- 
ment (anal portion). This is done with fine silk sutures which 
alternately pass through the whole thickness of the bowel and 



OPERATIONS UPON THE RECTUM. 353 

through the mucous membrane only. The edges of the anterior and 
posterior incisions in the lower segment of the rectum, including the 
ends of the sphincter, are then brought together in a similar manner, 
and thus the continuity of the bowel is restored. The incision in the 
skin in front of the anus and that behind the anus are only partly 
closed, and a strip of gauze is packed to the bottom of each incision, 
as thorough drainage is imperative. Before commencing the suture 
of the bowel the parts may be irrigated and a soft rubber tube sur- 
rounded by gauze introduced well up into the upper part of the 
rectum beyond the proposed site of suture. This is to prevent soil- 
ing of the suture line, and also to allow the passage of gas and pos- 
sibly fluid fasces during the few days immediately following the 
operation. 

If the peritoneal pouch has been opened and packed the end 
of the gauze packing emerges through the incision in the perineum 
in front of the anus. 

Eesection and Amputation of Rectum through the Sacral Route 
(Kraske). — This method is well adapted for resectio recti for disease 
situated high up, but with the lower end of the rectum and the anus 
still healthy. It also furnishes the best route for amputatio recti in 
those cases where the anal portion is also involved. 

The bowel should be thoroughly emptied before the operation 
by a course of laxatives and repeated rectal irrigations. This prepar- 
atory treatment should be thorough, and may require one or two 
weeks. If the stricture of the rectum is so tight that the bowel 
above the site of the constriction cannot be emptied before the 
operation, one may do a preliminary colostomy. This should be done 
one or two weeks before the rectal operation. The transverse colon 
should be used for this purpose, because if the sigmoid or the de- 
scending colon is used there may be some difficulty in drawing down 
the bowel at the time of the rectal operation. 

For Resectio Recti (the anal portion being healthy). 

The operation is described in three steps: — 

1. Sacral "Vor operation": resection of the coccyx and part of 
the sacrum. 

2. Resection of the diseased portion of the bowel. 

3. Apposition of the ends of the bowel and treatment of the 
incision, etc. 

Sacral "Vor Operation." — The patient lies upon the left side 
(Hochenegg), with the belly inclined somewhat toward the table, the 



354 



RECTUM. 



lower limbs strongly flexed at the knees and hips, and supported thus 
by an assistant, or he may rest upon the abdomen with the lower 
limbs hanging over the end of the table. A slightly curved incision 
with the concavity toward the left is made. It begins above on a 
level with the middle of the sacrum and from two to three fingers' 
breadth (about two inches) to the left of the middle line; it is carried 
down to the middle of the upper border of the coccyx, and from this 
point it is continued down in the middle line upon the coccyx, ending 
at its tip. This incision divides the skin, subcutaneous fat, and super- 
ficial fascia, and exposes in the upper part of the wound the lower por- 
tion of the gluteus maximus muscle, the fibers of which run at right 
angles to the line of the incision. 




^^ 



Fig. 143.— Incision for Resection of the Rectum (Kraslie). 



That part of the gluteus maximus muscle which presents itself 
in the wound is incised and retracted, and there are then exposed, 
lying underneath, the attachment to the sacrum of the greater and 
lesser sacro-sciatic ligaments. These structures are also divided close 
to the edge of the sacrum. 

In dividing the gluteus maximus muscle branches of the gluteal 
artery are cut; these may be clamped and tied. Penetrating through 
the fat in the ischio-rectal fossa the coccygeus, which is attached to 
the border of the coccyx and sacrum, and the levator ani, which is 
attached to the coccyx near its tip, are exposed. These muscles are 
covered over by a thin fascia — the anal; they are divided with the 
knife close to the edge of the sacrum and coccyx. The soft parts are 



OPERATIONS UPON THE RECTUM. 



355 



then separated with a periosteum elevator from the posterior surface 
and right border of the coccyx, and while it is forced forward the 
sacro-coccygeal joint is opened from behind and the bone seized with 
the bone forceps and extirpated. The sphincter ani is cut away from 
the tip of the coccyx close to the bone. If the arteria sacra media, 
which descends in front of the sacrum, is injured, it may be clamped 
and tied. 

The levator ani and coccygeus muscles having been already di- 
vided, the operator now penetrates through the loose, fatty tissue 
which lies behind the rectum with the fingers so as to expose the 
posterior surface of the rectum. The rectum moves with respiration, 
and shows an impulse if the patient coughs or strains. 




Fig. 144. — Back Part of Ilium and Sacrum. Coccyx removed. A, A, usual 
line of section through sacrum; A, B, line cf section to remove all of lower 
part of sacrum; SI, lower end of sacro-iliac articulation; 1, 2, 3, 4, poste- 
rior sacral foramina. 



In many cases one may proceed at once with the second step of 
the operation: the extirpation of the diseased part of the rectum. 
At times, however, the space is not sufficiently ample, especially if 
the tumor is adherent and cannot be readily drawn down into the 
wound, or if the space between the border of the sacrum and the 
ascending ramus of the ischium (spatium sacro-ischiadicum, Kraske) 
is unusually narrow. In these cases in order to obtain more room 
it will be necessary to resect a portion of the sacrum. This may be 
done with the chisel, bone forceps, or saw. The soft parts are sepa- 
rated from the lower part of the left half of the posterior surface of 
the sacrum with the periosteum elevator, and that portion of the 



35G RECTUM. 

sacrum then resected which lies below a line that commences at the 
left border of the bone, just below the level of the third posterior 
sacral foramen; curving downward and inward toward the middle 
line and passing between the third and fourth posterior sacral fo- 
ramina, this line terminates at the middle of the lower border of the 
sacrum. If necessary to get still more room the line of section 
through the sacrum may be carried straight across the sacrum, just 
below the third posterior sacral foramina from the left to the right 
border of the bone, thus removing all of the sacrum below the third 
sacral foramina. The line of section through the sacrum may ter- 
minate at any point between those described above. The guide to 
the location of the third sacral foramen is the lower end of the sacro- 
iliac articulation. The lower end of the sacro-iliac articulation lies 
just above the lower margin of the third posterior sacral foramen. 

In making the resection of the sacrum it is unwise to go above 
the lower border of the third posterior sacral foramen on account 
of the important structures which emerge from the first, second, and 
third anterior sacral foramina (sacral plexus). Through the fourth 
anterior sacral foramen branches emerge which are distributed to 
the bladder and the rectum. If these branches are damaged some 
disturbance of the function of these organs will follow, but this is 
only temporary, control being rapidly regained. If the left half only 
of the lower portion of the sacrum is removed, this disturbance will 
be much less marked. 

Kesection of the Diseased Portion of the Bowel (the 
Anal Portion being Free from Disease). — With the fingers the 
diseased portion of the rectum is freed upon its posterior aspect 
and upon the sides from the loose fat and connective tissue that sur- 
round it. It is then likewise freed upon its anterior aspect. As we 
proceed with the isolation of the rectum, it may be necessary to cut 
some connective tissue bands with the scissors. All blood-vessels 
are clamped and tied as they are divided. During this step of the 
operation one should take care not to open into the rectum. When 
the diseased part of the rectum has been thus freed all around, a 
heavy silk ligature or strip of gauze is tied tightly around it, just 
below the lower limits of the disease, and through the anus, the lower 
part of the bowel, after being again thoroughly irrigated, is packed 
with gauze. The bowel is then divided transversely below the liga- 
ture with the scissors or knife, thus cutting the diseased portion away 
from the lower healthy (anal) segment of the bowel. The wound is 



OPERATIONS UPON THE RECTUM. 



357 



not soiled, because the diseased segment is shut off by the ligature 
which has been applied about it, and the lower anal segment, besides 
having been thoroughly sterilized, is packed with gauze. 




Fig. 145. — Resection of Rectum (Kraske). Rectum exposed and ligature 
passed around it just below the diseased portion (*) that is to be excised. 
A, line of incision through rectum. 




Fig. 146.— Resection of Rectum (Kraske). Diseased portion (*) cut away 
from the healthy lower, anal portion. A ligature has been placed about the 
rectum just above the diseased portion. B, line of section that separates the 
diseased portion from the healthy upper portion. 



The diseased portion of the gut is now seized, and, while trac- 
tion is made, it is gradually dissected out of its bed of fat and con- 
nective tissue, being thoroughly isolated upon all sides, so that it 



358 RECTUM. 

can be pulled down as far as necessary. This is accomplished largely 
by blunt dissection with the fingers. Just beyond the upper limits 
of the disease, when this becomes feasible, a second ligature is thrown 
around the rectum and tied, and thus the contents of the diseased seg- 
ment are imprisoned within that portion of the bowel which is to be 
resected. The rectum is now drawn out of the wound as far as possible, 
and placed upon sterile, gauze pads, and the diseased part cut away 
from the upper healthy portion of the bowel. Before this is done an 
assistant grasps and compresses the lower part of the upper healthy 
segment of the bowel, beyond the intended line of section, between the 
fingers, so that, when the diseased portion is cut away, the end of 
the bowel cannot escape, and also to prevent the escape of its con- 
tents. Should there, however, accidentally be any leakage, the wound 
is protected by the compress which has been arranged beneath the 
bowel before the section is made. 

The diseased portion having been thus excised, the proximal, or 
upper, segment of the bowel is immediately packed with gauze. 
Bleeding from the edge of the bowel may be checked by clamps and, 
if necessary, ligatures. 

In freeing the rectum upon its anterior aspect, one has to deal 
with the pouch of peritoneum which dips down upon its front wall, 
between it and the uterus and vagina in the female and the bladder 
in the male. One should recognize this pouch, as it may be necessary 
to open it, and, indeed, this is probably desirable in all cases, as it 
enables one to bring down the upper part of the bowel with more 
ease. After an opening has been made into this pouch, it may be 
enlarged by cutting with the scissors, upon either side, close to the 
wall of the rectum; through the opening thus made two fingers may 
be introduced and the bowel drawn down; after it has been pulled 
down sufficiently, one may sew the edge of the opening in the peri- 
toneum to the peritoneal layer that covers the bowel, upon either 
side, with several catgut sutures; the anterior portion, however, 
should be left open for drainage. Kraske advises against closing this 
opening in the peritoneal pouch even in part. He says that it should 
be loosely packed with strip gauze, surrounding the rectum in front, 
upon the sides, and behind, and reaching well up into the peritoneal 
cavity; the extremities of the gauze strips are allowed to emerge 
through the upper part of the skin incision, and should be marked 
for identification, so that they may be removed after five or six days. 
If this fold of peritoneum is involved in the disease, it may be oblit- 



OPERATIONS UPON THE RECTUM. 359 

erated by its opposing surfaces having become agglutinated, or the 
growth may have extended still farther so as to involve the uterus or 
bladder. This will add to the difficulty of the operation; but some 
surgeons do not consider it a counter-indication to the continuance 
of the operation, because, if necessary, the parts of these organs that 
are involved may be resected. 

If the peritoneal fold is not involved in the disease it can usually 
be peeled away from the front wall of the rectum with the finger, 
and in this case one may be able to complete the operation without 
opening into the peritoneal cavity. 

Diseased lymphatic nodes located behind the rectum, between 
it and the sacrum, should also be enucleated. There may be con- 
siderable bleeding caused by separating the rectum upon its posterior 
aspect and sides from branches of the superior hemorrhoidal; they 
should be clamped and ligated. 

Sutttke of the Ends of the Bowel. — The upper segment 
should be sutured to the lower (anal portion), and this union may be 
either complete or partial. 

Complete Union, the Ideal Method. — During the application of 
the sutures care should be taken that no fasces soil the suture line; 
a wad of gauze packed into the upper, central, segment of the bowel 
prevents this. There should be no tension on the upper segment — 
no tendency for it to draw up into the abdomen away from the anal 
portion. Proper isolation of the rectum and the opening of the peri- 
toneal pouch will obviate this. 

One may further fix the upper, central, segment of the bowel in 
the wound by several non-perforating sutures. For uniting the ends 
of the bowel fine silk sutures should be used. One may commence 
the suture in the middle line anteriorly and work around upon either 
side toward the back. The sutures should be introduced from the 
inner surface of the bowel and tied so that the knots are within the 
lumen of the bowel — they should be interrupted, and each should 
include the whole thickness of the wall of the gut, and be placed 
about 1 / 2 cm. distant from each other. Those sutures which are 
introduced last, and which join the two segments of the bowel poste- 
riorly, must be introduced from the outer surface, and do not pene- 
trate the whole thickness of the wall of the bowel, but simply include 
the outer coats. When these latter sutures are tied, the knots will 
be found upon the outer aspect of the bowel. Before closing this 
posterior portion of the wound Hochenegg advises the introduction 



5G0 



RECTUM. 



of a rubber tube surrounded by gauze from the anus well up into 
the bowel beyond the suture line. This prevents soiling of the suture 
line and also permits the passage of gas and fluid fasces during the 
few days immediately following the operation. A strip of gauze 
should be introduced into the wound, so as to lead from the suture 
line upon each side of the bowel out through the incision, for the 
purpose of providing drainage for this part, in the event of the 
sutures giving way. There is some danger in complete closure of 
the bowel. The sutures may tear through and allow the contents 
of the bowel to escape into the wound, especially if the obstruction 




Fig. 147. — Resection of Rectum (Kraxlce). Diseased port'on has been ex- 
cised and the healthy upper and lower portions have been partially united 
with interrupted sutures that penetrate the entire thickness of the wall of 
the bowel. 



offered by the disease had prevented the complete evacuation of tbe 
bowel before the operation. Masses of fasces come down and put a 
strain upon the stitches; if this accident occurs, the wound becomes 
infected, and we may get, as a result, a fatal peritonitis. 

Union most often fails in the posterior part of the suture line 
in the bowel; this is due probably to the damage done to the vessels 
which supply the bowel, in isolating it. Such a break of the suture 
line, however, usually does no harm if proper drainage of the wound 
has been provided, and usually the resulting faecal fistula closes spon- 
taneously, or may be closed by use of adhesive plaster strips in dress- 
ing or by a subsequent operation. 



OPERATIONS UPON THE RECTUM. 361 

Partial Union. — Instead of making a complete union we may 
join the ends of the segment of the bowel only anteriorly and upon 
the sides, leaving the posterior part of the wound open. The upper 
segment of the bowel is then fixed in the wound to prevent its re- 
traction. In this case we wait for the faecal fistula that results to 
close spontaneously, or else we accomplish this by a subsequent 
operation. 

However the ends of the bowel are treated, the wound should 
be well packed with iodoform gauze — not too tight, but reaching 
well down to the bottom of all parts of the wound. This packing is 
allowed to remain until it becomes loosened, — usually for about one 
week, — when the wound is again dressed and repacked. The incision 
in the skin is partly closed. 

For Amputatio Eecti (the Anal Portion of the Bowel being 
Involved in the Disease).— If it is desired to remove the lower 
(anal) portion of the bowel, together with the rest of the rectum, the 
skin incision should be prolonged from the tip of the coccyx, so as to 
encircle the anus. After the coccyx and part of the sacrum have been 
resected as described above, the whole length of the bowel, including 
the anal portion, is isolated, beginning below at the anus and work- 
ing upward. Upon either side near the anus the attachment of the 
levator ani is separated from the rectum with the scissors, working 
close to the wall of the rectum. At times, some difficulty in sepa- 
rating the rectum from the prostate or the vagina is experienced. 
A sound may be introduced into the bladder, and this part of the 
operation done in the perineal position. This change of position, 
however, is probably unnecessary. When the bowel has been isolated 
to a point beyond the upper limits of the disease, a ligature may be 
thrown around the rectum and the diseased portion cut away. The 
end of the proximal (upper) part of the bowel into which a strip of 
gauze has been packed is then sewed to the margins of the skin in 
the upper part of the incision close to the edge of the sacrum with 
interrupted silk sutures. The wound is then packed carefully about 
the bowel, above and below, and the skin incision partly closed with 
several silk sutures. The bowel may be twisted through a quarter of 
a circle before uniting it to the margin of the skin, with the idea of 
making the artificial anus more retentive. 



PART VII. 

HERNIA, SPERMATIC CORD, TESTES, ETC. 



The Surgical Anatomy of the Groin. — The groin may be divided 
into the inguinal and femoral regions. These parts may be consid- 
ered more or less together, on account of the close relationship that 
exists between them. 

The inguinal region corresponds to that part of the anterior 
abdominal wall which lies just above Poupart's ligament, and is 
traversed by a canal for the passage of the spermatic cord, in the 
male, and the round ligament, in the female. By invaginating the 
integument of the scrotum, the finger may be introduced into this 
canal. 

The femoral region corresponds to the upper anterior part of 
the thigh — the area immediately below Poupart's ligament. Under- 
neath Poupart's ligament, between it and the pubic bone, there is a 
space through which the ilio-psoas muscle and anterior crural nerve, 
and the femoral vessels, etc., pass from the abdomen into the thigh. 

The Supekficial Layer of the Superficial Fascia. — Be- 
neath the skin of the groin there is a loose connective tissue layer 
which contains a varying amount of fat, and in which the blood- 
vessels, nerves, lymphatic glands, etc., are located. This layer is 
called the superficial layer of the superficial fascia. In some subjects 
it is very thick. It is continuous with the general fatty layer of the 
body. In the male it is continued on to the penis, where it is thin 
and loose, forming one of the coats of that organ, and in the scrotum 
is continued into the dartos. From the scrotum it may be traced 
back into the perineum, where it is known as the superficial layer 
of the superficial perineal fascia. In the female it is continuous with 
the fatty layer of the labia majora, each one of which corresponds 
to one-half of the scrotum. The vessels which are found in this 
layer, and which may be cut in making the skin incisions in operating 
upon these parts, are the superficial epigastric, superficial circumflex 
iliac, and superficial external pudic arteries, together with their cor- 
responding veins. 
(362) 



SURGICAL ANATOMY OF THE GROIN, ETC. 363 

The Lymphatic Glands. — The lymphatic glands of this region 
are arranged in two groups: one group, the inguinal, is spread along 
Poupart's ligament, and drains the external genitals, scrotum, penis, 
etc.; the other group lies along the saphenous vein, and in and about 
the saphenous opening. These drain the lower limb. In extirpating 
the inguinal group of glands there is but little hemorrhage, but it 
is necessary to avoid the spermatic cord. In extirpating the lower, 
femoral, group there may be considerable hemorrhage, and one must 
avoid injury to the internal saphenous vein and to the femoral vein, 
especially when excising those glands that are lodged in the saphe- 
nous opening. 

The Deep Latek of the Superficial Fascia. — After the fatty 
layer has been removed from this region the deep layer of the super- 
ficial fascia is exposed. This fascia is thin, and covers the aponeu- 
rosis of the external oblique muscle in the inguinal region, and the 
fascia lata in the femoral region. It is adherent, in the middle line, 
to the linea alba, and, just below Poupart's ligament, to the fascia 
lata. In the male it forms one of the coverings of the penis, and is 
continued into the scrotum, where it forms the dartos, and backward 
beyond the scrotum, into the perineum, where it forms the deep layer 
of the superficial perineal fascia. In the perineum it is attached 
laterally to the rami of the pubes, and behind to the transverse peri- 
neal raphe. In the female this layer is continued into the labia 
majora. This fascia is firmly attached to the margins, or pillars, of 
the external ring, and is known as the external spermatic fascia. 
Entrance into the inguinal canal cannot be effected until this layer 
of fascia has been incised. From the margins of the ring this layer 
of fascia is continued downward, surrounding the cord and forming 
one of its investments, and below, as already mentioned, it is found 
in the scrotum as the dartos. Below Poupart's ligament, in the 
femoral region, this layer of fascia is firmly adherent to the margins 
of the saphenous opening in the fascia lata, where it is perforated 
by numerous vessels and lymphatics, and is called the cribriform 
fascia. From this point on, the inguinal and femoral regions may be 
studied separately. 

The Inguinal Kegion. — The inguinal region is the site of in- 
guinal hernia. After removing the deep layer of the superficial 
fascia from the inguinal region (including the margins of the exter- 
nal ring), we expose the aponeurosis of the external oblique and the 
external inguinal ring, into which the finger may be introduced, and 



36-i HERNIA, ETC. 

from which the spermatic cord (the round ligament in the female) 
is seen to emerge. 

The aponeurosis of the external oblique is the strong, smooth, 
glistening, bluish-white, fibrous expansion of the external oblique 
muscle. Its fibers have an oblique direction downward and inward 
toward the middle line, and join with each other in the linea alba. 
The lower fibers of the aponeurosis of the external oblique are col- 
lected into a thick bundle to form Poupart's ligament. 

Poupart's ligament is a strong, fibrous band which extends from 
the anterior superior spinous process of the ilium downward and 
inward to the spine of the pubes. Both these bony processes are 
easily made out; the latter, the spine of the pubes, is readily felt 
beneath the soft parts upon the upper border of the pubic bone, 
about three-fourths inch from the symphysis. The fibers of the 
aponeurosis of the external oblique immediately above Poupari's 
ligament pass inward toward the middle line, interlacing with those 
from the opposite side, and are attached to the symphysis, and there 
is thus left a triangular opening in the aponeurosis, which is called 
the external inguinal ring. This so-called ring is simply a split in 
the aponeurosis of the external oblique. Its outer, or lower, border, 
or pillar, is formed by Poupart's ligament; its inner, or upper, 
border, or pillar, is formed by those fibers of the aponeurosis of the 
external oblique which are attached in the middle line to the sym- 
physis, interlacing with those of the opposite side. The apex of this 
opening is directed upward and outward; its base corresponds to the 
crest, or upper surface, of the body of the pubic bone, that portion 
of the bone which is included between the pubic spine, to which Pou- 
part's ligament is attached, and the symplrysis. Various stay fibers 
are seen in the aponeurosis, passing from below upward and imward, 
near the apex of the external ring. These serve to bind the pillars 
of the ring firmly together, and are called the intercolumnar fibers. 

The spermatic cord (round ligament in the female) is seen 
emerging from the external ring, and a director may be introduced 
through the ring upward and outward into the inguinal canal. From 
the inner end of Poupart's ligament — i.e.., from the external pillar 
of the ring — a triangular sheet of fibers is given off, which is reflected 
upward and inward toward the middle line, and is continued into the 
anterior layer of the sheath of the rectus muscle. This is called the 
triangular ligament, or Colles's ligament, and is situated behind the 
inner end of the external ring, and in front of the conjoined tendon, 




Fig. 1J8.— Inguinal and "Femoral Regions. FP, edge of falciform process; FV, femoral vein; 
LA, lineaalba; LS, linea semilunaris; P, Poupart's ligament. The external inguinal ring is shown 
with the spermatic cord emerging. The fibers crossing the upper outer angle of the ring are known 
as the intercolumnar fibers. 



SURGICAL ANATOMY OF THE GROIN, ETC. 365 

and serves to strengthen this part. If we examine still further this 
inner end of Poupart's ligament, — i.e., the external pillar of the 
ring, — we find given off from its lower border, just before its attach- 
ment to the pubic spine, a strong triangular band, which is attached 
to the ilio-pectineal line, a prominent ridge upon the upper surface 
of the pubic bone, which is continued outward and backward from 
the pubic spine to the edge, or brim, of the true pelvis. This band 
in known as Gimbernat's ligament. It presents an outer, sharp, 
curved edge, and is of much anatomical interest in the study of 
femoral hernia. 

The Inguinal Canal. — The inguinal canal is an oblique slit in 
the abdominal wall, and, under ordinary circumstances, the greater 
the intra-abdominal pressure, the tighter its closure. It is from 4 
to 5 cm. (one and one-half inches) long, and lies above and parallel 
with Poupart's ligament. It terminates beneath the integument at 
the external inguinal ring, a triangular opening in the aponeurosis of 
the external oblique, which is located just above the crest of -the 
pubes. 

If we introduce a director through the external ring into the 
inguinal canal, and pass it in a direction upward and outward under- 
neath the aponeurosis of the external oblique, to a point about half 
an inch above the middle of Poupart's ligament, — i.e., the location of 
the internal ring, — and then split the aponeurosis upon this, we 
open up the inguinal canal and expose its contents: the spermatic 
cord, in the male; the round ligament, in the female. The cut edges 
of the aponeurosis should be seized with artery forceps and separated 
freely from the underlying parts with the finger. The spermatic 
cord is a structure as big around as the little finger. It is made up 
of the vas deferens, which is the efferent duct of the testicle; the 
artery of the vas deferens and the cremasteric artery, and their 
corresponding veins; the spermatic artery, and the pampiniform 
venous plexus. As these structures traverse the inguinal canal they 
are all bound together into a single rounded cord by a strong sheath 
of fascia, the infundibular process of the transversalis fascia. De- 
scending upon the cord are also seen the fibers of the cremaster 
muscle, which are derived from the lower edge of the internal oblique 
in the descent of the testes. The cord is also accompanied, in its 
course through the inguinal canal, by the genital branch of the 
genito-crural nerve and the inguinal branch of the ilio-inguinal 
nerve. 



366 HERNIA, ETC. 

After the inguinal canal has heen opened hy splitting the apo- 
neurosis of the external oblique, the free, curved, fleshy edge of the 
internal oblique is exposed to view. This muscle, the part seen here, 
arises from the outer half of Poupart's ligament. If the edge of this 
muscle is raised and drawn upward and outward for a short distance, 
or incised, we expose the transversalis muscle, which lies beneath the 
internal oblique. That portion of the transversalis which is thus 
exposed arises from the outer third of Poupart's ligament, and is 
covered by the internal oblique, and is not seen until the edge of 
this latter muscle has been drawn aside. 

Toward the outer part of the inguinal canal these two muscles, 
where they arise from Poupart's ligament, are situated for a short 
distance in front of the spermatic cord. They then arch inward 
above the cord, and, joining with each other, become tendinous, and, 
as the conjoined tendon, descend behind the cord, to be attached to 
the upper surface of the pubic bone; i.e., the crest and the pectin- 
eal line. The conjoined tendon, at its attachment to the pubic 
bone, is placed behind the external ring, and participates in the 
formation of the inner part of the posterior wall of the inguinal 
canal. It is important to note that that portion of the posterior 
wall of the inguinal canal which is included between the arching 
free edge of the internal oblique muscle above and Poupart's liga- 
ment below is formed by the transversalis fascia only. This fascia 
is a fibrous layer which lines the whole inner surface of the abdomen, 
including the posterior surface of the anterior abdominal wall, and 
it is here exposed to view where the muscle is deficient; i.e., between 
The edge of the internal oblique muscle above and Poupart's ligament 
below. Through the outer part of the posterior wall of the inguinal 
canal the several structures which go to make up the spermatic cord 
(round ligament in the female) pass forward into the inguinal 
canal, being provided with a strong, fibrous sheath, which is known 
as the infundibular process, by the fascia transversalis. This sheath 
incloses the several elements of which the cord is composed, and 
serves to bind them together into a single bundle, which traverses 
the inguinal canal and emerges at the external inguinal ring. The 
point at which the structures which constitute the spermatic cord 
pass forward into the inguinal canal is the site of the internal ingui- 
nal ring. The internal ring is an opening in the transversalis fascia, 
which is located half an inch above the middle of Poupart's liga- 
ment. The inguinal canal proper has no internal opening; i.e., it 




Fig. U9. — The Inguinal Canal. The canal has been laid open by splitting- the aponeurosis 
of the external oblique {A), which is grasped, with the artery forceps and drawn upward; 
CT, edge of the internal oblique muscle (conjoined tendon); E, dotted line represents the course 
of the deep epigastric artery, which is located beneath the transversalis fascia ; P, Poupart's 
ligament; TF, transversalis fascia, which forms the posterior wall of the inguinal canal; 
TL, triangular ligament, which is given off from the inner end of Poupart's. 



SURGICAL ANATOMY OF THE GROIN, ETC. 367 

does not communicate with the abdominal cavity. The internal in- 
guinal ring is really the mouth of the infundibular process, which 
is, in reality, the sheath that is provided to the spermatic cord from 
the transversalis fascia. 

The infundibular process is a glove-finger-like diverticulum, or 
pocket, which is derived from the fascia transversalis, being pro- 
longed downward into the bottom of the scrotal sac, and, through 
this, the testicle, drawing the vas deferens, etc., after it, descends 
in its journey from the abdomen into the scrotum. After the testis 
has reached the bottom of the scrotal sac, the upper part of this 
infundibular process — i.e., the part which corresponds to the cord 
— contracts and shrinks so closely around the structures which make 
up the cord, and which are contained within it, that its cavity is, 
in this way, entirely obliterated, and the shrunken infundibular 
process remains permanently as the proper fibrous sheath of the 
spermatic cord. 

The lower part, however, of the infundibular process remains 
permanently unchanged as one of the layers of the scrotum. 

The contraction of the infundibular process about the upper 
part of the cord may be incomplete, and there may be thus left a 
space within the sheath of the cord (infundibular process), into 
which the point of the finger may be insinuated from within the 
abdomen. The finger under these circumstances does not enter the 
inguinal canal, but passes through the internal ring into the proper 
sheath of the spermatic cord. The mouth of the infundibular proc- 
ess, the "internal ring/' may be best studied from within the ab- 
domen, after the peritoneum, which lines this portion of the ab- 
dominal wall, has been stripped away. 

Beneath the transversalis fascia — i.e., the posterior wall of the 
inguinal canal- — -is found the parietal layer of the peritoneum, with 
an intervening stratum of loose connective tissue, containing fat, be- 
tween it and the transversalis fascia; this is the so-called subperi- 
toneal connective tissue layer. The layer of peritoneum which lies 
behind, or rather beneath, the posterior wall of the inguinal canal 
presents no opening whatever. Within the abdomen, about the 
mouth of the infundibular process, "internal ring/' the parietal peri- 
toneum is adherent to the transversalis fascia, and may show a slight 
bulging into the neck of the infundibular process (sheath of the 
cord). * 

In the study of these parts the deep epigastric artery plays 



368 HERNIA, ETC. 

an important role. This artery may be seen, or its pulsation felt, 
as it lies beneath the transversalis fascia in the subperitoneal con- 
nective tissue between the transversalis fascia and the peritoneum. 
The artery is accompanied by one or two veins. It arises from the 
external iliac (femoral) just before this vessel passes out of the ab- 
domen under Poupart's ligament, and ascends obliquely upward and 
inward toward the umbilicus to reach the outer border of the rectus 
muscle. It passes across the posterior wall of the inguinal canal 
about the middle, and so divides it into two parts, an outer and an 
inner. The outer part of the posterior wall of the inguinal canal, 
that part which lies external to the deep epigastric artery, is formed 
by the transversalis fascia and the underlying peritoneum, and pre- 
sents the opening through which the structures that form the 
spermatic cord (round ligament) leave the abdomen, the internal 
ring. The presence of this orifice tends to weaken this outer part 
of the posterior wall of the inguinal canal. The inner portion of the 
posterior wall of the inguinal canal, that part which lies internal 
to the deep epigastric artery, is strengthened, in part, by several 
additional layers. From before backward this part of the posterior 
wall of the inguinal canal is formed of the triangular ligament, 
conjoined tendon, transversalis fascia, and parietal peritoneum. 
This inner portion of the posterior Wall of the inguinal canal is, 
therefore, much more secure than the outer part. 

A hernia that protrudes through the posterior wall of the in- 
guinal canal external to the deep epigastric — i.e., one which passes 
through the "internal ring" and works its way downward along the 
cord — is an oblique, or external, inguinal hernia, the common va- 
riety. In those cases in which the upper part, or neck, of the infun- 
dibular process has failed to become tightly contracted around the 
elements of the cord right up to the point at which they emerge 
from the abdomen, the predisposition to hernia is, without doubt, 
more pronounced, and this is especially the case if, in addition, the 
peritoneum, which is normally adherent about the site of the "in- 
ternal ring," shows a certain degree of bulging into the mouth of 
the patent infundibular process. 

A hernia that bulges forward through the posterior wall of the 
inguinal canal to the inner side of the deep epigastric artery is a 
direct, or internal, inguinal hernia. Such a hernia does not pass 
through the "internal ring" and descend along the course of the 
cord, within its sheath (infundibular process), but bulges directly 



1. At Sixth Month. 

Testis located in the back part of the abdominal cavity, covered by the peritoneum upon 

its anterior aspect. 
G, gubemaculum of Hunter. 

IP, infundibular process of the transversalis fascia. 
P, peritoneum lining the interior of abdominal cavity. 
S, scrotum. 
T, testis. 

TF, transversalis fascia. 
VD, vas deferens. 

2. At the Seventh Month. 

The testis has descended into the inguinal region toward the mouth of the infundibular 
process — future internal inguinal ring. 

3. At the Eighth Month. 

The testis has entered the infundibular process, carrying a process of the peritoneum 

with it. 
VP, vaginal process of peritoneum. 

4. At Ninth Month. 

Testis has reached the bottom of the infundibular process, — scrotum, — carrying process 
of peritoneum with it. 

5. Third to Fourth Week after Birth. 

Testis is located in the bottom of the infundibular process — scrotum. Obliteration 
has begun in the vaginal process. 

•J. Several Months after Birth. 

Normal adult condition. 

Testis rests in bottom of infundibular process — scrotum. The vaginal process which 
accompanied the testis in its descent has become obliterated except for that portion 
of its extent which corresponds to the testis. This remains as the tunica vaginalis 
testis. 

CT, cavity of tunica vaginalis testis. 






Fig. 150. — Descent of the Testis. 



SURGICAL ANATOMY OF THE GROIN, ETC. 369 

forward into the inguinal canal, to the inner side of the cord, and, 
besides the transversalis fascia, it may have to push the conjoined 
tendon, etc., before it, or else force its way between the fibers of 
this structure. These accessory structures form a strong barrier 
against the formation of a direct hernia, which variety is much 
less common than the oblique. 

In the female the inguinal canal and rings are all less well de- 
veloped than in the male. The round ligament is a thin structure, 
often difficult to find. After passing through the inguinal canal 
it emerges from the external ring, and is then lost in the connect- 
ive tissue about the external ring and in the labia majora. 

Inguinal hernia is comparatively infrequent in the female. 
When it occurs, it is analogous to that in the male, and may de- 
scend into the labia majora. 

The Descent of the Testes. — The testes (ovaries in the 
female) are developed within the abdomen from the Wolffian body, 
and in early foetal life they are situated in the back part of the 
abdominal cavity near the kidneys. They lie not within the peri- 
toneal cavity, but, like the kidney, behind the peritoneum, which 
is adherent to their front surface. From this position, the testes, 
during the later months of fcetal life, gradually descend. They de- 
scend behind the peritoneum and enter the infundibular process 
through its mouth, the "internal ring." Finally, during the last 
month of intra-uterine life they arrive at their normal destination, 
the bottom of the scrotal pouch. 

The ovaries descend in an analogous manner, but do not pass 
out of the abdominal cavity. 

Preparatory to the descent of the testis there is a pouch-like 
bulging of the lower part of the anterior abdominal wall in either 
inguinal region. A shallow pouch is thus formed on either side, 
which gradually becomes deeper, and finally the two join together 
in the middle line to form the scrotum. Each of these pouches is 
lined on its internal aspect by a sac-like prolongation from the trans- 
versalis fascia (infundibular process). These pouches are empty 
and ready to receive the testes. 

Eeaching from the testis as it lies within the abdomen, down- 
ward into the bottom of the infundibular process (scrotum), there 
is a musculo-fibrous structure, the gubernaculum of Hunter. It 
serves to lead the testis down into the scrotal sac. 

About the sixth month of foetal life the descent of the testis 



370 HERNIA, ETC. 

begins. The gubernaculum contracts and draws the testis downward 
toward the inguinal region. About the seventh month the testis 
arrives at the "internal ring," the wide-open mouth of the infun- 
dibular process. The testis then passes into the infundibular proc- 
ess, and, as it does so, it brings a bag-like process of the peritoneum, 
which is adherent to it, with it. This is called the vaginal process 
of the peritoneum. At the eighth month the testis is found in the 
infundibular pouch, together with the vaginal process of the peri- 
toneum, which accompanies it, and during the last month of intra- 
uterine life it is found at the bottom of the infundibular pouch, the 
scrotum, together with its vaginal peritoneal process. 

The testis may be interrupted in its journey into the scrotum 
at any point, and may remain stationary either in the abdomen or 
in the inguinal canal. This condition occasionally complicates con- 
genital hernia. After the testis has reached the bottom of the 
scrotal sac, the peritoneal pouch, which accompanied it, becomes, 
for that part of its extent which corresponds to the vas deferens, 
gradually obliterated. This process of obliteration commences in 
the middle of the tube and extends upward toward its abdominal 
orifice, and downward toward the testis, and, in the adult, this ob- 
literated portion of the vaginal process is represented only by a 
fibrous strand that is found, together with the vas deferens, etc., 
inclosed within the proper sheath of the cord. 

The lower part of the vaginal process, that portion which corre- 
sponds to the testis, remains permanently as the tunica vaginalis 
testis. At birth the canal of the vaginal process is still pervious, 
but very much shrunken, and becomes rapidly obliterated during 
the first few weeks of extra-uterine life. 

If the peritoneal pouch, the vaginal process, which accompanies 
the testis in its descent, remains pervious after birth throughout 
its whole extent, and, if its orifice is large enough to permit, a coil 
of intestine may enter; and we shall then have a congenital hernia. 

In the female the round ligament is the remains of the guber- 
naculum. The ovary descends like the testis, but does not leave the 
abdominal cavity; it remains in the pelvis. It does, however, ex- 
ceptionally leave the abdominal cavity, and may then be found in 
the labia majora. Congenital hernia is uncommon in the female. 

To recapitulate: There are two varieties of inguinal hernia, 
the direct, or internal, and the oblique, or external. The direct 
is always acquired, and is less common than the indirect. In this 




Fig. 151. — Normal Condition of Inguinal Region, Scrotum, etc. Testis in bottom 
of scrotum and vaginal process obliterated. CT, cavity of tunica vaginalis testis,; 
IN, intestine within abdominal cavity; IR, internal inguinal ring — the mouth of the 
original infundibular process of the transversalis fascia; P, peritoneum lining ab- 
dominal cavity ; TF, transversal is fascia ; I'D, vas deferens; VP, vaginal process of 
peritoneum — obliterated. 




Fig. 152. — Condition of Parts in Presence 
of a Congenital (Oblique Inguinal) Hernia. 
Note that the vaginal process is patent, unoblit- 
erated, and that a coil of intestine has entered. 



Fig. 153. — Condition of Parts in Presence 
of an Acquired Oblique Inguinal Hernia. Note 
that the vaginal process {VP) is obliterated and 
that a coil of intestine has pushed its way 
down into the original infundibular process 
(sheath of the spermatic cord) , driving a new 
process of peritoneum (S) before it. This 
peritoneal process forms the sac of the hernia. 



SURGICAL ANATOMY OF THE GROIN, ETC. 371 

variety a pouch of peritoneum (the hernial sac) — containing, for ex- 
ample, a loop of gut — simply forces that part of the posterior wall 
of the inguinal canal that lies to the inner side of the deep epigastric 
artery before it into the inguinal canal, and finally down through 
the external ring. 

The oblique variety may be either congenital or acquired. 

A congenital hernia is due to the absence of obliteration in the 
vaginal peritoneal process. If this process remains patent through- 
out its entire length, the hernial contents — for example, a coil of gut 
— simply drop into- the open pouch, and we have the usual form of 
congenital hernia. 

An acquired oblique hernia is produced after the vaginal process 
has become completely and permanently obliterated. In this variety 
the contents — for example, a coil of gut — must force an entirely new 
pouch of peritoneum, which constitutes the hernial sac, before it. 
This peritoneal sac enters the mouth of the infundibular process 
("internal ring") like a wedge, and works its way downward along the 
spermatic cord, inclosed within the sheath of the cord (infundibular 
process), which it simply distends; or else, after passing through the 
internal ring into the infundibular process (sheath of the cord), it 
causes a bulging of a circumscribed portion of the sheath of the cord, 
with the result that a pocket, or pouch, is formed, which is really 
an offshoot from the proper sheath of the cord, and in this pouch the 
hernial peritoneal sac is found, together with the hernial contents. 

An acquired hernia may traverse the whole length of the in- 
guinal canal and enter the scrotum, but its sac is always entirely 
distinct from the original vaginal peritoneal process, and its con- 
tents are never to be found in the same cavity with the testis, as 
is the case in the congenital variety. 

A partial obliteration of the vaginal process of the peritoneum 
may occur, and we may then have an infantile, or encysted, hernia. 
In this case the vaginal process is occluded at or near its mouth, 
but remains open throughout a part of its extent below. "We then 
have a hernia, with its own newly acquired peritoneal sac, like an 
ordinary acquired hernia, passing through the internal ring and 
downward within the sheath of the cord, pushing the closed, but 
unobliterated, vaginal peritoneal process in front of it. When such a 
hernia is operated upon, it looks as though there were two separate 
and distinct sacs. The. unobliterated vaginal process, within which 
the testis is found, is entered first, and then a second serous sac, the 



372 HERNIA, ETC. 

true hernial sac, is met with and incised, and within this the hernial 
contents are encountered. 

The Femoeal Kegion. — The area immediately helow Poupart's 
ligament is known as the femoral region. 

The Fascia Lata is exposed after the skin and superficial fascia 
have been removed. This is a strong, aponeurotic layer which en- 
tirely surrounds the muscles of the thigh, and serves to hind them 
into a compact mass. It is attached above, in front, to the whole 
length of Poupart's ligament, from the pubic spine to the anterior 
superior iliac spine; externally, to the crest of the ilium; behind, 
to the sacrum; and, internally, to the rami of the pubes and ischium. 

Just below Poupart's ligament, where the internal saphenous 
vein enters the femoral vein, the fascia lata presents an oval open- 
ing, the saphenous opening. It is only exposed after the cribriform 
fascia (that part of the deep layer of the superficial fascia which is 
attached to the margins of the saphenous opening) has been re- 
moved. The outer margin of the saphenous opening is sharp and 
curved, and was called by Allan Burns the falciform process. If 
the falciform process is traced upward and inward, it is found to be 
continuous with the inner end of Poupart's ligament and with Gim- 
bernat's ligament, some of its fibers being attached, with this latter 
ligament, to the pubic bone. Below, the falciform process is seen 
to curve inward underneath the internal saphenous vein, becoming 
continuous here with that part of the fascia lata which covers the 
pectineus muscle (pubic portion of the fascia lata). The free edge of 
the falciform process, and that part of the fascia lata external to 
it, cover the femoral sheath upon its anterior aspect, and are known 
as the "iliac portion" of the fascia lata. It is attached above to the 
whole length of Poupart's ligament, and externally is continuous 
with the sheath of the sartorius muscle. 

That portion of the fascia lata upon which the internal saphe- 
nous vein rests, and which covers the pectineus muscle, may be traced 
upward, under Poupart's ligament, as far as the ilio-pectineal line, to 
which it is attached, and from which the pectineus muscle arises. 
This is known as the "pubic portion" of the fascia lata. Beneath the 
femoral vessels this pubic portion of the fascia lata is continuous, 
externally, with the fascia which covers the ilio-psoas muscle (fascia 
iliaca). Above, under Poupart's ligament, this fascia, which covers 
the pectineus muscle, is thickened, and is known as the pubic liga- 
ment of Cooper. These two portions of the fascia lata, the iliac and 



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SURGICAL ANATOMY OF THE GROIN, ETC. 373 

pubic portions, are so arranged that a slit-like opening, the saphenous 
opening, exists between them, and through this the internal saphe- 
nous vein joins the femoral vein. 

The femoral vessels, inclosed within their sheath, are sand- 
wiched in between these two portions of the fascia lata, resting 
behind upon the fascia which covers the pectineus and ilio-psoas 
muscles, and covered in front by the iliac portion of the fascia lata. 
The two portions of the fascia lata, which have just been described, 
the iliac and pubic portions, are simply parts of one and the same 
fascia, and are seen to be directly continuous with each other, below 
the saphenous opening upon the front of the thigh. The pubic 
portion of the fascia lata, which corresponds to the pectineus muscle, 
is, as already said, continuous externally, behind the sheath of the 
femoral vessels, with the iliac fascia, which invests the ilio-psoas 
muscle. One should not confuse the names "iliac portion of the 
fascia lata" with "iliac fascia/' 

The Space Beneath Poupart's Ligament. — Through this space 
the ilio-psoas muscle and the anterior crural nerve and the femoral 
vessels pass out of the abdomen into the thigh. 

The ilio-psoas muscle, with the anterior crural nerve, occupies 
the outer part of the space. The ilio-psoas muscle is a thick mass 
of muscle which has its origin within the abdomen from the iliac 
fossa, bodies of the lumbar vertebras, etc. It consists of the psoas 
and iliacus muscles, and passes downward under Poupart's ligament 
into the thigh, where it is attached to the lesser trochanter of the 
femur and to the surface of the bone immediately below this. 

Within the abdomen the ilio-psoas muscle is covered by a thick 
fascia, the fascia iliaca, which is attached to the bodies of the lumbar 
vertebrae and to the sacrum, to the crest of the ilium, and to the 
brim of the pelvis. 

At Poupart's ligament, that part of the iliac fascia which covers 
the outer portion of the ilio-psoas muscle — i.e., corresponding to the 
outer third of Poupart's ligament — does not pass down into the 
thigh with the muscle, but is attached to Poupart's ligament, whence 
it is reflected upward, becoming continuous with the transversalis 
fascia, which lines the whole posterior surface of the anterior ab- 
dominal wall. Internal to this, however, corresponding to the inner 
portion of the ilio-psoas muscle, the fascia which covers the muscle 
passes with the muscle, underneath Poupart's ligament, down into the 
thigh, and in the upper part of the thigh is continuous, behind the 



374 HERNIA, ETC. 

sheath of the femoral vessels, with the fascia which covers the pectin- 
ens muscle (pubic portion of the fascia lata). Immediately beneath 
Poupart's ligament the iliac fascia is thickened, and this thickened 
portion is called the ilio-pectineal ligament. This is not an isolated 
ligamentous band of fibers, but simply a thickened portion of the 
fascia iliaca as it passes with the ilio-psoas muscle under Poupart's 
ligament into the thigh. It extends from the junction of the outer 
and middle thirds of Poupart's ligament downward and inward to 
the ilio-pectineal eminence, and serves thus to divide the space un- 
derneath Poupart's ligament into two portions: an outer, the ilio- 
psoas space, which contains the ilio-psoas muscle and the anterior 
crural nerve, and an inner and upper, the femoral space, through 
which the femoral vessels pass from the abdomen into the thigh. 

The femoral space is bounded above by Poupart's ligament; 
below, it is bounded externally by the ilio-pectineal ligament, and, 
internally, by the pubic ligament of Cooper. The so-called pubic 
ligament of Cooper is simply the thickened upper portion of the 
fascia which covers the pectineus muscle. Internally, the space is 
bounded by the sharp, curved edge of Gimbernat's ligament. The 
space is limited externally by the junction of Poupart's ligament 
and the ilio-pectineal ligament. 

The Femoral Sheath. — As the femoral vessels pass into the thigh, 
through the femoral space, they are inclosed in a special connective 
tissue sheath, and rest upon the ilio-psoas and pectineus muscles. 
The femoral sheath is a funnel-shaped connective tissue envelope 
which is prolonged downward from the margins of the femoral space, 
inclosing the vessels as they pass into the thigh. Corresponding to 
its commencement at Poupart's ligament, the femoral sheath is wide- 
mouthed, and attached all around to the margins of the femoral 
space. Above, it is attached to Poupart's ligament; below, to the 
ilio-pectineal ligament (thickened portion of the fascia covering the 
ilio-psoas muscle) and to the ligament of Cooper (thickened upper 
portion of the fascia that covers the pectineus muscle). Internally, 
it is attached to the edge of 'Gimbernat's ligament. The femoral 
sheath is continued but a short distance downward upon the femoral 
vessels, becoming narrow and contracted below, and closely applied 
to the walls of the vessels. 

The femoral sheath is divided into three compartments, which 
are entirely separate and distinct from each other, by connective 
tissue septa. In the outer compartment the femoral artery is 




Fig. 156.— The Pelvis and Ligaments of the Ilio-pubic Region. FS, femoral 
space; G, Gimbernat's ligament; IP, ilio-pectineal ligament; IPS, ilio-psoas space; 
P, Poupart's ligament ; PS, pubic spine. 




Fig. 157.— Femoral Space. Femoral vessels and sheath as they pass under Pou- 
part's ligament have been cleared away. Poupart's ligament lifted upon hook. The 
iliacus and psoas muscles are covered by their fascia, the fascia iliaca ; IP, ilio-pectineal 
ligament— thickened portion of the fascia that invests the ilio-psoas muscle ; LP, 
Poupart's ligament; P, pubic ligament of Cooper— upper thickened part of the fascia 
that covers the pectineus muscle. 




Fig. 158. — Deep Femoral Region — the Femoral Vessels, etc., Cut Across as they Emerge Under 
Poupart's Ligament. AC, anterior crural nerve ; CT, edge of the conjoined tendon; CR, crural ring; 
E, dotted line indicates the course of the deep epigastric artery ; FS, femoral sheath; G, Gimbernat's 
ligament; IP, ilio-pectineal ligament; P, Poupart's ligament; PE, pectineus muscle. This muscle 
rests upon the pubic bone and is covered by its fascia, — the pectineal fascia, — which is somewhat 
thickened immediately beneath Poupart's ligament, where it is known as the pubic ligament of Cooper. 
It will be noticed that the femoral sheath is divided into three compartments : the outer for the femoral 
artery ; the middle for the femoral vein ; the inner (CR) is the crural ring, the mouth of the crural 
canal. 



SURGICAL ANATOMY OF THE GROIN, ETC. 375 

lodged; in the middle, the femoral vein; the inner compartment 
contains a lymphatic gland and some loose connective tissue, and 
gives passage to the lymphatic vessels that enter the ahdomen from 
the lower extremity. This space, the inner, is called the crural canal. 
It is inclosed within the femoral sheath, and reaches from Gim- 
bernat's ligament downward upon the inner side of the femoral vein 
as far as the junction of the internal saphenous vein with the fem- 
oral, at which point the crural canal ceases to exist, because here the 
femoral sheath is applied directly to the wall of the femoral vein. 

The orifice of this crural space, or canal, is called the crural 
ring. The crural ring is bounded above by Poupart's ligament; be- 
low, by the pectineus muscle and the fascia which covers it, and 
which is here thickened and called the pubic ligament of Cooper; 
internally, by Gimbernat's ligament; and, externally, by the femoral 
vein. A femoral hernia, as it descends into the thigh, usually oc- 
cupies this crural canal, lying to the inner side of the femoral vein, 
and, just above the junction of the internal saphenous vein with 
the femoral vein, where the crural canal terminates, it presents in 
the saphenous opening. 

Study of the Inguinal and Femoral Regions from Within the 
Abdomen. — To examine these regions from within the abdomen, an 
incision is made through the anterior abdominal wall, on either side, 
passing from the umbilicus outward and then downward to a point 
just external to the anterior superior spine of the ilium. 

The Inguinal Kegion. — The bladder is seen to occupy the an- 
terior median portion of the true pelvis, and when moderately full 
reaches as high as the symphysis. It will be observed that the 
peritoneum which covers the bladder is continued forward from the 
fundus of that organ over on to the posterior surface of the ante- 
rior wall of the abdomen, where it presents several folds, or ridges, 
which are caused by the projection of prominent underlying struct- 
ures. These several ridges, or plicas, converge in a direction upward, 
toward the umbilicus, and include between them areas which are 
more or less depressed, and which are called fovea;. In the middle line, 
reaching from the summit of the bladder upward to the umbilicus, the 
peritoneum is raised in the shape of a fold by the superior ligament of 
the bladder, the remains of the fcetal urachus. External to this, pass- 
ing from either side of the body of the bladder upward to the um- 
bilicus, there is a fold, beneath which the obliterated hypogastric 
artery runs. Still more externally there is another fold, which corre- 



376 



HERX1A, ETC. 




Fig. 159. — The Inguinal and Femoral Regions from TVithin the Abdomen. Upon 
the right side the peritoneum has been stripped off, exposing the transversalis fascia. 
AC, anterior crural nerve imbedded in the ilio-psoas muscle; D, semilunar fold of 
Douglas — the lower edge of the posterior layer of the sheath of rectus; E, deep epi- 
gastric artery; E 1 , plica epigastriea (the deep epigastric vessels are situated beneath 
this fold); F.I., cut edge of the fascia iliaca, which invests the ilio-psoas muscle; GL, 
Gimbernat's ligament; H, obliterated hypogastric artery; I.E., fovea inguinalis externa; 
/./., fovea inguinalis interna; IL, sawn surface of the ilium; IPL, ilio-pectineal liga- 
ment, a thickened portion of the iliac fascia; P, cut edge of the peritoneum; P. I., 
cut edge of the ilio-psoas muscle; PL, Poupart's ligament; PM, pectineus muscle cov- 
ered by its fascia, which is here somewhat thickened and is known as the pubic liga- 
ment of Cooper; SY, fovea supravesical ; 7.L., plica vesico-umbilicalis lateralis (the 
obliterated hypogastric artery lies beneath this fold); T.M., plica vesico-umbilicalis 
media (the urachus, which reaches from the fundus of the bladder to the umbilicus, is 
situated beneath the fold). Above the middle of Poupart's ligament there is an opening 
in the transversalis fascia — internal inguinal ring — mouth of the infundibular process. 
The vas deferens and other component parts of the spermatic cord which pass in and 
out of the abdomen through this orifice have been cut short in the picture; this open- 
ing is the exit for indirect inguinal hernia. Beneath Poupart's ligament the femoral 
vessels, inclosed with their sheath, are seen. These structures have been divided close 
to Poupart's ligament. The femoral sheath occupies the space described as the femoral 
space, and is divided into three compartments — the outer for the artery and the middle 
for the vein; the orifice of the inner compartment is called the crural ring. 



SURGICAL ANATOMY OF THE GROIN, ETC. 377 

sponds to the course of trie deep epigastric artery; this is a large vessel 
given off from the external iliac (femoral) just before it passes out of 
the abdomen under Poupart's ligament, and is accompanied by one or 
two veins. The peritoneal folds are named, respectively, the plica 
vesico-umbilicalis media, corresponding to the urachus, in the middle 
line; the plica vesico-umbilicus lateralis, corresponding to the oblit- 
erated hypogastric artery; and the plica epigastrica, corresponding to 
the epigastric artery and vein. Between these peritoneal folds, or 
plica, are the fovea?, already mentioned, which are deeper in some 
subjects than in others. External to the plica epigastrica is the fovea 
inguinalis externa. Between the plica epigastrica and the plica vesico- 
umbilicalis lateralis is the fovea inguinalis interna. Between the plica 
vesico-umbilicalis lateralis and the plica vesico-umbilicalis media is 
the fovea supravesicalis. 

The Fovea Inguinalis Externa. — After the peritoneum has been 
stripped off from this area, and some loose connective tissue (sub- 
peritoneal connective tissue) which lies beneath it has been removed, 
we expose the transversalis fascia. This fascia presents the opening 
into the infundibular process, the so-called "internal ring," which is 
located about half an inch above the middle of Poupart's ligament. 
The vas deferens, spermatic artery, veins, etc., structures of which 
the spermatic cord is formed (in the female, the round ligament), 
pass into this opening. The lower, inner, margin of the internal 
ring presents a distinct, sharp, crescentic edge. A probe or the finger 
can be introduced into the internal ring, and may be insinuated for 
a greater or less distance into the sheath of the spermatic cord, 
infundibular process. About the internal ring the peritoneum is 
more or less plaited upon itself, and is adherent to the margins of 
the ring, and may bulge for a certain distance into it. A fibrous 
cord passes from the peritoneum into the internal ring, and may be 
traced downward into the infundibular process along with the other 
constituents of the spermatic cord. This fibrous band, or string, 
represents the shrunken, obliterated vaginal process of peritoneum 
which accompanies the testis in its descent into the scrotum. Di- 
rected upward and inward toward the umbilicus, and passing to the 
inner side of the internal ring is the deep epigastric artery, with its 
accompanying vein. If a hernial protrusion occurs in this location, 
the process of peritoneum which forms the sac of the hernia forces 
its way through the internal ring (to the outer side of the deep 
epigastric), and gradually works its way downward within the fibrous 



378 HERNIA, ETC. 

sheath of the cord, which is the remains of the original infun- 
dibular process, and we then have a typical external, or oblique, 
inguinal hernia. The coverings of this variety of hernia, from 
within outward, are, besides its peritoneal sac, the infundibular fascia 
(pouch derived from fascia transversalis), cremaster muscle and fascia, 
deep la} r er of the superficial fascia (spermatic fascia), superficial layer 
of the superficial fascia (fat), and the skin. 

If a congenital hernia is present, the vaginal peritoneal process 
which accompanied the testis in its descent into the scrotum is found 
patent, unobliterated, reaching downward through the internal ring 
and along the cord within its sheath (infundibular process) to the 
bottom of the scrotum. 

The coverings of a congenital hernia are the same as those given 
for the oblique, or external, acquired variety. The difference be- 
tween the oblique acquired and the congenital is that the acquired 
must form a peritoneal sac for itself, whereas the congenital finds 
its sac already present; i.e., the unobliterated vaginal peritoneal 
process. 

The Fovea Inguinalis Interna. — This is the space between the 
plica epigastrica and the plica vesico-umbilicalis lateralis. After the 
peritoneum has been stripped away from this part we expose the trans- 
versalis fascia. The fovea inguinalis interna is the part which is in- 
volved in direct inguinal hernia. It presents no opening. In the 
event of a direct inguinal hernia, a bulging or pouching of this part 
of the posterior wall of the inguinal canal occurs, and the hernial 
sac, composed of the parietal peritoneum, will have as coverings, 
from within outward, the various layers that form this part of the 
posterior wall of the inguinal canal, viz.: the fascia transversalis, 
the conjoined tendon, and the triangular ligament, and, in addition, 
the deep layer of the superficial fascia (spermatic fascia), the super- 
ficial layer of the superficial fascia (fat), and the skin. 

The neck of the sac in a direct inguinal hernia lies to the inner 
side of the deep epigastric vessels. 

Fovea Supravesical. — This is the space between the plica 
vesico-umbilicalis lateralis and media. Its floor is formed by the 
rectus muscle. This region is of but little surgical interest, and is 
not the site of hernial protrusions. 

The Femoral Kegion. — Below Poupart's ligament we have the 
femoral region. This part is, at times, depressed, and is called the 
fossa cruralis. If we dissect away the peritoneum, we expose Pou- 



SURGICAL ANATOMY OF THE GROIN, ETC. 379 

part's ligament, passing from the anterior superior spinous process 
of the ilium inward and downward, to be attached to the spine of 
the pubes. From the lower border of Poupart's ligament, just be- 
fore its attachment to the pubic spine, a triangular band of fibers, 
which is attached to the ilio-pectineal line, is given off. This is 
called Gimbernat's ligament. Its sharp outer edge may be readily 
felt. 

Between Poupart's ligament and the pubic bones there is a large 
space through which the ilio-psoas muscle and anterior crural nerve 
and the femoral vessels pass into the thigh. The ilio-psoas muscle 
arises within the abdomen and passes down toward Poupart's liga- 
ment in one mass, which is invested by a strong fascia, the iliac. 
At Poupart's ligament, the fascia that covers the outer part of the 
psoas-iliacus — i.e., that part of it which corresponds to the outer 
third of Poupart's ligament — is attached to Poupart's ligament, and 
is thence reflected upward, becoming continuous with the transver- 
salis fascia, which lines the whole posterior surface of the anterior 
abdominal wall. Internal to this, however, where the femoral ves- 
sels pass out under Poupart's ligament, the fascia is continued down- 
ward with the muscle underneath Poupart's ligament, into the 
thigh. As the femoral vessels descend into the thigh they rest upon 
the pectineus and ilio-psoas muscles, separated from them, however, 
by the fascia which covers them, the pectineal fascia 1 covering the 
pectineus muscle, and the iliac fascia covering the ilio-psoas muscle. 

The fascia iliaca, immediately beneath Poupart's ligament, is 
thickened, and is called the ilio-pectineal ligament. It reaches from 
the junction of the outer and middle thirds of Poupart's ligament to 
the ilio-pectineal eminence, and serves to divide the space under 
Poupart's ligament into two portions: that for the ilio-psoas muscle 
and anterior crural nerve, below and externally, and that through 
which the femoral vessels pass, above and internally. This latter 
is called the femoral space. The boundaries of the femoral space 
are, above, Poupart's ligament; below and externally, the ilio-pec- 
tineal ligament (thickened portion of the iliac fascia); below and 
internally, the pubic ligament of Cooper (the upper thickened por- 
tion of the fascia that covers the pectineus muscle); internally, the 
edge of Gimbernat's ligament. 

As the femoral vessels pass down through the femoral space 



1 That part of the pubic portion of the fascia lata that covers the pectineus muscle. 



380 HERNIA, ETC. 

into the thigh, they are inclosed in a connective tissue sheath, which 
is prolonged downward from the margins of this space. It is called 
the femoral sheath. The femoral sheath is divided into three com- 
partments by septa: the outer contains the artery; the middle one, 
the vein; the innermost, that between the vein and the edge of 
Gimbernat's ligament, is the so-called crural canal, and gives pas- 
sage to lymphatics from the thigh to the abdomen. The abdominal 
orifice of the crural canal is called the crural ring. 

In the event of a femoral hernia, a process of peritoneum (her- 
nial sac) is forced into the crural ring and down through the crural 
canal, appearing below in the upper part of the thigh in the saphe- 
nous opening. 

The coverings of a femoral hernia, from within outward, are, 
besides its peritoneal sac, the femoral sheath, the deep layer of the 
superficial fascia (the cribriform fascia), the superficial layer of the 
superficial fascia (fat), and the skin. 

The Obturator Foramen. — This foramen is located below the 
brim of the pelvis. It is an opening in the upper part of the ob- 
turator membrane, between its upper edge and the lower border of 
the ramus of the pubes. This foramen gives exit to the obturator 
artery, vein, and nerve, and is sometimes the site of a hernial protru- 
sion. The obturator artery usually arises from the external iliac, 
passes forward just below the brim of the pelvis, and out through 
the obturator foramen into the thigh. Occasionally, however, this 
artery is derived from the deep epigastric, close to the origin of this 
vessel from the external iliac (femoral), and in its course to reach 
the obturator foramen it is found in close proximity to the margin 
of the crural ring. After its origin from the deep epigastric, in its 
course to reach the obturator foramen, it either passes around the 
upper and inner margins of the crural ring or else it descends close 
to the inner wall of the femoral vein and behind the outer border of 
the crural ring. 

OPERATIONS FOR HERNIA. 

Herniotomy. — Incision of the coverings of a hernia, opening 
into the sac, and the division of constricting rings or bands constitute 
the operation of herniotomy. The operation is done for the purpose 
of liberating a strangulated hernia. The constriction may be caused 
by bands in the body of the sac or by the neck of the sac itself, but in 



OPERATIONS FOR HERNIA. 



381 



most cases it is probably caused by the firm, unyielding ring by which 
the neck of the sac is encircled. 

At one of the usual sites of a hernial protrusion there is found a 
tense, elastic tumor. The incision is placed over the most prominent 
part of the tumor, cutting carefully through the skin and the deeper 
layers until the sac proper is reached. The sac may then be pinched 
up with two forceps and incised between them, when there is an 
escape of serous fluid, and the contents of the sac are exposed. 




Fig. 160. — Irregular Origin of Obturator Artery. In its course into the 
pelvis it lies close to the inner side of the femoral vein. A, femoral artery; 
E, deep epigastric artery; GL, Gimbernat's ligament; IR, internal inguinal 
ring; O, obturator artery; PL, Poupart's ligament; V, femoral vein. The 
space between the femoral vein and Gimbernat's ligament is known as the 
crural ring, and through this femoral hernia leaves the abdomen. 



The contents vary; they may consist of intestine, large or small; 
of omentum, or of both; and occasionally there may be other organs, 
such as the bladder, ovary, etc. After the sac has been freely 
opened, its contents should be examined. Any constricting bands in 
the body of the sac should be divided, and an attempt then made to 
pull the gut down so as to ease it at the point of constriction; but 
in this effort much force should not be used. An effort is made to 



382 



HERNIA, ETC. 



insert the finger into the neck of the sac, and, if this is successful, a 
probe-pointed, curved knife may be introduced upon the finger and 
the constricting ring incised. If one is unable to insert the finger 
into the neck of the sac, a director may be carried through, and upon 
this the ring may be divided. In freeing the constriction, a suc- 
cession of nicks should be made rather than a single free cut, and 
these may be repeated until the parts are liberated. 

For the relief of an indirect inguinal hernia the incision in the 




Fig. 161.— Irregular Origin of Obturator Artery. In Its course into the 
pelvis it curves around the upper and inner edge of the crural ring. Letters 
same as 160. 



constricting ring should be directed upward. For a direct inguinal 
hernia the incision should be directed upward and inward, toward 
the umbilicus. For a femoral hernia the incision should be directed 
inward toward Gimbernat's ligament and somewhat upward. 

For practical purposes, if in doubt as to the exact variety of the 
hernia, the direction of the liberating incision for both varieties of 
inguinal and for femoral hernia may be upward and inward, toward 
the umbilicus. By cutting in this direction, upward and inward, 



OPERATIONS FOR HERNIA. 383 

toward the umbilicus, we work in a line which is parallel with the 
course of' the deep epigastric vessels, and the danger of wounding 
these is thus obviated. 

Occasionally the obturator artery, as described above, is given 
off from the deep epigastric, and in its course to reach the obturator 
foramen this vessel would then have a close relationship to the neck 
of the sac of a femoral hernia. From its origin, at the deep epigas- 
tric, the obturator artery either descends close to the inner wall of 
the femoral vein, and therefore behind the outer margin of the crural 
ring, and would thus lie to the outer side of the neck of a femoral her- 
nial sac, or else it curves inward and then downward, behind the up- 
per and inner borders of the crural ring, and would then lie above and 
to the inner side of a femoral hernial sac. In the first case, this ves- 
sel would be out of the way in making the liberating incisions at 
the crural ring, whereas in the second instance the vessel would be 
jeoparded in making the liberating incisions if caution were not exer- 
cised. 

If the constriction at the neck of the sac is relieved by a 
succession of nicks, rather than by a single free incision, we will 
be very much less liable to divide an abnormally placed obturator 
artery. After the contents of the sac have been liberated they may 
be drawn down for examination, especially at the points of constric- 
tion. If omentum is present, this may be ligated and amputated. 
As to the treatment of the gut, careful deliberation must be used. 
If the gut is healthy, it may be returned at once into the abdomen. 
If doubtful, one may wait for a short time to note if it tends to clear 
up. After the gut has been reduced the finger should be introduced 
through the neck of the sac in order to make certain that there are 
no adhesions about the neck which might continue to constrict the 
gut. 

If the gut is gangrenous, or too doubtful to return into the ab- 
domen, the incision in the abdomen at the neck of the sac should 
be enlarged and the gut drawn down and resected; or else the gut 
may be allowed to remain without disturbing the adhesions about the 
neck of the sac, and an artificial anus made by incising the strangu- 
lated coil of gut, if it has not already sloughed through. The wound, 
under these circumstances, should be left open and packed. 

Radical Operation for Inguinal Hernia (Bassini Method). For 
an Oblique Acquired Hernia. — An incision is made through the 
skin, commencing at a point half an inch above and somewhat ex- 



384 



HERNIA, ETC. 



fcernal to the middle of Poupart's ligament, carrying it downward 
and inward as far as the spine of the pubes; or it may be prolonged 
for a short distance downward upon the scrotum, if necessary. This 
incision penetrates into the subcutaneous fatty layer. In its upper 
part the incision should be deepened until the fibers of the aponeu- 
rosis of the external oblique are plainly visible. The fingers are 
then introduced into this upper, deeper part of the incision, and it 





V 



Fig. 162.— Operation for Inguinal Hernia. Incision penetrates through the 
skin and fat, exposing the aponeurosis of the external oblique. 80, spermatic 
cord emerging from the external inguinal ring. 



is torn open down to its lower end. After this has been done the 
aponeurosis of the external oblique and the pillars of the external 
ring, through which the cord emerges, are exposed. 

Any bleeding points are caught in artery forceps; but it is not 
necessary to ligate them immediately, as the hemorrhage usually 
ceases after a few minutes' compression. 

A blunt director is now passed into the external ring, and car- 



OPERATIONS FOR HERNIA. 385 

ried upward and outward beneath the aponeurosis of the external 
oblique to a point beyond the middle of Poupart's ligament, the 
location of the "internal ring/' and upon this the aponeurosis is 
divided. Some obstruction to the introduction of the director 
through the external ring will be experienced if the deep layer of the 
superficial fascia, which is attached to the margins of the ring, has 
not been incised. 

The edges of the split aponeurosis of the external oblique are 
seized with artery forceps and separated with the finger from the 
structures which lie immediately beneath. The inguinal canal is 
thus laid open, and the spermatic cord, together with the hernial 
sac, is exposed. The lower, free fleshy edge of the internal oblique 
muscle is seen arching inward over the cord and hernial sac. It is 
blended with the tendon of the transversalis muscle to form the con- 
joined tendon, which descends behind the cord, and which can be felt 
as a strong, resistant band attached to the crest of the pubic bone. 

The spermatic cord, together with the hernial sac, which is 
usually found empty, unless its contents are irreducible or the pa- 
tient is straining, is now hooked up, upon the finger, and we proceed 
to separate the sac from the cord. At times it is difficult to recog- 
nize the sac. It is formed of the pouch of peritoneum, with some 
loose connective tissue (subperitoneal connective tissue layer) and 
is situated within the proper sheath of the spermatic cord (infundib- 
ular process of transversalis fascia), which must be incised or torn in 
order to expose it (the sac). The sac has a peculiar, white, aponeurotic 
appearance, and may be very thin or of moderate thickness. The isola- 
tion of the sac from the cord is accomplished chiefly by tearing and 
separating with the fingers, occasionally cutting a resisting band with 
the scissors. At times the sac is very intimately united with the 
cord, and much patience is required to separate it. One should 
recognize the vas deferens, and constantly be familiar with its loca- 
tion, in order to avoid injuring it. In isolating the sac, one may 
have considerable hemorrhage from the pampiniform plexus of veins, 
which runs along with the vas deferens, etc., in the cord. It usually 
ceases, however, after clamps have been applied to the bleeding 
points for a few minutes. If one of the arterial branches which run 
in the cord is torn, it will be necessary to apply a ligature. One may 
begin the separation of the sac from the cord above at the neck of 
the sac and work downward, toward its lower part (fundus), or com- 
mence at the fundus and work upward, toward the neck. The op- 



386 HERNIA, ETC. 

erator may assist himself in separating the sac from the cord by in- 
cising it in order to introduce the finger into it, and thus inform 
himself of its limits. 

After the sac has been completely separated from the cord, espe- 
cially above, about the neck at the location of the "internal ring/' 
it is raised, and (if not already incised) is seized by an assistant with 
the fingers of both hands, or with two artery forceps, and incised 
between them with the knife. In incising the sac, especially if the 
contents are adherent, or if operating upon a strangulated hernia 
when there is much distension, one should use caution not to wound 
the parts within. After the sac has been opened the contents may 
be reduced, and, if there are no adhesions, this is very readily done. 
If there is a considerable amount of prolapsed omentum in the sac, 
this may be tied off with stout catgut and amputated in preference 
to returning it to the abdomen. If the contents are adherent to the 
sac, they must be gently separated before they can be reduced. This 
can usually be accomplished with the finger, taking care to avoid 
tearing the gut, and ligating any points that bleed freely. Dense 
adhesion bands may be first tied double and then divided between 
the ligatures. If omentum is adherent within the sac, it may be 
ligated and amputated. The contents should be free, especially at 
the neck of the sac, in order that they may be properly reduced. 

After the sac has been emptied we may tie it off. The finger is 
introduced into the sac and carried well within its mouth, and a catgut 
ligature (No. 2) thrown around its neck. As this ligature is drawn 
tight and tied, one should feel it slip over the end of the finger, 
which is within the mouth of the sac. It should be applied about 
the neck of the sac as high up as possible, in order to avoid leaving 
any pouched portion of the sac to invite the recurrence of the her- 
nia. The ligature is left long for use as a tractor, and the sac is cut 
away, about one-fourth inch distal from the ligature. Then, after 
a final examination of the stump of the sac, the ends of the ligature 
are cut short, and the stump of the sac allowed to retract into the 
abdomen. If the sac is rather wide-mouthed, instead of simply 
surrounding it with a ligature one may transfix it with a ligature 
carried in a curved needle and tie double. 

The next step in the operation is the strengthening of the poste- 
rior wall of the inguinal canal, and this is done by approximating 
the free edge of the internal oblique and transversalis muscles (con- 
joined tendon) above to Poupart's ligament below. While this is 




Fig. 16'!. — Bassin" Operation for Inguinal Hernia. The inguinal canal laid open by splitting 
the aponeurosis of the external oblique. The edges of the split aponeurosis are seized with artery 
forceps and drawn aside. Spermatic cord pulled aside with a loop of gauze preparatory to suturing 
the edge of the conjoined tendon to Poupart's ligament; CT, edge of conjoined tendon ; P, edge of 
Poupart's ligament ; TF, transversalis fascia, which forms the posterior wall of the inguinal canal. 




Fig. 164. — The Bassini Operation. The edges of the split aponeurosis held aside;. with artery 
forceps. Conjoined tendon sutured to the edge of Poupart's. Spermatic cord (S.C.) 'drawn' aside 
with gauze loop. 



OPERATIONS FOR HERNIA. 387 

being done the spermatic cord is held out of the way of the operator 
upon a strip o'f gauze, and the upper edge of the divided aponeurosis 
of the external oblique, which is held in an artery forceps, is re- 
tracted, in order that the edge of the internal oblique and trans- 
versalis (conjoined tendon) may be made out. These parts can be 
readily seen and may be plainly felt by the finger in the wound. 
Poupart's ligament is likewise freely exposed, when the lower edge 
of the aponeurosis of the external oblique is strongly retracted. This 
structure may be recognized as a sharp, white band. These parts, 
the conjoined tendon above and Poupart's ligament below, are now 
brought together with three to five interrupted sutures of some per- 
manent material, such as silk-worm gut, silk, silver wire, kangaroo 
tendon, or chromieized gut. These sutures are introduced with a 
large, curved needle grasped in a needle holder. The first suture is 
placed externally, just to the inner side of where the cord emerges 
from the abdomen; the last one or two sutures, those nearest the 
middle line, should take a sufficiently broad bite to include, together 
with the conjoined tendon, the edge of the rectus muscle. Ea h 
suture should take a good, broad bite. In introducing the sutures 
through Poupart's ligament there is said to be some danger, espe- 
cially with the middle sutures, of piercing the femoral vein with 
the needle. This might happen if the needle were inserted too 
deeply, but this is not necessary, as a good, broad bite of the liga- 
ment is easily secured without introducing the needle deep enough 
to reach the vein. The sutures are left long, and are not tied until 
all are introduced. Usually three or four sutures suffice; sometimes 
five are necessary. The most external suture should be placed so as 
to leave just space enough for the cord to emerge comfortably with- 
out constriction between the edge of the internal oblique and trans- 
versalis above and Poupart's ligament below. When the sutures are 
tied, the edge of the internal oblique and transversalis muscles (eon- 
joined tendon) and Poupart's ligament are seen to be closely ap- 
proximated, and in this way there is formed a solid posterior wall 
to the inguinal canal, upon which the cord rests when it is dropped 
back into the wound. The edges of the split aponeurosis of the 
external oblique are now brought together over the cord with a con- 
tinuous suture of catgut, simple or chromieized, No. 2. This suture 
is commenced above and externally, and terminates below at the site 
of the former external abdominal ring. In this way the anterior wall 
of the inguinal canal is restored, and beneath this the cord is situ- 



388 HERNIA, ETC. 

ated. One should take care that the cord is not gripped too tightly 
between the posterior and anterior walls of the new canal, and that, 
at the site of the external ring, sufficient space is left for the cord 
to emerge without danger of its becoming strangulated. 

The wound should be dry — free from oozing. No drainage is 
necessary. The incision in the skin may be closed with a continuous 
intracuticular catgut suture. 

In the female this operation is simplified in that we have no 
spermatic cord to consider; the round ligament, its analogue, is sim- 
ply cut away, and the deep sutures which strengthen the posterior 
wall of the inguinal canal introduced in the manner described above. 

For a Congenital Hernia. — In this variety of hernia the sac 
is formed of the unobliterated vaginal process of the peritoneum, at 
the bottom of which the testis usually lies. In some cases the testis 
does not reach the bottom of the scrotum in its descent, and may 
remain stationary, in any part of the inguinal canal or within the 
abdomen, when it may be wise to remove it. The incision in the 
skin and aponeurosis of the external oblique are made as in the fore- 
going operation. After the inguinal canal has been laid open, the 
cord, together with the sac, is picked up, upon the finger. The her- 
nial sac is really included within the proper sheath of the cord, in- 
fundibular process, and its isolation from the elements of the cord 
may be somewhat difficult. The sheath of the cord (infundibular 
process of the transversalis fascia) must be incised or torn through 
in order to reach the sac. In separating the sac we may commence 
above at the neck of the sac, and work downward, toward the testis. 
After the sac has been separated from the cord, vas deferens, etc., to 
a point which is just above the testis, it is opened and its contents 
reduced. The sac is then cut across, allowing the lower part, that 
which corresponds to the testis, to remain to form the tunica vag- 
inalis. The upper part of the sac, after having been thoroughly iso- 
lated, is then tied off at the point where it emerges from the abdo- 
men, and the edge of the internal oblique and transversalis (con- 
joined tendon) sutured to Poupart's ligament, as already described 
in the preceding operation. The lower part of the vaginal process 
(hernial sac) which remains, and which corresponds to the tunica 
vaginalis testis, is then closed with a continuous catgut suture, so 
that the testis is shut up within its tunica vaginalis. The edges of 
the split aponeurosis of the external oblique are then brought to- 
gether over the cord, and the incision in the skin closed. If the 



OPERATIONS FOR HERNIA. 389 

testis has been much handled, it may be wise to introduce a thin 
strip of gauze into the cavity of the tunica vaginalis, through the 
bottom of the scrotum, for the purpose of drainage; usually, how- 
ever, this is not necessary. 

Foe a Dieect Inguinal Heenia. — In this variety of hernia the 
peritoneal pouch (hernial sac) does not enter the "internal ring," 
mouth of the infundibular process, and work its way down along the 
cord, within the sheath of the cord, but bulges directly forward, into 
the inguinal canal, to the inner side of the deep epigastric artery, 
pushing the transversalis fascia, conjoined tendon, and triangular 
ligament before it, and is found upon the inner side of the spermatic 
cord as this descends through the inguinal canal. The sac consists 
of a wide-mouthed pouch of peritoneum and subperitoneal connect- 
ive tissue, and, as it presents into the inguinal canal, is covered 
by the transversalis fascia, the conjoined tendon, and the triangular 
ligament. It is also covered by the aponeurosis of the external 
oblique, superficial and deep layers of the superficial fascia, and the 
skin. The mouth of the sac is wide, and may reach from the external 
edge of the rectus as far outward as the deep epigastric artery, or 
even beyond this, pushing the artery in front of it, in which case 
the artery may form a deep groove upon the sac, and thus divide 't 
into two pouches. Under these circumstances it may be necessary to 
tie the artery double and divide it. There may be no well-formed 
sac present, but simply a wide, conical bulging of the posterior wall 
of the inguinal canal. In direct hernia the sac is readily separated 
from the cord, after which it is opened and its contents reduced. If 
the sac is very wide-mouthed, it may be necessary to approximate the 
margins of the opening with a catgut suture, and then cut away what 
remains of the sac. The operation is completed as described above for 
the oblique variety. While the cord is held aside, the edge of the con- 
joined tendon (internal oblique and transversalis muscles) is sutured to 
Poupart's ligament. The cord is then replaced and the edges of the 
aponeurosis of the external oblique sutured over it, and finally the 
incision in the skin closed. 

Halsted's Operation for Inguinal Hernia. — The incision reaches 
from a point 5 cm. above and external to the site of the internal 
ring, which is located half an inch above the middle of Poupart's 
ligament. It is carried downward and inward as far as the spine of 
the pubes (site of the external ring). This incision extends through 
the skin and superficial fascia, freely exposing the aponeurosis of 



390 HERNIA, ETC. 

the external oblique muscle and the external inguinal ring. All 
bleeding points are clamped. As a rule, it is not necessary to tie 
them, as the hemorrhage ceases after a few minutes' compression. 

The next step in the operation consists in the division of the 
aponeurosis of the external oblique, the internal oblique and trans- 
versalis muscles, and the transversalis fascia. These structures are 
incised from the external ring below to a point about 2 cm. above 
and external to the location of the internal ring, or farther if neces- 
sary, in order that the upper and outer part of the incision may ex- 
tend into the fleshy part of the internal oblique and transversalis 
muscles. The vas deferens is now sought, and, together with its 
vessels, isolated, and then all the veins which accompany the vas 
deferens except two or three, after being tied off above and below, 
are excised. In this way the size of the cord is markedly dimin- 
ished. The remains of the cord are now held to one side, and the 
isolation of the hernial sac is begun. After this has been completed, 
the sac is incised and its contents returned into the abdomen. When 
the transversalis fascia is incised the constriction about the neck of 
the sac disappears, and its mouth, from a narrow orifice, becomes a 
wide-open space, through which one may easily introduce several 
fingers or the whole hand into the peritoneal cavity. The margins 
of the mouth of the sac are now brought together with a continuous 
or interrupted suture of catgut, and the sac below this suture line 
resected. This step of the operation is really like closing any ordi- 
nary opening in the parietal peritoneum. During the application of 
this suture a gauze pad may be introduced, through the opening into 
the peritoneal cavity, to prevent the intestine from prolapsing into 
the wound. After the mouth of the sac, peritoneum, has been thus 
sutured and closed, and the sac cut away, we proceed with the next 
step of the operation, the approximation of the cut edges of the 
several layers of the abdominal wall. While this is being accom- 
plished the cord is raised upon a hook and held out of the way, well 
toward the outer part of the incision. To unite these parts from six 
to eight mattress sutures of silk are required. The layers which are 
approximated consist above of the aponeurosis of the external 
oblique, the internal oblique and the transversalis muscles (con- 
joined tendon), and the transversalis fascia. Below they consist of 
Poupart's ligament and the aponeurosis of the external oblique and 
the transversalis fascia, and in part, externally, of the cut edges of 
the internal oblique and transversalis muscles. The sutures pass 



OPERATIONS FOR HERNIA. 



391 



through all these layers. Between the two most external of these 
sutures the -cord emerges through the abdominal wall, between the cut 
edges of the internal oblique and transversalis muscles. The cord 
should be firmly grasped by these muscles, but not tightly enough 




\ 



Fig. 165.— Halsted's Operation. The vas deferens, with a few remaining 
vessels of the cord, drawn aside with a hook. Mattress sutures have been 
applied, uniting the different layers that have been cut, including the apo- 
neurosis of the external oblique. 



to strangle it. The cord, as it emerges through the abdominal wall, 
in its new position, should be surrounded by the fleshy fibers of these 
muscles; it should not emerge between the tendinous portions of 
the muscles. If the incision through the internal oblique and trans- 



392 HERNIA 3 ETC. 

versalis muscles and the transversalis fascia has not heen carried 
sufficiently far, in a direction upward and outward, to accomplish 
this, it should he extended farther, so as to reach well into the fleshy 
portion of these muscles. 

After the mattress sutures have been applied and the parts al- 
ready mentioned approximated, the cord is dropped back into the 
wound and rests upon the aponeurosis of the external oblique. The 
edges of the skin are then sutured over the cord with a continuous 
intracuticular suture, thus completing the operation. The cord is 
transplanted so that it emerges through the abdominal wall above 
and external to the site of the "internal ring," where it is surrounded 
by muscular fibers and lies just beneath the skin, instead of beneath 
the aponeurosis of the external oblique. 

Operation for the Radical Cure of Femoral Hernia. — Femoral 
hernia descends through the crural canal upon the inner side of the 
femoral vein, and presents in the thigh, just below Poupart's liga- 
ment. In order to expose the sac of the hernia an incision is made 
below and parallel with Poupart's ligament, the middle of the in- 
cision being over the center of the tumor. This incision is carried 
through the skin and subcutaneous fatty tissue and the deep layer 
of the superficial fascia (cribriform) down to the sac. Instead of 
being placed parallel with Poupart's ligament, the incision may be 
made in an oblique direction from above downward. 

The sac is now isolated, and separated from the adjoining parts 
up to and beyond the level of Poupart's ligament. Special care is 
required in separating the sac on the side which adjoins the femoral 
vein. After the sac has been thoroughly isolated it is opened and 
the contents reduced. The sac is then twisted and tied off as high up 
as possible. It may be surrounded with a simple catgut ligature, or 
it may be transfixed and tied double. The portion of the sac below 
the ligature is then cut away, the ends of the ligature cut short, and 
the stump of the sac pushed back beyond Poupart's ligament into 
the abdomen. 

We are now ready to close the orifice through which the hernia 
descended into the thigh. We should first recognize the margins of 
this orifice, the crural ring. This is bounded above by Poupart's 
ligament; internally by the edge of Gimbernat's ligament; below 
by the fascia that covers the pectineus muscle, the upper, thickened 
portion of which is called the pubic ligament of Cooper, and which ex- 
tends from Gimbernat's ligament to the pectineal eminence; externally 




Fig. 166. — Operation for Femoral Hernia. FV, femoral vein. Poupart's ligament jhas been 
sutured to the upper part of the fascia that covers the pectineus muscle. 



SPERMATIC CORD, SCROTUM, ETC. 393 

it is bounded by the femoral vein. The edge of the falciform process 
should also be recognized, and likewise the internal saphenous vein, 
where it joins the femoral. The crural ring is obliterated by sutur- 
ing the lower edge of Poupart's ligament to the fascia which covers 
the pectineus muscle; i.e., to that part of it which covers the upper 
part of the pectineus — the pubic ligament of Cooper. The stitches 
should be of silk, and should be introduced with a short, full-curved 
needle. The first suture catches Poupart's ligament just external to 
its attachment to the pubic spine, and should take a good bite. After 
the needle is drawn through Poupart's ligament is pulled upward and 
backward with a blunt hook in order to permit the needle to catch 
the pectineal fascia as high up under Poupart's ligament as pos- 
sible; i.e., near the ilio-pectineal line, from which the pectineus mus- 
cle arises. Half a centimeter external to this suture a second suture 
is introduced in a similar manner, and then, at a distance of another 
half-centimeter, a third suture. These three sutures suffice to close 
the opening. The third and last suture is located about 1 cm. to the 
inner side of the femoral vein. When these sutures are tied, the 
lower edge of Poupart's ligament and the pectineal fascia (the thick- 
ened portion, high up near the origin of the pectineus muscle from 
the ilio-pectineal line) are approximated, and the crural ring is thus 
obliterated. The opening in the skin is closed in the usual way. No 
drainage is required. 

THE SPERMATIC CORD, SCROTUM, ETC. 

The Spermatic Cord. — The spermatic cord descends through the 
inguinal canal, emerging at the external inguinal ring. As it emerges 
from the external ring it lies just beneath the integument in the sub- 
cutaneous fat, and descends into the scrotum, where it is joined to 
the posterior border of the testis. It is about as thick around as the 
little finger, and is made up of a bundle of structures, the vas deferens, 
the artery of the vas deferens, and the cremasteric artery, their corre- 
sponding veins, the spermatic artery, and a tortuous venous plexus, 
the pampiniform. The vas deferens, the efferent duct of the testis, 
occupies the posterior part of the cord. The vas deferens is about 
as big around as a goose quill, has a firm feel, and may be readily 
recognized as it is rolled between the fingers. The artery of the vas 
deferens ramifies upon the vas deferens, supplies it, and anastomoses 
below with the spermatic artery. The cremasteric artery is distributed 



394 HERNIA, ETC. 

to the constituents of the cord, and supplies its sheath. The spermatic 
artery is given off from the aorta; it supplies the testis and has a 
strong current of blood. The pampiniform plexus is a tortuous, in- 
tercommunicating plexus of venous channels that accompanies the 
other elements of the cord. Through this plexus the blood is returned 
from the testis. The vessels of the pampiniform plexus join together 
above to form the spermatic vein. This vein upon the right side 
enters the vena cava directly; upon the left side it empties into the 
renal vein, so that the venous return on the left side is less direct 
than upon the right side. Varicocele is usually found upon the left 
side. 

As these structures traverse the inguinal canal they are all con- 
tained within the infundibular process, which serves to bind them 
together into a single bundle and which forms the real fibrous sheath 
of the cord, the fascia propria. Descending upon the cord is a series 
of looped, muscular fibers, each joined to the other by an intervening 
thin fascia. These are the cremaster muscle and fascia. These fibers, 
that form the cremaster muscle, are derived from the lower border of 
the internal oblique. 

As the cord emerges from the external inguinal ring, the deep 
layer of the superficial fascia (spermatic fascia), which is attached to 
the pillars or margins of the ring, is continued down upon the cord, 
inclosing it and forming one of its investments. 

The Scrotum. — The scrotum is a pouch with two compartments, 
one on each side, separated by a median septum. It consists of sev- 
eral layers, from without inward. The skin is redundant, corrugated, 
and wrinkled. Beneath the skin is the dartos. The dartos is a loose, 
reddish, contractile layer, which is found immediately beneath the 
skin. It contains some muscular fibers, and is continuous behind with 
the two layers of the superficial perineal fascia, and laterally with 
the same layers in the groin. It sends a septum into the scrotum, 
which divides it into its two halves. Beneath the dartos is the cre- 
master muscle and fascia, and beneath this the infundibular fascia, 
and, finally, most internal, the parietal layer of the tunica vaginalis. 

The Testes. — The testes are situated in the scrotum, each sus- 
pended by its spermatic cord. They are partially invested by a closed, 
serous sac, the tunica vaginalis. This is the unobliterated part of the 
vaginal process of the peritoneum, the peritoneal pouch that accom- 
panies the testis in its descent from the abdomen into the infundibular 
process, the scrotum, before birth. 



CT, cavity of the tunica 
vaginalis testis. 

CV, cremaster artery and 
artery of the vas deferens 
and their corresponding 
veins, all in close proxim- 
ity to the vas deferens. 

//?, internal inguinal ring — 
the mouth of the original 
infundibular process — 
through which the struct- 
ures that constitute the 
cord escape (the infundib- 
ular process becomes con- 
tracted around the elements 
of the cord and forms their 
proper sheath — the fascia 
propria [red line]). 

P, peritoneum that lines the 
interior of the abdomen. 

S, symphysis pubis. 

SAV, spermatic artery and 
veins (below, along the 
course of the cord, the 
spermatic veins consist of 
a plexus of intercommuni- 
cating branches — the pam- 
piniform plexus). 

TF, transversalis fascia. 

VD, vas deferens. 

VP> remains of the obliter- 
ated vaginal process of per- 
itoneum that accompanies 
the testis in its descent into 
the scrotum (the arrow 
indicates the site of the 
former opening or mouth 
of this process). 




Fig. 107. — Spermatic Cord. 




AP 

Fig. 168. — Cross Section of Spermatic Cord. 



AP, spermatic artery and 
pampiniform plexus. 

FP, fascia propria (sheath of 
the cord and original in- 
fundibular process). 

VD, vas deferens surrounded 
closely by the cremaster 
artery and artery of the 
vas deferens and their 
corresponding veins. 

VP, remains of the obliter- 
ated vaginal process. 




Fig. 169. — Exposure of Spermatic Cord. The spermatic cord has been hooked 
up out of the incision upon the finger, and its sheath incised preparatory to sepa- 
rating the vas deferens and adjoining vessels from the other structures of the cord. 



OPERATIONS UPON SPERMATIC CORD, SCROTUM, ETC. 395 

If we cut through the anterior wall of the scrotum, through 
these various layers, we enter the cavity of the tunica vaginalis, which 
contains normally a small quantity of serous fluid. The testis pre- 
sents into this cavity, being partially invested by the visceral layer 
of the tunica vaginalis. The posterior border of the testis is not 
covered by the tunica vaginalis, and is excluded from the cavity of 
the tunica vaginalis. 

Along the posterior border of the testis is the epididymis. It 
surmounts the testis above like a cap. It has a body, an upper, larger 
portion, the globus major; and a lower, smaller portion, the globus 
minor. The vas deferens is the continuation of the epididymis. It 
commences at the lower end of the globus minor, and, passing upward 
along the posterior, inner border of the testis, is found in the pos- 
terior part of the spermatic cord, passing through the "internal ring" 
into the abdomen. Within the abdomen it dips down into the pelvis, 
to terminate between the base of the bladder and the rectum, where 
it joins with the duct of the seminal vesicle of the corresponding side 
to form the ejaculatory duct. 

The Ejaculatory Ducts. — The ejaculatory ducts are two in num- 
ber, one on each side. They are about three-fourths inch long, pass 
forward through the prostate gland, one on either side of the middle 
line, between the middle and lateral lobes of the prostate, and open 
upon the floor of the prostatic urethra. 

OPERATIONS UPON THE SPERMATIC CORD, SCROTUM, ETC. 

For Varicocele. Open Opekation. — An incision is made, about 
one and one-half inches long, into the upper part of the front of the 
scrotum, commencing just below the spine of the pubes, and passing 
through the skin into the subcutaneous fatty layer. This incision 
can be made by pinching up the skin and transfixing it with a sharp- 
pointed knife or by cutting it with the scissors. The cord is then 
hooked up, upon the finger, out of the loose, fatty layer in which it 
lies, and with one or two strokes of the knife its sheath (the spermatic 
fascia and the fascia propria) is opened. The vas deferens is sought 
and recognized, and together with the immediately adjacent veins is 
separated from the other parts of the cord. This is done with the 
fingers, holding the vas deferens and the several adjacent veins, which 
are to be allowed to remain securely between the finger and thumb 
of the left hand, while the work of separating the other structures of 



396 



HEKNIA, ETC. 



the cord, veins of the pampiniform plexus and the spermatic artery, 
from the vas deferens, may be accomplished with the fingers of the 
right hand. 

After the vas deferens, together with the several immediately 
adjacent veins, has been isolated for a distance varying from one to 
two inches, depending upon the laxness of the scrotum and the length 
of the cord, etc., a double catgut ligature is passed with an artery 
forceps and then cut so that we have two ligatures. These ligatures, 
which surround all those structures of the cord that have been sepa- 
rated from the vas deferens, etc., are tied, one above and the other 




Fig. 170. — Varicocele. The vas deferens and adjoining vessels (.4) have 
been separated from the other structures of the cord — from the spermatic 
artery and pampiniform plexus (B). Ligatures have been tied about B above 
and below preparatory to excising the intervening portion. 



below. The portion intervening is excised with the scissors, not too 
close to the ligatures, and the ends of the ligatures, which have been 
purposely left long, are then tied together, in this way bringing the 
ends of both stumps into apposition. The ends of these two portions 
may be still further secured by one or two catgut sutures, which 
should take a good bite through the whole thickness of each stump. 

The portion of the cord which is stripped away from the vas 
deferens, and which is ligated and excised, is composed of all the 
veins of the pampiniform plexus and the spermatic artery. When 
the vas is isolated, the artery of the vas deferens, which anastomoses 



OPERATIONS UPON SPERMATIC CORD, SCROTUM, ETC. 397 

below with the spermatic artery, and the cremasteric artery, together 
with their -corresponding veins, go with it; these vessels are there- 
fore not interfered with, and they are sufficient to provide for the 
nutrition of the testis after the pampiniform plexus and the sper- 
matic artery have been ligated. 

For the ligatures, plain catgut, not too thick (No. 1 or 2) may 
be used, and special care should be taken to apply the upper ligature 
securely that it may not slip, as this would result in a very free hem- 
orrhage from the end of the spermatic artery. 

In this operation one not only ties off the veins of the pam- 
piniform plexus, but also shortens the cord, and thus draws the testis 
up, a result which is much to be desired. Before closing the incision 
in the skin all bleeding points should be clamped and ligated or 
twisted, and the wound should be dry. The edges of the incision 
in the skin are brought together with a continuous stitch of catgut, 
which may be intracuticular. 

For Hydrocele. — A condition in which the tunica vaginalis is 
distended with serous fluid. The testis is usually found in the lower, 
back part of the sac, the fluid being collected above and in front 
of it. 

Puncture and Injection. — This is suitable for simple cases, 
and for those where tapping has not been previously resorted to. 
The scrotum is grasped in the left hand, in order to make it tense 
and to steady it. A fine needle, attached to a hypodermic syringe, is 
introduced through the anterior wall of the scrotum, and a small 
quantity of the fluid drawn off, both for the purpose of confirming 
the diagnosis and to demonstrate the fact that the needle is in the 
cavity of the tunica vaginalis. The hypodermic needle is left in situ, 
its end free in the cavity of the tunica vaginalis. A fairly large 
trochar is then thrust through the bottom of the scrotum rather 
toward the front, and in an upward direction into the cavity of the 
tunica vaginalis. In doing this one should remember that the testis 
occupies the lower back part of the sac. With the trochar in the cavity 
of the tunica vaginalis one should be able with it to touch the hypo- 
dermic needle previously introduced into the sac above. The sac is 
allowed to empty itself through the cannula, and this is then with- 
drawn. 

The barrel of the hypodermic syringe is now filled with the 
fluid to be injected. Twenty minims of a 95-per-cent. carbolic-acid 
solution may be used, with satisfactory results, for this purpose. 



398 



HERNIA, ETC. 



This is thrown into the cavity of the tunica vaginalis through the 
hypodermic needle, and then this needle is also withdrawn. The 
fluid that has been thus introduced into the cavity of the tunica 
vaginalis is distributed over the whole cavity by manipulating the 
scrotum. The punctures made by the instruments are covered over 
with a thin coat of collodion, and a very thin film of absorbent 
cotton. 




Fig. 171. — Hydrocele, Tapping. CTV, cavity of the tunica vaginalis testis; 
T, testis; V, vas deferens. Hypodermic needle introduced into the upper part 
of the sac; trochar cannula into the lower part. 



This operation is usually followed by some effusion into the sac, 
and with but little or no pain. After a few days' rest in bed with 
the scrotum supported, these symptoms subside. The operation is 
not painful, but the part where the trochar is to be introduced may 
be anaesthetized with ethyl chloride if desired. 

Open Operation (Volkmann). — This operation is suitable for 
those cases that have already been tapped many times or where the 
operation previously described has been tried and has failed. 




Fig. 172.— Volkmann Operation for Hydrocele. Edge of tunica vaginalis sutured 
to the edges of the skin incision. 



OPERATIONS UPON SPERMATIC CORD, SCROTUM, ETC. 399 

The scrotum is grasped by an assistant in order to make it tense 
and to steady it. An incision is made through the anterior wall of 
the scrotum, opening into the cavity of the tunica vaginalis. The 
length of the incision depends upon the size of the tumor, hut is 
usually two or three inches. When the tunica vaginalis has been 
opened, and while the fluid is escaping, the edge of the parietal layer 
of the tunica vaginalis — i.e., the inner lining of the scrotal sac — is 
seized on either side with an artery forceps, and with the finger this 
is torn away from its attachment to the inner aspect of the scrotum, 
and excised in part with the scissors. If the tumor has been very 
large, it will be necessary to excise more of the tunica vaginalis than 
if the tumor is smaller. The tunica vaginalis may be much thick- 
ened. In trimming away this redundant portion of the tunica vag- 
inalis one must take care to leave enough to conveniently cover the 
testis and also avoid cutting into the epididymis. It is rather better 
to excise too little than too much of the tunica vaginalis. After this 
part of the operation has been done the edge of that portion of the 
tunica vaginalis which remains is fixed to the corresponding edge 
of the skin incision all around with a continuous or with several 
interrupted fine catgut sutures. Then, with a wad of cotton on a 
stick, the whole interior of what remains of the tunica vaginalis, in- 
cluding that covering the testis, is swabbed out with 95-per-cent. 
carbolic acid. The cavity is then loosely packed with sterile gauze. 
The strips should reach well down into the deepest recesses of the 
cavity, but the packing should not be tight. A loose dressing is 
applied, which may be held in place by a T-bandage. The packing 
should be removed at the end of forty-eight hours, simply retaining 
a strip in the opening in the skin, and the parts allowed to granulate. 
If too much of the tunica has been removed, there will be too much 
inversion of the skin, and this will delay the healing process. 

Excision of the Tunica (von Bergmann). — After the tunica 
vaginalis sac has been opened and its contents evacuated, the parietal 
layer of the tunica vaginalis is seized and stripped away from its 
attachment bluntly with the fingers as far back as the posterior bor- 
der of the testis, or rather epididymis, and then excised in its en- 
tirety with the scissors. After all bleeding has been controlled with 
forceps and ligatures, the wound in the skin is closed with sutures, 
without any drainage whatever. As a rule, the skin incision heals 
by first intention, and the patient is able to be around in about twelve 
days. 



400 HERNIA, ETC. 

This method is very satisfactory, and is especially applicable to 
those cases where the tunica vaginalis is excessively redundant after 
the evacuation of a large hydrocele, or when the tunica is markedly 
thickened. 

Betkoveesion of the Tunica Vaginalis. — This method has 
been variously ascribed to Jaboulay, Doyen, Garampozzi, and Win- 
kelmann. An incision is made in the front of the scrotum, usually 
about two inches in length, into the cavity of the tunica. Through 
this opening the fluid contents of the distended tunica vaginalis 
escape, and the testis is then drawn forward out of the scrotum. 




Fig. 173.— Hydrocele. Retroversion of the tunica vaginalis. The tunica has heen 
turned back beyond the epididymis and fixed there by sutures. 



As the testis is drawn forward out of the scrotum, the vaginal 
layer of the tunica is reflected backward, — turned inside out, as it 
were, — so that the opening in the parietal layer of the tunica, 
through which the testis bas been drawn, gets to lie behind the testis, 
encircling the cord and covering over the epididymis, and in this 
position it is fixed by joining its edges together with several catgut 
sutures so that it may not again slip forward over the testis. The 
edges of the incision in the scrotum are now sufficiently detached to 
allow the integument of the scrotum to be drawn forward and cover 




Fig. 17-1. — Castration. Cord has been divided. The end of the lower por- 
tion grasped with an artery forceps. A ligature has been tied around the end 
of the upper stump. It will be noticed that the vas deferens is not included in 
the ligature. 



OPERATIONS UPON SPERMATIC CORD, SCROTUM, ETC. 401 

over the testis and reflected tunica vaginalis, and they are thus united 
to each other without drainage, in this way completing the operation. 

The result of this operation is that the free secreting surface of 
the tunica vaginalis which has been turned inside out is brought into 
contact with the raw internal wound surface of the scrotum, to which 
it becomes united, effecting the cure. 

If the tunica vaginalis is very redundant after evacuating a 
large hydrocele, a part of the tunica may be excised with the scissors, 
leaving just enough to complete the operation as described above; but 
for those very large hydroceles, and those with a markedly thickened 
tunica, the von Bergmann is probably the more satisfactory opera- 
tion. 

Castration (Extirpation of the Testis). — An incision, about two 
inches long, is made upon the front of the upper part of the scrotum 
through the skin and fat, commencing at a point just below the ex- 
ternal ring — the spine of the pubes. If operating for malignant dis- 
ease, and if the skin is involved, the incision may be arranged so as 
to circumscribe that part of the skin which is involved. In the upper 
part of the incision the cord is found, and hooked up, upon the finger, 
and just below the point where it emerges from the external ring its 
sheath is incised with the point of the knife. The vas deferens is then 
recognized, and should be separated from the rest of the cord. A 
catgut ligature is then passed about those parts of the cord which 
have been separated from the vas deferens, and tied so tightly 
that it cannot slip off. This ligature should include all the elements 
of the cord except the vas deferens. The ends of this ligature are 
left long, to serve as a tractor; the cord, including the vas deferens, 
is then divided with the scissors, at least half an inch below, distal 
to the ligature. Before dividing the cord it is grasped, below the 
point at which it is to be divided, with an artery clamp. The cord 
having been divided, the lower end, that which is held in the grasp 
of the artery forceps, together with the testis, and including the tunica 
vaginalis, is enucleated from the scrotum, usually without opening 
into the cavity of the tunica vaginalis, and almost entirely by blunt 
dissection. Where the knife or scissors is used to assist in this enu- 
cleation one should take care not to cut through the septum into 
the other half of the scrotum, and one should also avoid button-holing 
the skin. 

After the testis has been enucleated we return to the stump of 
the cord. This may be brought into view by drawing upon the liga- 



402 HERNIA, ETC. 

ture, which was left long to serve as a tractor, and if there is no bleed- 
ing this ligature may be cut short and the stump of the cord allowed 
to retract up into the inguinal canal. Should there be any bleeding 
points, these may be clamped and ligated. One should avoid includ- 
ing the stump of the vas deferens in the ligature, as it may result in 
disagreeable symptoms; e.g., colicky pain, etc. 

The wound is large, and may be closed with catgut sutures; in 
most cases, however, it is well to place a drain in the lower end of the 
wound. If operating for tuberculosis, the cord should be divided as 
high up as one can reach. 



PART VIII. 

THE URINARY SYSTEM. 



THE KIDNEYS. 

The Surgical Anatomy of the Kidney. — One kidney may be absent 
in apparently normal subjects, the left more frequently than the right. 
This is said to occur once in about two thousand four hundred sub- 
jects. Absence of one kidney has been met with twice in five hundred 
subjects in the writer's experience. When one kidney is absent that 
which is present is usually larger and assumes the function of both 
kidneys. 

There may be two kidneys present, joined together below or 
above, horseshoe kidney, or both above and below, either with con- 
nective tissue or kidney tissue. This condition is met with about 
once in one thousand subjects. 

At times the kidney becomes loosened in its bed, and may become 
dislodged,— movable kidney, — or it may be provided with a nearly 
complete peritoneal covering and mesentery and enjoy a considerable 
range of motion, when it is called "floating, or wandering," kidney. 

The kidneys lie in the upper back part of the abdomen, one on 
each side of the vertebral column, from the twelfth dorsal to the third 
lumbar vertebra. They are extraperitoneal organs, being covered by 
peritoneum upon their anterior surface only. 

The kidneys are provided with a fibrous capsule, which is usually 
very thin and closely adherent to the organ. They are lodged within 
a bed of loose fat and connective tissue, out of which they may be 
readily enucleated. The anterior surface of the kidney is directed for- 
ward and outward, and is covered by the peritoneum. The descending 
part of the duodenum lies in front of the right kidney, the pancreas 
in front of the left kidney. 

The upper part of the posterior surface of the kidney is separated 
from the eleventh and twelfth ribs by the diaphragm and pleura; the 
lower part of the posterior surface of the kidney rests upon the quad- 
ratus lumborum muscle, which is covered by the anterior layer of the 
lumbar fascia. Normally the upper half of the kidney lies above the 
twelfth rib, and the lower half below the twelfth rib. 

(403) 



404 URINARY SYSTEM. 

The inner border of the kidney is concave, and is directed toward 
the psoas muscle and the vertebral column; the inner border of the 
kidney really rests upon the edge of the psoas muscle, and the 
kidney is thus tilted somewhat outward. Corresponding to the inner 
border of the kidney are the artery and vein and the ureter. At the 
hilum the relation of these structures from before backward is vein, 
artery, and ureter; upon the left side the artery lies above the vein, 
and upon the right side the vein lies above the artery; upon both sides 
the ureter is the lowest of the three structures. 

The outer border of the kidney is rounded and convex, and is 
related, the right, with the ascending colon, and the left with the 
descending colon. The colon really lies a little in front of the kidney, 
as well as to its outer side. 

The upper end of the kidney is covered by the suprarenal cap- 
sule, which sits upon it like a cap. The upper end of the right kidney 
is in close relation with the under surface of the liver. The upper 
end of the left kidney lies close to the spleen. The lower end of the 
kidney reaches to within one or two inches of the crest of the ilium. 

The right kidney is located about one inch lower than the left, 
and this is due to the presence of the liver upon the right side; the 
right kidney is, therefore, more accessible than the left, and this is 
also the one which is more frequently movable and the object of 
operative measures. 

OPERATIONS UPON THE KIDNEY. 

Nephropexy. — Suture or fixation of a movable or floating kidney. 

A movable kidney is one that enjoys a limited range of motion 
in the posterior part of the abdomen, but which does not leave the 
lumbar region. A floating kidney is one that is more or less com- 
pletely invested with a peritoneal coat and provided with a more 
or less complete mesonephron, and therefore enjoys a considerable 
range of motion, and is capable of leaving the lumbar region entirely. 

In operating upon the kidney through the lumbar incision the 
patient may be placed prone upon the table with an Edebohls cushion 
under the abdomen, or he may rest upon the side of the body corre- 
sponding to the kidney which is not the object of operation, with 
the knees and thighs somewhat flexed and the front of the body 
turned toward the table. In this latter position the patient is 
steadied with sand bags placed against the chest and abdomen; an- 



OPERATIONS UPON THE KIDNEY. 



405 



other sand bag or cushion may be placed between the lower part of 
the side of the chest and the table, with the idea of increasing the 
space between the lower border of the twelfth rib and the crest of 
the ilium upon the side of operation. 

It is important that the abdomen be relaxed in order that the 
assistant during the operation may be able through the abdominal wall 
to push the kidney upward toward the incision in the loin. Probably 
the most satisfactory position is with the patient lying prone upon the 




^ 




Fig. 175.— Incision to Expose Kidney. A, along the edge of the erector 
spina?. A', additional incision along the edge of the last rib. 



table with the Edebohls cushion under the abdomen, especially if both 
kidneys are to be exposed during the operation. 

The incision corresponds to the outer border of the erector 
spinas muscle, commencing, above, just below the twelfth rib, about 
two and a half inches from the middle line (spinous processes); it 
passes downward, curving somewhat outward, and terminates just 
above the crest of the ilium. This incision should extend through 
the skin and subcutaneous fat down to the surface of the latissimus 
dorsi, the fibers of which muscle are exposed. The incision is then 
carried through the fibers of the muscle, when the outer border of 



406 URINARY SYSTEM. 

the erector spinas may be recognized; without opening its sheath, 
this muscle is drawn toward the middle line with retractors. The 
quadratus lumborum, covered by its layer of lumbar fascia, is then 
exposed in the bottom of the wound. The fascia that covers the 
quadratus lumborum is incised along the outer border of the mus- 
cle, which is then also drawn toward the spine. It is important 
to recognize the edge of this muscle. One should be on the lookout 
for the ilio-hypogastric nerve, which is derived from the lumbar 
plexus and passes downward and outward across the front of the 
quadratus lumborum; this nerve is usually seen after the edge of the 
quadratus lumborum has been exposed, and should not be cut, but 
rather drawn aside, out of the way. 

There remains now only the deepest and last layer of the lum- 
bar fascia to incise, and this should be split the full length of the 
skin incision. In cutting through the various layers of the back, 
if the patient rests upon the side, there is a tendency to work in- 
ward, toward the spinal column, instead of directly downward, 
through the different layers, toward the kidney, and this should be 
avoided. The incision should reach above to the lower border of the 
last rib, but should not be carried beyond this level by carelessly 
passing the point of the knife, within the wound, upward under- 
neath the last rib, as the pleural cavity may be thus accidentally 
opened. 

After having cut through the deepest and last layer of lumbar 
fascia, the fatty capsule, in which the kidney is imbedded, is en- 
countered. This is separated from the kidney bluntly, with the 
fingers in the wound, in order to bring the kidney into the incision 
for fixation. 

During this step of the operation one should be careful not to 
penetrate through the proper fibrous capsule of the kidney, since, 
if this accident occurs, one may detach the true capsule of the kidney 
from the kidney substance proper, instead of isolating the kidney 
with its proper capsule intact from the loose mass of fat in which 
it is lodged. If the kidney is displaced, movable, it is easy to reach it, 
as it then lies lower in the abdomen. The right kidney normally 
is situated lower than the left. When the kidney is sufficiently free, 
its outer, rounded border is brought up into the wound; this is 
greatly facilitated by the assistant forcing it up by pressure from 
the front of the abdomen if the patient lies upon the side. If the 
patient lies prone, with the Edebohls cushion under the abdomen, 



OPERATIONS UPON THE KIDNEY. 407 

the kidney may be brought into the wound or entirely out upon the 
back without any counter-pressure being made upon the abdomen 
from in front. 

The proper fibrous capsule is incised from above downward 
along the whole length of the outer, rounded border of the kidney, 
and each edge seized and separated from the kidney substance — it 
peels off easily — for a distance of about one inch on each side. 

Either edge of the detached capsule is then sutured above and 
below with chromicized catgut to the corresponding edge of the 
muscles deep in the wound. Two additional sutures of No. 2 chro- 
micized catgut are passed through the edges of the muscles and car- 
ried deep through the kidney tissue proper: one of these sutures passes 
through the upper part of the kidney and one through the lower part. 
It is probably more convenient to pass these two deep kidney sutures 
first, leaving them untied, to be used as tractors to hold the kidney in 
position until the stitches through the capsule have been introdiiced 
and tied. The two deep stitches are then tied also, but not too tight, as 
they might cut through the kidney tissue. When all the sutures have 
been tied, it will be seen that the external, rounded border of the 
kidney, denuded of its capsule, is firmly fixed to the edges of the 
muscles deep in the wound, and in this position it remains fixed as 
the wound heals. Before tying the two sutures that pass through 
the kidney the edges of the muscles in the incision may be united by 
several deep catgut stitches. 

The incision is closed with interrupted silk-worm gut stitches, 
which pass deep through both the skin and muscles, or the muscles 
may be united separately by several deep, interrupted, catgut su- 
tures. It is unnecessary to drain the wound. 

There are usually no large vessels encountered during the op- 
eration, but any spurting points may be clamped and ligated. 

Nephropexy (Edebohls). — An incision is made which reaches 
from the twelfth rib to the crest of the ilium along the outer border 
of the erector spina?; it passes through the skin and fat down to the 
latissimus dorsi. The fibers of the latissimus dorsi are not cut, but 
are separated bluntly, in the direction of their course, with the 
handle of the knife. 

Corresponding to the outer edge of the quadratus lumborum 
muscle, Avhich lies beneath the erector spina?, the transversalis fascia 
is incised, thus entering the abdomen and exposing the mass of fat 
(fatty capsule) within which the kidney, enveloped in its proper 



408 UKINARY SYSTEM. 

fibrous capsule, is imbedded. One should avoid division of the ilio- 
hypogastric nerve, a moderately large branch of the lumbar plexus 
which passes obliquely downward and outward across the front sur- 
face of the quadratus lumborum; it should be sought for at the 
outer edge of the quadratus lumborum, and drawn to one side. 

Upon its anterior aspect and near its outer edge the sheath of 
the quadratus lumborum is now incised from the twelfth rib to the 
crest of the ilium; this exposes a considerable area of the raw ante- 
rior surface of the muscle. With the fingers in the wound the fatty 
capsule is peeled off the kidney, and the organ, enveloped in its proper 
fibrous capsule, is delivered through the wound out upon the back. 
At times the kidney, still enveloped in its fatty capsule, may be de- 
livered through the wound, and under these circumstances the fatty 
capsule may be separated from the kidney almost as far as the pelvis, 
and excised with the scissors. 

The position of the patient, prone, and with the Edebohls 
cushion underneath the abdomen, makes the delivery of the kidney 
comparatively easy. If the opening in the loin is not sufficiently 
roomy, it may be enlarged by nicking the outer edge of the quad- 
ratus lumborum below, near its attachment to the ilium. 

A small incision is made in the capsule of the kidney, near the 
middle of its outer, rounded border, and through this opening a 
director is introduced upon which the capsule is divided along the 
entire length of the outer border of the kidney. The capsule is then 
peeled back, about half-way toward the pelvis upon either surface, 
thus laying bare about one-half of the entire kidney surface. The 
detached part of the capsule is not excised unless it is quite redun- 
dant; it is simply folded back toward the pelvis of the kidney upon 
the non-detached portion. 

Four fixation sutures of forty-day chromicized catgut are now 
introduced through the capsule; these pass through the capsule 
only, two on each side, one above and the other below. Each of 
these fixation sutures should take a good, broad bite, and passes 
through both the detached and the non-detached portions of the 
capsule, parallel with and close to the margin that corresponds to 
the line of its reflection. After these four fixation sutures have been 
introduced the kidney is returned into the abdomen. 

The ends (eight in number) of the fixation sutures are then, in 
succession, one after the other, threaded in a large curved Hagedorn 
needle, and carried through the muscles and fascia that correspond 



OPERATIONS UPON THE KIDNEY. 



409 



to the edges of the incision, from within outward. The sutures are 
not tied until later. Those sutures that pass through the inner 
edge of the incision penetrate the retracted edge of the incised sheath 
of the quadratus, the quadratus itself, and the erector spina? and 
latissimus dorsi; the sutures that pass through the outer edge of 
the incision pierce the edge of the transversalis fascia and the latis- 
simus dorsi muscle. 

Now, hefore tying the fixation sutures the edges of the wound 
in the back are approximated with from four to six chromicized cat- 




Fig. 176.— Nephropexy (E deli oh Is). Kidney delivered through an incision 
in the back. Proper fibrous capsule reflected and two fixation sutures intro- 
duced, one above (A, A') and one below (B, B'). These sutures pass through 
the reflected and attached portions of the capsule close to the line of reflec- 
tion. The two sutures that secure the capsule upon the opposite side of 
kidney are not seen. 



gut sutures; these are interrupted, and pass through all the fascia? 
and muscles in the edges of the wound. The fixation sutures are 
then tied; they emerge upon the posterior surface of the latissimus 
dorsi, four upon each side of the line of division in the muscle. They 
are not tied across the wound, hut the adjoining ones of each side 
are tied to each other upon the same side of the wound. 

The edges of the skin are finally united without drainage with 
an intracuticular suture. 

The result of this operation is to fix the denuded, raw surface 



410 URINARY SYSTEM. 

of the kidney, corresponding to the whole length of its convex bor- 
der, and extending half way to the pelvis upon either surface, to the 
denuded anterior surface of the quadratus lumborum, the upper ex- 
tremity of the kidney projecting upward, beneath the last ribs. 

Nephrotomy. — Cutting into the kidney for the purpose of evac- 
uating an abscess or to explore the pelvis of the kidney. 

The position of the patient and the incision are as described for 
nephropexy (page 404). The patient is placed either prone, with the 
Edebohls cushion underneath the abdomen, or else he rests upon 
the well side. The incision is carried down, step by step, until the 
last layer of the lumbar fascia has been cut and the kidney is reached. 
If operating for nephritic abscess, we may find, as soon as the kidney 
is exposed, that the indications of the abscess immediately present 
themselves, or it may be necessary to search with an exploring needle. 
When pus is located, the cavity containing it is incised with the point 
of the scalpel and enlarged with dressing forceps, which are intro- 
duced closed and expanded as they are withdrawn. At times the 
entire kidney substance is destroyed, and simply a bag of pus re- 
mains. We may or may not find a stone. The abscess cavity is irri- 
gated and packed loosely with a strip of iodoform gauze, the end of 
which emerges through the lower part of the wound in the loin. 

In closing the incision in the back the stitches should be carried 
deep in order to include the muscles, together with the skin; the 
lower part is left open for drainage. 

At times, in order to explore the pelvis of the kidney or to 
drain it, it may be necessary to bisect or split the kidney from its 
posterior rounded border right through into its pelvis. In doing 
this care should be exercised to divide the kidney midway between 
its two surfaces, as this is attended with less hemorrhage. The 
kidney must be brought up into the wound, and may be steadied 
there by an assistant exercising pressure from in front. It is usually 
sufficient if the incision in the kidney extends through only a part 
of its length. In this way a stone which may escape the exploring 
needle may be detected and removed, or, if there is no stone present, 
and the symptoms are due to an inflammatory condition of the pelvis, 
this may be drained through the kidney by leaving a small tube or 
a strip of iodoform gauze, which reaches from the pelvis of the kid- 
ney and emerges through the incision in the loin. A resulting urinary 
fistula usually closes spontaneously, provided the ureter is not ob- 
structed. 



OPERATIONS UPON THE KIDNEY. 411 

The cut surfaces of the kidney may he brought together, thus 
controlling hemorrhage from the renal vessels, by passing several 
deep sutures through the substance of the kidney. If an individual 
spurting artery of some size is seen, it should he ligated separately. 
For these sutures catgut should be used, and they should be passed 
in a curved surgeon's needle. 

The wound in the loin is closed in part by interrupted, silk- 
worm gut sutures, which penetrate deep through the edges of the 
muscles, or the edges of the muscles may be united separately by 
several interrupted catgut sutures. 

Nephrolithotomy. — Cutting into the kidney for stone. 

The steps of this operation are like those already described in the 
preceding operation. After the kidney has been reached and brought 
up into the wound it may be palpated and punctured with a fine 
needle, here and there, in order to locate the stone. It may be found 
in the pelvis of the kidney or in the kidney tissue proper. With the 
point of the knife, which is passed along the needle as a guide, an 
incision is made in the kidney, this opening being enlarged with an 
artery forceps, or the pelvis of the kidney may be incised, and the stone 
•extracted. 

If one is unable to locate the stone with the exploring needle, 
and the symptoms warrant it, the kidney may be laid open, as in 
the preceding operation. 

As a rule, pus is associated with stone, and it is, therefore, usu- 
ally necessary to drain these cases. 

If there is no pus, or if small in quantity and if the ureter is not 
obstructed, one may omit drainage and allow the wound in the kid- 
ney to close; if the opening is large, a suture may be introduced. 
If the pelvis of the kidney has been opened, it may be closed with 
•several catgut sutures introduced with a small, curved needle in a 
holder. It is well to provide drainage for the incision in the back, a 
strand of gauze being packed into the wound down to the site of the 
incision in the kidney or pelvis of the kidney. 

Nephrectomy. — Extirpation of the kidney. 

The position of the patient is the same as that already described 
for nephropexy. The steps of the operation are as above indicated 
down to the point of exposing the kidney. The incision is the same 
as that described for nephropexy (page 404) and should reach from 
the last rib to the crest of the ilium. If necessary, we may obtain 
more room by curving the lower end of the incision forward, above the 



412 URINARY SYSTEM. 

upper border of the crest of the ilium., or we may make a cut from 
the upper end of the lumbar incision outward along the lower border 
of the last rib (see Fig. 175). 

The isolation of the kidney must be thorough, and this is ac- 
complished with the hand in the wound, working patiently, with the 
fingers, around the kidne}', care being taken not to tug upon the 
kidney, as one may tear the vessels at the hilum. The suprarenal 
capsule may be left behind, although, if diseased, it may be removed 
also. After the kidney has been isolated, its outer, rounded border 
is brought well into the wound, or, as may be done in nearly all 
cases, the kidney is brought entirely out of the wound, so that a liga- 
ture may be thrown around it and worked down about the structures- 
at the hilum — the vein, artery, and ureter — and tied, or one may pass 
the ligature with a large, curved, blunt ligature carrier, the ligature 
being carried about the artery and vein, without including the ureter,, 
which lies below the vessels and on a plane posterior to them. 

The ligature should be of strong catgut; after the ligature has 
been tied its ends should not be cut short, as it is desirable to use the 
ligature as a tractor to bring the stump of the kidney into view for final 
inspection. 

In cutting away the kidney the division should not pass through 
the pedicle, which is made of the vessels, but, if possible, should pass 
through the kidney tissue near the hilum, in order to leave a little 
mass of kidney tissue as a cap, or knob, to prevent the slipping of 
the ligature. 

The wound is treated as in the foregoing operations; it is prob- 
ably better to introduce a drain, which is left for seventy-two hours. 

When the kidney is the seat of a very large tumor, it may he- 
difficult to remove it through this posterior incision. 

We should be positive that a second kidney, which is capable 
of carrying on the work, is present, and, if necessary at the time of 
the operation, an incision may be made down upon the other kidney 
in order to satisfy ourselves of its presence. 

Decortication of the Kidney (Edebohls). — This operation was- 
first suggested for the cure of chronic Bright's disease, by Edebohls. 
The operation is recent, and its real value still sub judice. The bene- 
ficial effect of the operation is, no doubt, due to the increased supply 
of blood that is brought to the kidney through the new vascular con- 
nections that are formed between it and the adjacent parts. 

Edebohls says that one may use the anresthetic, ether or chloro- 



SURGICAL ANATOMY OF THE BLADDER. 413 

form, with which he is most familiar. Mixed nitrous oxide and oxygen 
is very well adapted to certain cases. It would seem that chloroform 
would be more satisfactory in most cases. Spinal analgesia would, no 
doubt, be appropriate in some of these cases, where the patient's con- 
dition counter-indicates the use of a general anaesthetic. 

The patient lies prone upon the table, with the Edebohls cushion 
under the abdomen. The incision, the same as that described for 
nephropexy (page 407), corresponds to the edge of the erector spina?, 
and penetrates the transversalis fascia along the outer edge of the 
quadratus lumborum. The kidney is recognized in the mass of fat, 
fatty capsule, that incloses it. 

With the fingers in the wound the fatty capsule is separated 
bluntly from the surface of the kidney as far as the pelvis. The kid- 
ney, inclosed within its unbroken fibrous capsule, is then drawn into 
the wound, or, if possible, lifted out of the wound upon the back. 

Corresponding to the middle of the outer, rounded border of the 
kidney, the capsule proper is incised, and divided upon a director 
along the entire length of the outer, rounded border of the organ, and 
around its extremities, above and below. Each half of the capsule is 
then stripped away from the surface of the kidney toward the pelvis, 
taking care not to break or tear the kidney substance proper, which 
may be friable and firmly adherent to the capsule. 

The stripped off capsule is finally cut away near the pelvis of the 
kidney, and removed. If the kidney cannot be brought out through 
the incision in the back, the capsule must be peeled off the kidney, 
with the fingers in the wound, and excised, as far as possible. 

Any portion of the capsule that still remains may be rolled back 
toward the pelvis of the kidney, where it remains coiled up, upon 
itself. 

The kidney is finally replaced in the abdomen, and the incision 
closed without drainage. At the time of operation it may appear that 
but one kidney is the seat of chronic Bright' s disease, but it is prob- 
ably wise in all cases to decapsulate both kidneys at the same sitting. 

THE BLADDER. 

Surgical Anatomy of the Bladder. — The bladder is a hollow mus- 
cular organ whose function is to receive and hold the urine during 
the intervals of micturition. It has a capacity ordinarily of about 
sixteen ounces. 



414 URINARY SYSTEM. 

In the infant the bladder is rather conical, and projects into the 
abdomen above the level of the symphysis. 

In the adult the bladder, when empty, lies deep within the pelvis 
behind the symphysis, its cavity obliterated and its walls collapsed 
and in contact with each other. When distended moderately, it 
reaches as high as the symphysis, farther distension causing it to rise 
up, out of the pelvis, into the abdominal cavity a varying distance 
toward the umbilicus. When it is distended with about a pint of 
fluid, the bladder is pear-shaped, and reaches for a distance of about 
four inches above the symphysis. 

The body of the bladder is free, and, when the organ is distended, 
rises out of the pelvis into the abdomen, toward the umbilicus. 

The base of the bladder in the male is in close relation with the 
anterior surface of the second part of the rectum, and upon its inner 
aspect, on either side, shows the openings of the ureters. 

The neck of the bladder is continuous with the commencement 
of the urethra, and in the male is surrounded by the prostate, like a 
collar. 

Eelations of the Bladdek. In the Male the bladder is in rela- 
tion, behind, with the rectum, the base of the bladder lying directly 
in front of the second portion of this part of the bowel, the two being 
joined together more or less intimately by connective tissue. 

The seminal vesicles and vas deferens are located on either side 
of the middle line, in the space between the contiguous walls of the 
rectum and the bladder; they converge anteriorly toward the pros- 
tate, which surrounds the neck of the bladder, and which is readily 
felt through the rectum. 

In the Female the uterus and vagina are located behind the 
bladder. 

In both sexes the bladder lies immediately behind the symphysis 
pubis, from which it is separated by a space, which is filled with loose 
connective tissue more or less firmly connected with the anterior wall 
of the bladder, and which is called the space of Eetzius. When the 
bladder is distended, it reaches above the symphysis, and is then in 
relation, in front, with the anterior abdominal wall. 

Passing from the summit of the bladder to the umbilicus is the 
urachus, which occasionally remains patent after birth. 

The peritoneum covers the sides, part of the posterior surface, 
and the summit of the bladder, but does not cover its anterior surface, 
being reflected from the summit of the bladder over on to the poste- 



OPERATIONS UPON THE BLADDER. 



415 



rior surface of the anterior abdominal wall. When the bladder is 
well distended, it rises upward into the abdomen; its summit, as it 
approaches the umbilicus, carries the peritoneum with it, and its ante- 
rior surface, which is devoid of peritoneum, then comes into relation 
with the abdominal wall; so that under these circumstances the blad- 
der may be entered through an incision in the anterior abdominal 
wall, low down, close to the symphysis, without molesting the peri- 
toneum or entering the peritoneal cavity. 




Fig. 177. — An Anteroposterior Section Showing Relations of the Perito- 
neum to the Bladder, etc. Bladder moderately distended. P, prostate gland 
surrounding commencement of the urethra (neck of the bladder) ; PP, ante- 
rior fold of peritoneum reflected from the posterior aspect of the anterior 
abdominal wall over on to the fundus of the bladder; SP, symphysis pubis; 
VS, vesiculse seminales. 

The higher the bladder ascends into the abdomen, the larger the 
area of its anterior, non-peritoneal surface which is presented for 
operation. 



OPERATIONS UPON THE BLADDER. 

Suprapubic Cystotomy. — The patient is placed in the usual 
position upon the back and fully anaesthetized, so as to relax the ab- 
dominal muscles. If one is unable to distend the bladder, owing to 



416 URINARY SYSTEM. 

the existence of an impassable stricture of the urethra, etc., much 
advantage is gained by placing the patient in the Trendelenburg 
position. 

A soft rubber catheter is introduced into the bladder, and, 
through this, the bladder is washed out with boric-acid solution, 10 to 
12 ounces being allowed to remain; the catheter is then withdrawn, 
and a band tied about the penis to prevent the escape of the fluid. 
The fluid which is thrown into the bladder causes it to ascend into 
the abdomen, carrying the peritoneum with it; so that its anterior 
surface, uncovered by peritoneum, is exposed for several inches for 
operation. It is well not to introduce more than 10 to 12 ounces, as 
oftentimes the capacity of the bladder is diminished, and a quantity 
above 12 ounces might do harm. 

In order to throw the distended bladder farther forward toward 
the anterior abdominal wall, a bag may be introduced into the rectum 
and distended with about 6 ounces of water. Most operators dispense 
with the rectal bag as unnecessary. The incision, which is placed in 
the middle line, linea alba, commences below, at the symphysis pubis, 
and reaches upward, toward the umbilicus, for a distance of about 
three inches, and extends through the skin and fat down to the deep 
fascia. Bleeding vessels in the skin are clamped. 

The incision is carried down through the linea alba, between the 
edges of the recti and pyramidales, until the layer of connective tissue, 
which is located in front of the bladder, dipping down between it and 
the symphysis pubis, is reached. 

The edges of the wound are then drawn apart with retractors, 
and this layer of connective tissue, which covers the anterior wall of 
the bladder, is scraped upward, toward the umbilicus, with the finger- 
nail; so that, in case the fold of peritoneum reaches abnormally low, 
or the bladder has not been sufficiently distended, we may thus still 
separate it and carry it upward toward the umbilicus. The muscular 
wall of the bladder is then easily recognized, especially if the organ is 
distended. A plexus of veins, more or less visible, which ascends 
upon the anterior wall of the bladder from below, may help to identify 
it. 

With a curved surgeon's needle two rather stout silk stitches are 
introduced, one on either side of the middle line, through the whole 
thickness of the bladder wall, and these are used as tractors to steady 
the bladder while it is being incised. 

In cutting into the bladder the point of the knife is introduced 



OPERATIONS UPON THE BLADDER. 417 

between the two silk tractor stitches about one inch above the sym- 
physis, and the bladder incised in a direction downward, toward the 
symphysis. When the bladder is opened the fluid contained within 
it escapes in part. The incision should be large enough to permit 
the introduction of one or two fingers for the purpose of exploration, 
etc. 

The incision in the bladder may be enlarged sufficiently to allow 
necessary manipulation; caution should be exercised in extending the 
opening in the bladder, for any considerable distance, in an upward 
direction, toward the umbilicus (fold of peritoneum). 

If a stone is present, it may be removed with the forceps, guided 
by the finger; if the stone is very large, it may first be crushed. One 
should search the bladder carefully for stones which have become 
almost completely encysted in pockets in the bladder wall. If the 
operation is done for ulcer of the bladder, the diseased area may be 
scraped or cauterized, etc. With the patient in the Trendelenburg 
position and the edges of the wound drawn asunder with broad re- 
tractors, the interior of the bladder may be illuminated and made 
visible; an hypertrophied prostate may be enucleated through the 
suprapubic opening. 

After the work within the bladder has been completed, the open- 
ing may be closed with a line of sutures. They should bring the edges 
of the opening in the bladder into accurate apposition, and should 
pass through all the layers of the wall of the bladder down to, but 
not including, the mucous membrane. None of the sutures should 
pass through the whole thickness of the wall of the bladder. Fine 
silk or catgut may be used. 

If the opening in the bladder wall is closed, the incision in the 
wall of the abdomen should be left open, at least in part, and packed, 
in order to provide drainage; it will also be necessary to leave a cath- 
eter in the urethra for several days. In most cases it is probably wise 
to leave the incision in the bladder unclosed, stitching the margins of 
the opening in the bladder to the edges of the muscles in the abdom- 
inal wound with two or three interrupted silk sutures on either side, 
their ends being left long to facilitate their removal later. There 
are introduced through the suprapubic opening into the bladder two 
drainage tubes. One of the tubes is long, and reaches from the bottom 
of the bladder over the side of the bed into a bottle partly filled with 
an antiseptic solution and suspended from the side of the bed. The 
second tube, which is short, is for the purpose of assisting siphonage 



418 URINARY SYSTEM. 

of the bladder and to facilitate irrigation. These tubes are fixed in 
the bladder by passing the silk tractor stitches (which were introduced 
in the early stage of the operation) through the tubes. The wound 
is packed loosely about the tubes with iodoform gauze. 

The fistula that remains after the tubes are removed rapidly 
diminishes in size, and finally closes spontaneously, provided the ure- 
thral canal is unobstructed. In many cases it will suffice to fix the 
tubes in the bladder with the silk tractor sutures, omitting the sutur- 
ing of the edges of the opening in the bladder to the abdominal inci- 
sion. 

Puncture of the Bladder may be made in the middle line just 
above, the symphysis, or through the rectum. It is done for the pur- 
pose of drawing off the urine when the patient is unable to empty the 
bladder through the urethra. One should first satisfy himself by per- 
cussion, etc., that the bladder is actually distended. 

A medium-sized curved trochar is introduced above the symphy- 
sis; it should be thrust through the anterior abdominal wall in the 
middle line just above the symphysis, and in a direction backward and 
downward, toward the sacrum, for a distance of two or three inches. 

If introduced through the rectum, the trochar should be guided 
upon the finger into the rectum beyond the base of the prostate, at 
which point it is thrust into the bladder in a direction upward and 
forward, toward the symphysis. The suprapubic route is probably 
preferable. 

THE PENIS. 

Surgical Anatomy of the Penis. — The penis when erect is pris- 
moid in shape. It is composed of the corpora cavernosa and the 
corpus spongiosum. 

The corpora cavernosa are two cylinders of erectile tissue which 
run parallel with each other and occupy the upper part of the organ. 
They consist of a mesh-work of vascular spaces, which may readily 
become distended with blood, thus bringing the penis into a con- 
dition of erection. They are each provided with a strong, fibrous 
envelope, the tunica albuginea, and behind diverge, to be attached 
to the rami of the pubes. 

The corpus spongiosum is situated below the corpora cavernosa, 
and contains the urethral canal, which is also surrounded by cavern- 
ous, or erectile, tissue. 

The end of the penis is enlarged, rather bulbous, and is known 



OPERATIONS UPON THE PENIS. 419 

as the glans; this is really the enlarged extremity of the corpus 
spongiosum. Behind, in the perineum, the corpus spongiosum is 
enlarged and forms the hulh. The penis at its root is firmly con- 
nected to the symphysis hy a fibrous band, the suspensory ligament. 

The three cylinders which together form the penis are bound 
together by a fibrous sheath, and covered with a soft, loose, movable 
envelope of skin, which, at the extremity, is reflected over the glans 
for a greater or less distance, forming the prepuce. The constriction 
behind the glans is called the corona. 

Passing forward along the dorsal surface of the penis, in the 
groove between the corpora cavernosa, are two arteries, one on each 
side, the dorsal arteries of the penis, branches of the internal pudic, 
and lying between the two arteries is the single dorsal vein. 

OPERATIONS UPON THE PENIS. 

Forcible Dilatation of the Prepuce for Phimosis. — This may be 
practiced in many cases, especially in newborn and young children, 
instead of a dorsal section or circumcision. An anaesthetic is unnec- 
essary. The skin of the prepuce is seized and peeled forcibly back- 
ward over the glans as far as the corona. This is readily done in 
most cases, even when the orifice of the prepuce is quite narrow. 
The margin of the prepuce stretches and suffers slight tears here 
and there about its circumference; it should be drawn back and 
forth several times, and again repeated daily for several days. When 
the prepuce is drawn back, any hardened smegma that has accumu- 
lated should be removed, and the glans washed and smeared with 
oil or vaselin; the skin is then again drawn forward over the glans, 
since the constriction of the narrow prepuce might cause some incon- 
venience if allowed to remain back behind the glans. After the fore- 
skin has been drawn back and forth over the glans a dilator may be 
introduced into its orifice, and it may then be forcibly and thoroughly 
dilated. In most cases this is unnecessary. 

Dorsal Section. — This operation is done for phimosis in the 
young, when one is unable to retract the skin and when it is not 
desirable to clo a complete circumcision, and in adults in all cases 
where it is necessary to expose the glans for treatment. 

The skin of the penis is rolled slightly back toward the root of 
the organ with the finger and thumb, and one blade of a blunt- 
pointed scissors introduced beneath the prepuce, between it and the 



420 



URINARY SYSTEM. 



glans, as far back as the corona, and the foreskin then divided along 
the middle line, steadying it so that it will not roll or slip. The 
scissors should be sharp, especially toward the ends. 

The prepuce should not be divided for its whole length, but only 
to within a short distance of the corona. 

One should be careful not to introduce the blade of the scissors 
into the urethral canal instead of between the glans and prepuce; 
this. might happen if the prepuce were intimately adherent to the 
surface of the glans, as is sometimes the case. 

Instead of using the scissors the section may be made with a 
sharp-pointed, curved bistoury, guided upon a grooved director, 




Fig. 178. — Dorsal Section (Roser). Prepuce has been divided upon the 
dorsal aspect. M, edge of incised mucous membrane; 8, edge of skin. Dotted 
lines indicate little triangular flap (F) of mucous membrane that is cut from 
the mucous to the skin edge of the divided prepuce. The flap is turned back 
and sutured into the angle of the wound; the edge of mucous membrane and 
skin may also be joined on each side with one or two stitches. 



which is introduced underneath the prepuce, between it and the 
glans. As a rule, there is but little hemorrhage. 

If the parts are not infected, one or two catgut stitches may be 
introduced on either side. Usually no suture is necessary in the 
child. 

Eosee's Method of Doesal Section. — After the dorsal section 
has been made, the mucous membrane not being cut as far back as 
the skin, an oblique incision is made, on either side, from the corner 
of the mucous membrane backward and outward as far as the edge of 
the skin. The little triangular mucous membrane flap which is thus 
formed is then turned up into the angle in the skin, to insure rapid 



OPERATIONS UPON THE PENIS. 421 

healing in the corner of the incision; it may be held in place with one 
stitch in the* angle of the incision. One or two stitches may also be 
introduced on either side of the incision proper. 

Circumcision. — In children an aneesthetic is necessary; in adults 
the operation may be done under the influence of cocain, which is 
injected into the prepuce after a strip of gauze has been tied fairly 
tight about the body of the penis near its root to prevent diffusion 
of the cocain. One should avoid cutting the skin too short. After 
the parts have healed there should be a little redundancy of the skin 
marking the previous reflection of the prepuce, and this is best ac- 
complished by drawing the skin a little backward, toward the root 
of the penis, before applying the constricting band. The first step 




Fig. 179. — Circumcision. Dorsal section has been made. The corners of 
the divided prepuce are grasped with artery forceps preparatory to trimming 
it away with the scissors. 

in the operation is the dorsal section of the prepuce. One blade of 
a scissors is introduced underneath the prepuce to a point just in 
front of the corona, and the prepuce then divided to within a short 
distance of the corona. Either corner of the divided prepuce is seized 
with an artery clamp close to the edge of the incision, and with a 
straight, blunt-pointed scissors the redundant portion of the prepuce 
is trimmed off, first around one side and then around the other as 
far as the attachment of the frsenum, and finally cut through in this 
situation, just in front of the frsenum and without dividing the fras- 
num. 

The entire length of the prepuce should not be amputated; 
about one-fourth its length should remain. 



422 URINARY SYSTEM. 

As a rule, the bleeding stops when the ligature around the penis 
is removed and after a few minutes' compression. Bleeding arterial 
points, however, should he seized with a clamp and twisted. All 
bleeding should be checked before suturing, if necessary applying 
fine catgut ligatures. 

The edges of the skin and mucous membrane are united with 
interrupted catgut sutures, the first being applied in the middle line 
above, the next in the middle line below, then one on each side, and 
finally in the intervals between these, making eight sutures in all. 
In the child, as a rule, the four sutures are sufficient. 
Circumcision with the Clamp. — After the parts have been anaes- 
thetized, etc., the edge of the prepuce is seized above in the middle 
line and below in the middle line with artery forceps, and drawn 
forcibly forward over the glans. That part of the prepuce which 
is thus pulled beyond the glans is grasped between the blades of a 
long, straight clamp, which is applied obliquely from above downward 
and forward; the clamp should seize the foreskin firmly, and care 
should be observed that the glans is not included; this accident, how- 
ever, is not likely to occur. 

That part of the prepuce which protrudes beyond the blades of 
the clamp is trimmed off with a sharp knife or with the scissors plane 
with the surface of the clamp, and the clamp then removed. The 
hemorrhage is controlled and the sutures applied as above. 

Amputation of the Penis. — This operation is done for malignant 
disease. A sound is passed into the urethra, and, supported upon 
this, the penis is lifted away from the body. An elastic ligature is 
placed about the organ close to its root. 

A circular incision is made through the integument and a flap 
reflected sufficiently long to cover over the stump of the penis; it 
should be equal in length to half the diameter of the penis plus one- 
third for shrinkage. After the flap has been turned back like a cuff 
the portion of the penis that is to be amputated is cut away. The 
urethral portion of the penis should be cut about one-fourth inch 
longer than the part that corresponds to the corpora cavernosa. 

The blade of the scalpel is thrust flatwise through the penis 
between the urethral portion, which may be recognized by the sound 
within, and the corpora cavernosa, and carried a good one-fourth 
inch forward toward the glans, when the urethral portion is cut 
through with a circular sweep of the knife down upon the sound 
contained within. The corpora cavernosa are then divided upon a 



OPERATIONS UPON THE PENIS. 



423 



plane farther back, corresponding to the base of the skin flap, so that 
the urethral' portion will project about one-fourth inch beyond the 
cut surface of the corpora cavernosa. 

The tourniquet is now removed from the root of the penis. The 
dorsal arteries bleed, and require to be clamped and ligated. The 
arteries of the corpora cavernosa usually require no ligatures; if they 




Pig. 180.— Amputation of the Penis. CC, corpora cavernosa; F, skin flap 
turned back; U, urethral portion cut long. 

spurt, they may be clamped or touched with the Paquelin. A few 
minutes' compression usually suffices to check bleeding from any re- 
maining sources. 

The edges of the urethra are seized with two artery clamps, and 
the urethra then split upon its under aspect for a distance of about 
one-fourth inch. The skin flaps are turned over the end of the 




Fig. 181.— Amputation of the Penis. Edges of skin flap united to each 
other over the ends of the corpora cavernosa and to the edges of the split 
urethral portion. 

stump, and are united from before backward with several inter- 
rupted sutures, and the edges of the split urethral orifice are sewed 
to the adjoining edges of the skin flaps. 

The object of cutting the urethra long and splitting it is to 
provide a larger orifice to allow for subsequent contraction. 

A soft rubber catheter is introduced into the bladder and al- 



42 -± URINARY SYSTEM. 

lowed to remain for several days, its end emerging through the 
dressings. It may be fixed with a silk stitch to the edge of the urethral 
orifice. 

THE PERINEUM AND ISCHIO=RECTAL REGION. 

The Floor of the Pelvis from "Without Inward. — This space is 
lozenge-shaped; its front portion is limited on either side by the 
rami of the pubes and ischium; its posterior part is limited on either 
side by the edges of the great sacro-sciatic ligaments. The anterior 
angle corresponds to the symphysis pubis, the posterior angle to the 
tip of the coccyx, and on either side the tuber ischii may be felt. 
There is a more or less complete fibrous raphe running from before 
backward in the middle line, and also one from side to side where 
all the layers of the perineal fascia are blended together. Where these 
lines intersect there is a point where muscles are attached and take 
origin and where all the fasciae are joined. This is known as the cen- 
tral tendinous point of the perineum. The space in front of the trans- 
verse raphe is the perineum proper; the space behind it is occupied 
by the anus and upon either side by the ischio-rectal fossa, and is 
known as the ischio-rectal region. 

The Superficial Layer of the Superficial Perineal 
Fascia. — Beneath the skin there is a layer of loose fascia which is 
continuous with the superficial fascia of the thighs and buttocks. 
This is the superficial layer of the superficial fascia of the perineum 
and ischio-rectal regions; it corresponds to the subcutaneous fat, and 
is continuous in front with the dartos layer of the scrotum, and be- 
hind, upon either side of the anus, it is packed into the ischio-rectal 
fossa as a pyramidal plug of fat and loose connective tissue. 

The Deep Layer of Superficial Perineal Fascia. — If we 
remove this superficial layer of fascia and fat, including the mass 
from the ischio-rectal fossa, we come down upon a second layer of 
fascia, the deep layer of the superficial fascia of the perineum. Cor- 
responding to the perineal region proper, the fascia is attached upon 
each side to the edge of the pubic arch and behind to the transverse 
raphe; in front it is continuous with the dartos of the scrotum; be- 
hind, in the ischio-rectal region, it is continuous with the anal fascia, 
which covers the perineal surface of the levator ani muscles. 

Anteriorly this fascia is dense, and serves to close in the struct- 
ures proper to the perineum. If fluid is injected underneath this 
layer of fascia, it will not spread backward beyond the transverse 



PERINEUM AND ISCHIORECTAL REGION. 425 

raphe, because this layer of fascia is attached along this raphe with 
the next underlying fascial layer; it will not escape laterally, owing 
to the attachment of the fascia to the margins of the bony pelvic 
arch; but anteriorly it will escape, passing into the dartos tissue of 
the scrotum and thence upward upon the front of the pubes. 

The Ischio-rectal Region. — This is the region which lies behind 
the transverse raphe — that part which corresponds to the anus and 
the ischio-rectal fossa. 

In the middle is the anus, surrounded by its external sphincter 
muscle. This muscle arises from the tip of the coccyx behind, and, 
passing forward, is attached, in front of the anus, to the middle 
tendinous point of the perineum, which corresponds to the junction 
of the sphincter from behind, the transversus perinei from each side, 
and the bulbo-cavernosus from in front. 

On either side of the anus there is a pyramidal space, the ischio- 
rectal fossa; this space is occupied by a mass of fat and loose con- 
nective tissue, the base of which corresponds to the superficial layer 
of superficial perineal fascia, and reaches from the tuberosity of the 
ischium to the anus. This space is about two inches deep. Its outer 
wall is formed by the tuber ischii and the obturator internus muscle, 
which muscle is covered over by a layer of fascia, the obturator fascia. 
Passing forward upon this outer wall of the ischio-rectal fossa, be- 
neath the obturator fascia and about one and one-half inches above 
the tuberosity of the ischium, are the internal pudic vessels and 
nerve. 

The inner wall of the ischio-rectal space is formed by the levator 
ani (to be described later). The superficial surface of this muscle, 
which looks into the ischio-rectal space, is covered by the anal fascia, 
which is derived from the obturator fascia along the line of the 
origin of the levator ani from the side of the pelvis. This anal 
fascia is attached in front to the transverse fibrous raphe and is 
continuous there with the deep layer of the superficial perineal fascia. 

The ischio-rectal space is thus walled off from the perineal space 
proper and from the rectum. It is the seat of the so-called ischio- 
rectal abscess, and when this breaks through into the rectum it forms 
the fistula in ano. 

Some small vessels and nerve branches cross this space trans- 
versely just beneath the skin, passing from the tuberosity of the 
ischium toward the anus, and these are cut when incisions are made 
into the space. 



426 



URINARY SYSTEM. 



The Perineum. — Upon removing the deep layer of superficial peri- 
neal fascia we open into the proper perineal space. 

Occupying the middle of the space is a thin muscle, the bulbo- 
cavernosus; it arises from the middle tendinous point of the peri- 
neum, and, passing forward, covers the bulb of the urethra, which is 
the posterior enlarged portion of the corpus spongiosum, joining, 




Fig. 182. — The Perineum and Ischio-rectal Region. The superficial and 
deep layers of the superficial perineal fascia have been removed. The space 
in front of the transversus perinei (TP) corresponds to the perineum; that 
behind the transversus perinei to the ischio-rectal region. The floor of the 
space {TL) corresponds to the anterior layer of the triangular ligament. BG, 
bulbo-cavernosus muscle; C, tip of coccyx; GC, corpus cavernosum (crus 
penis) ; G8, corpus spongiosum (the posterior part of the corpus spongiosum 
is called the bulb of the urethra); G, edge of gluteus maximus muscle; IG, 
ischio-cavernosus muscle; LA, levator ani muscle; R, ramus of the pubes 
and ischium; SA, sphincter ani; 8L, edge of great sacro-sciatic ligament; 
TI, tuberosity of the ischium; TL, superficial or anterior layer of the tri- 
angular ligament; TP, transversus perinei muscle. 



with fibers from the muscle of the opposite side upon its upper sur- 
face, in a strong aponeurosis. The most anterior fibers of the bulbo- 
cavernosus muscle are attached on either side to the crus penis, some 
entirely encircling these bodies and joining upon the upper surface 
of the root of the penis in such a way as to bind down the dorsal 
vessels of the penis, obstructing the return flow through the vein. 



PERINEUM AND ISCHIORECTAL REGION. 427 

This muscle shows a median fibrous raphe. Upon either side, arising 
from the as'cending ramus of the ischium, is the ischio-cavernosus. 
The fibers of this muscle partly cover the crus penis, and are attached 
to its sheath. The crus penis is the posterior portion of the corpus 
cavernosum, and is attached to the ramus of the ischium and pubes. 

Forming the posterior border of this space on either side is the 
transversus perinei muscle. This muscle arises from the inner surface 
of the tuberosity of the ischium; it passes inward and forward to the 
central tendinous point of the perineum, where it is attached, joining 
with the muscle of the opposite side and the other muscles already 
described. 

Passing forward through this space are the superficial perineal 
vessels and nerve, and directed inward along the border of the trans- 
versus perinei is the transverse perineal artery. 

The floor of this space is formed by a dense layer of fascia, the 
superficial layer of the deep perineal fascia, or, better, of the triangular 
ligament. This layer of fascia is perforated by the urethral canal 
about one and one-half inches below the symphysis. Beneath this 
layer of fascia there is a second layer, similar in structure, the deep 
layer of the deep j)erineal fascia or triangular ligament. 

Behind, corresponding to the transverse perineal raphe, these 
two layers of deep fascia are blended with each other and with the 
deep layer of the superficial perineal fascia. They are attached later- 
ally to the inner surface of the rami of the pubes and ischium; above, 
in front, they do not reach to the symphysis, but terminate in the 
ligamentum transversum pelvis, a ligamentous band passing between 
both pubic rami, leaving a space above, between it and the symphysis, 
for the passage of the vena dorsalis penis. 

Between the two layers of the triangular ligament the deep trans- 
verse perineal muscle, the compressor urethra?, is located; this mus- 
cle is made up chiefly of striped muscular fibers passing across from 
one pubic ramus to the other above and below the urethra, and also 
of unstriped fibers which pass in various directions, some encircling 
the membranous part of the urethra. 

The two layers of the triangular ligament, together with the 
muscle contained between them, form the uro-genital diaphragm. In 
the space between the two layers of the triangular ligament, besides 
the muscle, are contained the urethra, its membranous portion, and 
behind, on either side, Cowper's gland, the duct of which is seen 
passing forward to enter the bulbous portion of the urethra. Poste- 



428 URINARY SYSTEM. 

riorly, close to the lateral border of the space, is seen the internal 
pudic artery. It gives off the artery of the bulb, and passing forward 
divides into the artery of the cms penis, which enters the cms, and 
the dorsal artery of the penis, which perforates the suspensory liga- 
ment and runs forward along the upper surface of the penis. 

As the urethra perforates the superficial layer of the triangular 
ligament it is provided with a fibrous prolongation, which is con- 
tinued forward upon the bulb of the urethra. 

The posterior or deep layer of the triangular ligament is con- 
tinous (within the pelvis) with the fascia which covers the obturator 
internus muscle and the upper or pelvic surface of the levator ani 
muscle, and at the side of the prostate it is reflected upward upon 
this gland. 

The prostate gland, which encircles the neck of the bladder and 
contains the prostatic portion of the urethra, rests upon the upper, 
or pelvic, surface of the triangular ligament and the levator ani. 

The levator ani serves to close in that part of the pelvic outlet 
which lies posterior to the triangular ligament. The anterior fibers 
of the muscle unite in the middle line with those of the opposite side 
in a sling-like fashion to support the prostate. The fibers more poste- 
riorly are continued into either side of the rectum and to the tip of 
the coccyx. 

The seminal vesicles and the vas deferens lie within the pelvis, 
between the second part of the rectum and the base, or trigone, of the 
bladder, above the upper border, or base, of the prostate. They may 
be brought into view by separating the rectum from the base of the 
bladder and drawing it backward toward the coccyx. 

The Pelvic Cavity from Within. — Examining the pelvic cavity 
from within, after removal of the bladder and rectum, we find it 
bounded in front by the pubic bones, behind by the coccyx and sa- 
crum, laterally by the pubes and ischium and the sacro-sciatic liga- 
ments. The lateral wall of the pelvic cavity is partly covered by the 
obturator internus muscle, which arises from the inner surface of the 
pubes and ischium around the margin of the obturator foramen. 

The obturator internus is covered by a thick fascia, which is at- 
tached above to the margin of the brim of the pelvis, being continuous 
above with the fascia that covers the psoas and iliacus muscles (the 
fascia iliaca). In front this obturator fascia is continued into the 
posterior or deep layer of the triangular ligament. 

The obturator fascia is marked by a thick, white, fibrous band, 



PERINEUM AND ISCHIORECTAL REGION. 429 

which extends along the lateral wall of the pelvis from before back- 
ward, from "the posterior surface of the pubic bone in front to the 
spine of the ischium behind, and is known as the tendo arcuatum. 
Along this line upon either side of the pelvis the levator ani takes its 
origin. The muscles pass in a general direction obliquely downward 
and inward, joining with each other in the middle line. The ante- 
rior fibers pass downward, inward, and backward, and unite in the 
middle line underneath the prostate, which they support in a sling-like 
manner. The more posterior fibers pass downward and inward, and 
are inserted into the sides of the rectum just above the anus; the 
fibers behind these are attached to the tip of the coccyx. 

Still more posteriorly lies the coccygeus. This muscle looks 
like a continuation of the levator ani, and serves to close in the out- 
let of the pelvis behind the levator ani. It is fan-shaped, and is 
attached by its apex to the spine of the ischium and by its broad 
base to the lateral margin of the coccyx. 

Lying upon the same plane, but still farther above and behind, 
and corresponding to the upper border of the coccygeus muscle, is 
the pyriformis. This muscle arises from the sides and from the ante- 
rior surface of the sacrum, and passing outward leaves the pelvis 
through the great sacro-sciatic notch, and closes the pelvic cavity 
behind. 

Thus, taking part in the formation of the floor of the pelvis, 
there is a muscular layer which is formed in front by the levatores 
ani, behind this by the coccygei, and still farther behind and above 
by the pyrif ormi. 

In the front part of the floor of the pelvis, between the margins 
of the levatores ani, there is a space which corresponds to the poste- 
rior, or deep, layer of the triangular ligament. 

The fascia that covers the obturator muscle, the obturator 
fascia, is continuous in front with the posterior, or deep, layer of the 
triangular ligament; corresponding to the line, the tendo arcuatum, 
which marks the origin of the levator ani, this obturator fascia, which 
is simply a portion of the general pelvic fascia, gives off a layer that 
covers the pelvic surface of the levator ani; farther back the pelvic 
surface of the coccygeus and the pyriformis and the front of the 
sacrum are also covered by a continuation of this same fascia. 

Where this fascia, after covering the pelvic surface of the levator 
ani, strikes the prostate and the rectum, it is reflected upward upon 
the sides of these organs. 



430 URINARY SYSTEM. 

A process of this fascia is reflected inward between the rectum 
and the base of the bladder, and serves to bind the seminal vesicles 
and vas deferens to the base of the bladder. 

The under surface of the levator ani, which is directed toward 
the perineum and ischio-rectal fossa, is also covered by a thin layer 
of fascia, which is derived from the obturator fascia along the line 
of the origin of the levator ani. This is called the anal fascia. 

The anal fascia is continued backward upon the under surface 
of the coccygeus muscle, and anteriorly is continued forward into the 
deep layer of the superficial perineal fascia, joining along the trans- 
verse septum, or raphe, with all the other fascia? of the perineum. 

OPERATIONS UPON THE PERINEUM, ETC. 

Perineal Section (External Urethrotomy) With a Guide. — This 
operation is performed for stricture of the deep urethra or for the 
purpose of draining the bladder. The patient is placed in the 
lithotomy position and a tunneled sound introduced through the 
urethra into the bladder. 

An assistant steadies the sound with the right hand, throwing 
the groove as much as possible toward the surface of the perineum, 
and at the same time drawing the whole urethra upward, away from 
the rectum toward the symphysis. The scrotum is drawn up toward 
the symphysis, out of the way of the operator. 

An incision is made in the middle line from the base of the 
scrotum backward to within a short distance of the anus. This in- 
cision reaches through the skin and fat down to the deep layer of 
the superficial perineal fascia. 

The edges of the wound are drawn asunder with small, sharp 
retractors, and with another stroke of the knife the deep layer of 
the superficial perineal fascia is incised and the bulb of the urethra 
exposed in the forward part of the wound. Then, with the finger 
in the wound, the groove in the tunneled guide within the urethra 
is recognized and the point of the knife, guided upon the finger-nail, 
is placed in the groove of the sound, piercing the membranous part 
of the urethra just behind the bulb. The knife is then shoved back- 
ward, carrying the point of the blade along the groove of the sound 
toward the neck of the bladder and raising the handle, at the same 
time, toward the symphysis. Having carried the point of the knife 
beyond the location of the stricture into the prostatic portion of the 



OPERATIONS UPON THE PERINEUM, ETC. 43 1 

urethra, the handle is depressed, the knife at the same time heing 
withdrawn and cutting as it is withdrawn; in this way the mem- 
branous portion of the urethra is laid open and the stricture divided. 

While the urethra is being incised upon the grooved sound the 
sound should be lifted straight up toward the symphysis, carrying 
the urethra with it, and thus drawing it farther away from the 
rectum. If some urine or fluid is in the bladder, its escape will demon- 
strate the fact that the bladder has been entered. 

A director gorget may now be introduced into the bladder along 
the groove of the sound and the latter withdrawn. A soft rubber 
catheter of large caliber is introduced through the opening into the 
bladder, and fixed in place to the edge of the incision in the skin 
with a silk stitch, and the wound then packed. 

Usually there are no vessels to tie, although spurting arterial 
branches should be clamped and twisted and, if necessary, ligated. 
One should avoid wounding the bulb of the urethra if possible, and, 
for a certainty, the rectum and anus. 

Before dismissing the patient, a large metal sound, at least a 
No. 30 F., should be passed through the anterior urethra and into 
the bladder to make certain that no remaining obstruction exists in 
any part of the canal. 

Perineal Section Without a Guide. — This is a difficult procedure. 

All attempts to introduce a guide through the constricted part 
of the urethra into the bladder fail. One should not be satisfied with 
a single attempt, but should try, if possible, to at least get a small 
whalebone or rubber guide through. After having made the attempt 
and found it impossible to get any guide whatever past the stricture, 
a tunneled sound may be introduced as far as the obstruction. 

As described in the preceding operation, an incision is made in 
the perineum and the urethral canal opened upon the guide just in 
front of the stricture. After all the bleeding has been arrested, the 
edges of the wound, including the edges of the incised urethra, are 
retracted with small, sharp hooks, and an effort then made to find 
the opening through the stricture into the posterior part of the ure- 
thra by inspection or by attempting to pass a fine probe-pointed 
director or a fine whalebone guide. At times pressure upon the 
bladder will force a few drops of urine through the orifice of the 
stricture, and this may assist us in locating it (Koenig). 

If we do not succeed in getting through the stricture by these 
means an effort may be made to open into the urethra behind the 



432 URINARY SYSTEM. 

stricture, and then, if this is successful, the stricture may be divided 
from behind. It is difficult, however, to locate the deep urethra 
(membranous portion) without a guide. It lies between the layers 
of the triangular ligament, reaching from the bulbous portion of the 
urethra to the apex of the prostate gland. Occasionally the urethra 
is diverted from the middle line or a false passage may be encount- 
ered which will still further confuse us. 

At times, especially if the bladder contains fluid and pressure be 
made above the pubes, the urethra may be felt as a rounded, com- 
pressible tube, occupying the middle line and perforating the tri- 
angular ligament about one and one-half inches below the symphysis. 

The prostatic urethra, which is the continuation of the mem- 
branous urethra, is surrounded by the prostate gland, and, if one 
finger is introduced into the rectum and the thumb placed in the 
incision in the perineum the operator may get the prostate between 
them, and the apex of the prostate may thus serve as a clue to the 
location of the membranous urethra. One should refrain from blindly 
jabbing in the wound in the hope of accidentally striking the urethra. 

If all these measures fail, a suprapubic cystotomy may be per- 
formed and a guide passed from within the bladder into the urethral 
canal, in this way locating the posterior part of the deep urethra for 
the purpose of incision. 

If it becomes necessary to do a suprapubic cystotomy, this may 
be more conveniently done with the patient in the Trendelenburg 
position. A suprapubic cystotomy under these circumstances is also 
a difficult procedure, as the bladder may contain little or no urine 
and may therefore lie very low in the pelvis behind the symphysis. 

Median Lithotomy. — This operation is performed for small calculi. 
The bladder should be washed out with boric-acid solution, 5 or 6 
ounces being allowed to remain in the bladder. The operation is 
practically the same as the preceding perineal section (with a guide) 
except that the incision into the urethra is made rather more ex- 
tensive, cutting through the anterior part of the prostatic as well as 
through the membranous portion of the urethra. The incision should 
not extend entirely through the prostate. Oftentimes after the blad- 
der has been opened a small stone will of itself drop out of the 
wound, or it can be removed with forceps, scoop, etc. It may be 
necessary to enlarge the internal urethral orifice somewhat with a 
dilator or with the finger. If necessary, a larger stone may be 
crushed before removal. 



OPERATIONS UPON THE PERINEUM, ETC. 433 

The finger should be introduced into the bladder to search for 
partially encysted stones, etc. Finally the bladder is washed out and 
a large, rubber catheter introduced through the perineal wound and 
fixed to the edge of the skin with a silk stitch. The wound is packed 
about the catheter and left open. 

Lateral Lithotomy. — The bladder is washed out with boric-acid 
solution, lor 5 ounces being left remaining in the bladder. A tun- 
neled sound is introduced through the urethra into the bladder and 
steadied by an assistant. An incision is made through the skin and 
fat, commencing in front at the base of the scrotum and passing back- 
ward and outward to a point midway between the tuberosity of the 
ischium and the anus. A second sweep of the knife incises the deep 
layer of the superficial perineal fascia. The index finger of the left 
hand is then introduced into the wound, and the finger-nail placed in 
the groove of the sound in the front part of the wound, just behind 
the bulb of the urethra. The sound is then' drawn upward toward the 
symphysis, thus lifting the whole urethra away from the rectum, and 
the point of the knife placed in the groove of the sound, cutting 
through the membranous urethra. The handle of the knife is then 
elevated and the point shoved backward along the groove of the guide 
into the prostatic urethra. The handle of the knife is then depressed, 
at the same time withdrawing the blade and cutting as it is with- 
drawn. In this way the membranous urethra, together with the side 
of the prostate itself, are incised, the division of these deep structures 
being made along the line of the skin incision. 

In making this last incision upon the sound the superficial trans- 
verse perineal muscle, and the artery of the bulb, together with the 
membranous urethra, the prostate gland, and the triangular ligament, 
are cut. It is usually necessary to clamp and tie the artery of the bulb, 
and sometimes, if the incision extends too far backward and outward, 
the internal pudic may be divided; this branch bleeds profusely, and 
must be tied. After the bleeding has been controlled and the stone 
removed, a catheter is introduced into the bladder and fixed to the 
edge of the incision. The wound is packed about the catheter and 
left unsutured. 

Prostatectomy (McGill-Fuller).— The bladder is washed out with 
boric-acid solution, and 8 or 10 ounces of this allowed to remain in 
the organ. A suprapubic cystotomy is then done, as already described, 
with the patient in the ordinary position, lying upon the back. The 
incision in the abdomen and bladder may be held open with long, 



434 URINARY SYSTEM. 

rather broad retractors, and the interior of the bladder explored. The 
retractors are then removed and the fingers of the left hand introduced 
into the bladder, and the wall of the bladder incised over the enlarged, 
prominent prostate, which is readily recognized by the fingers in the 
bladder. 

This incision is made with long scissors, which are guided by the 
fingers in the bladder, and extends through the whole thickness of 
the bladder wall into the substance of the hypertrophied prostate; it 
is placed transversely and just behind the urethral orifice, and is made 
sufficiently large to admit the finger. The finger is then introduced, 
and, working between the wall of the bladder and the prostate, the 
entire hypertrophied mass is enucleated. While this is being accom- 
plished the whole perineum is forced up from below by counter-press- 
ure made in the crotch by the closed fist of the operator enveloped 
in a sterile towel. Guiteras makes this counter-pressure with two 
fingers in the rectum. Cutting forceps or a sharp spoon may be used 
to assist in the extirpation of the mass, although this is usually un- 
necessary and undesirable. 

The hypertrophied middle or lateral lobes, or practically the 
whole prostate, may be removed in this way. The hemorrhage is con- 
siderable, chiefly oozing, but this is, as a rule, easily controlled by 
irrigating the bladder with hot saline solution. 

The bladder may be drained through the suprapubic opening, 
introducing two tubes, as already described for suprapubic cystotomy. 
It is probably well, in addition, to do a perineal section and introduce 
a third tube through the opening thus made in order to drain the 
bladder from below (Fuller). The perineal opening is readily made 
upon a tunneled sound. The tubes may be left in the suprapubic 
opening for several days and fixed by the two silk tractor sutures 
which are passed through the wall of the bladder; if the tubes are 
thus secured, one may usually omit fixing the edges of the opening in 
the bladder to the margins of the abdominal incision. 

In enucleating the hypertrophied prostate one should work with 
the fingers close to the surface of the mass and avoid any such force 
as might tear into the rectum. 

Prostatectomy (Alexander). — A suprapubic cystotomy is per- 
formed, and then placing the patient in the lithotomy position a peri- 
neal section is made and the membranous urethra opened back to the 
apex of the prostate (see "Perineal Section"). 

The fingers of the left hand are introduced into the bladder 



OPERATIONS UPON THE PERINEUM, ETC. 435 

through the suprapubic opeuing, and the enlarged prostate pressed 
down into the perineal wound and steadied. 

According to Guiteras, the prostatic mass may be pressed down 
into the perineum, without opening the bladder, through an incision in 
the lower part of the linea alba as for suprapubic cystotomy, with two 
fingers in the prevesical space of Eetzius. 

The forefinger of the right hand is introduced into the perineal 
wound, and, pushing the rectum backward away from the prostate, 
we tear or poke through the capsule of the prostate upon its posterior 
inferior surface (that which presents toward the rectum), and then 
with the finger the whole of the hypertrophied prostate may be shelled 
out, working close to the surface of the mass so as to avoid tearing 
through the mucous membrane of the neck of the bladder and pro- 
static urethra. In this way the lateral lobes are first enucleated, and 
then the middle lobe, if this is also enlarged, may be removed in a 
similar manner. 

The hypertrophied prostatic mass may be seized with vulsella 
forceps and traction made first toward one side and then toward the 
other during its enucleation. The bladder is drained through the 
perineal wound, but in addition two tubes may be introduced through 
the suprapubic opening and fixed to the edges of the opening in the 
bladder; these are allowed to remain for several days. 

Prostatotomy (Bottini's Operation). — The apparatus consists of 
an incisore prostatico and a rheostat to regulate the current accu- 
rately. 

One should have previously made an examination with the cys- 
toscope for stone, etc. The patient lies upon the back with his legs, 
hanging over the end of the table and the thighs spread apart. The 
bladder should contain about 6 ounces of boric-acid solution. 

Usually sufficient local anaesthesia is obtained by the use of a 
solution of cocain which is thrown into the urethra and stripped 
backward into the posterior urethra with the finger, or a general 
anaesthetic may be employed. With the finger in the rectum the 
size and the shape of the prostatic tumor may be determined. 

The incisore is introduced into the bladder beyond the enlarged 
prostate and its nose turned downward toward the base of the blad- 
der, so that, as it is slowly withdrawn, it catches or hooks upon the 
prostatic mass. The extremity of the instrument may be felt with 
the finger in the rectum through the bladder wall above the prostatic 
tumor. The instrument is now held firm and steady in the whole of 



436 URINARY SYSTEM. 

the left hand and the current closed and regulated by the rheostat 
until sufficiently strong to give a red heat, which usually requires 
fifteen seconds. Now, slowly turning the screw in the handle of the 
instrument, the heated blade is gradually withdrawn, thus burning 
a furrow through the prostatic mass. If the ear is held near the 
symphysis, a sizzling sound can be heard. If, -in withdrawing the 
blade, we note increased resistance in the mass, the current is aug- 
mented; if too little resistance to the blade — if it cuts too easily — 
the current is correspondingly diminished. After the incision has 
been made sufficiently long the blade is shoved back with a little 
increase of the current. 

Several such channels or incisions, usually three, should be made 
through the prostatic mass: one through the middle line, toward the 
rectum, with the nose of the instrument directed downward; one 
with the nose of the instrument directed upward toward the sym- 
physis; and one upon one or both sides of the middle line with the 
nose of the instrument again pointed downward toward the rectum. 
The operation should occupy from five to ten minutes. 

The incisore resembles a lithotrite, having a male and a female 
blade, the male blade fitting into the female and consisting of plati- 
num iridium, which may be heated to any degree by the electric cur- 
rent, whose strength is regulated by the rheostat. 

By turning the screw at the handle the male blade is withdrawn 
from the groove in the female blade, and is thus made to cut or burn 
its way through the hypertrophied prostatic mass. 

The shaft of the instrument is hollow, so that it may be supplied 
with a current of cold water, which flows in through one tube and out 
through another; these tubes are both placed near the handle. The 
cold water current is for the purpose of keeping that part of the 
instrument cool which rests in the anterior part of the urethra. 

Immediately before using the instrument it should be tested with 
the current, and an observation made upon the rheostat to determine 
just what degree of current is necessary to bring the blade to the 
proper heat; usually about 45 amperes are required. The screw in 
the handle permits of an incision up to 4 cm. in length being made. 



PART IX. 

THE UPPER EXTREMITY. 



THE AXILLA. 

The Axilla is a four-sided pyramidal space. Its apex is above, 
and corresponds to the depression upon the upper surface of the first 
rib;, external to the attachment of the tendon of the scalenus anticus 
muscle,, where the subclavian artery enters the axillary space to be- 
come the axillary. The base of the axilla corresponds to the fold of 
skin and fascia which is stretched between the edge of the pectoralis 
major in front and that of the latissimus dorsi behind. 

The anterior wall of the axilla is made up of the pectoralis major 
and pectoralis minor; the posterior wall is formed by the subscapularis 
and the tendon of the latissimus dorsi and the teres major. The inner 
wall corresponds to the side of the chest, and is made up of the first, 
second, third, and fourth ribs and corresponding intercostal muscles 
and the upper serrations of the serratus magnus. The outer wall of 
the axilla is a narrow space, which is included between the anterior 
and posterior walls and corresponds to the floor of the bicipital groove. 
In the bicipital groove is lodged the long tendon of the biceps. The 
coraco-brachialis muscle, which arises from the coracoid process, de- 
scends in the outer part of the axillary space, lying close to the 
humerus. 

To the anterior lip of the bicipital groove is attached the tendon 
of the pectoralis major, and to its posterior lip are attached the ten- 
dons of the latissimus dorsi and teres major. 

The contents of the axilla consist of the axillary artery and vein, 
the large nerve-trunks which are derived from the brachial plexus, 
lymphatic vessels and nodes, and a mass of loose connective tissue and 
fat which is continuoiis with the connective tissue and fat of the root 
of the neck and the mediastinum. 

The Axillary Artery. — The axillary artery is the continuation 
of the subclavian, and passes through the axillary space from its apex 
to its base, where it is prolonged downward into the arm as the brach- 
ial. The vessel passes through the upper part of the axillary space, 

(437) 



438 



UPPER EXTREMITY. 



lying close to its anterior wall. The lower, or outer, portion of the 
artery lies close to the humerus, beneath the edge of the coraco-brachi- 
alis, resting upon the tendon of the latissimus dorsi, and covered by 
the pectoralis major. The axillary vein, which is sometimes double, 
accompanies the artery, lying below it, and both artery and vein are 
in close relation with the nerve-trunks which traverse the axillary 
space. With the arm extended to a right angle, the course of the 
artery is nearly straight, and corresponds to an imaginary line which 
is drawn from the junction of the inner and middle thirds of the clav- 




Fig. 183. — Axillary Region. Costo-coracoid membrane has been cleared 
away to show upper part of the axillary vessels, etc. C.V., cephalic vein; 
EX. C.N. , external cutaneous nerve; IX. C.N. , internal cutaneous nerve; 
M.N., median nerve; S.V., subscapular vein; U.N., ulnar nerve. 

icle to a point upon the front of the elbow midway between the two 
condyles; with the arm hanging by the side, the artery describes a 
curve which is convex upward and outward. 

After the pectoralis major has been separated from its attach- 
ment to the clavicle and reflected downward, the pectoralis minor, 
together with the costo-coracoid membrane, will be exposed. The 
costo-coracoid membrane is a rather thickened sheath of fascia which 
reaches from the inner border of the pectoralis minor upward, to be 
attached to the under surface of the clavicle and to the first rib; it 
is simply a reflection of the deep fascia which invests the pectoralis 



AXILLA. 439 

minor, and serves to cover in the upper, or first, part of the axillary 
vessels and adjoining structures. 

The axillary artery is crossed about its middle by the pectoralis 
minor muscle, and may be conveniently considered in three parts. 
The upper, or first, part of the artery reaches from its commencement 
at the first rib to the inner border of the pectoralis minor, and is not 
exposed until after the costo-coracoid membrane has been cleared 
away; the second part of the artery is that portion which lies behind 
the pectoralis minor muscle, and the third is that part which reaches 
from the outer border of pectoralis minor to the point below where it 
becomes the brachial. 

In the first part of its course the three trunks of the brachial 
plexus lie above the axillary artery. In the second part of its course 
one trunk lies above, one behind, and one below it. In the third part 
the cords of the brachial plexus communicate with each other, sur- 
rounding the axillary artery, and divide into a number of branches to 
supply the upper extremity. The median nerve lies external to the 
artery, taking one root from the external cord of the plexus and a 
second root from the internal cord, the latter root passing across the 
front of the artery. The external cutaneous nerve also lies to the 
outer side of the vessel, being derived from the outer cord of the 
plexus. To the inner side of the artery, and derived from the inner 
cord, are the ulnar, internal cutaneous, and lesser internal cutaneous 
nerves. Derived from the posterior cord of the brachial plexus and 
situated behind the artery are the posterior circumflex and the mus- 
culo-spiral nerves. Immediately after its origin the circumflex passes 
directly backward between the subscapularis and latissimus dorsi (and 
teres major) muscles, and is distributed to the deep surface of the 
deltoid. 

The cephalic vein pierces the costo-coracoid membrane and passes 
across the first part of the axillary artery to empty into the axillary 
vein. 

The lymphatic vessels and nodes are intimately related to the 
axillary vessels along their whole course within the axilla. 

From the upper, or first, part of artery are given off the superior 
thoracic and acromial thoracic branches, which are distributed to the 
anterior wall of the axilla and to the axillary contents. A branch from 
the acromial thoracic is found in company with the cephalic vein in 
the groove between the deltoid and pectoralis major muscles (Mohren- 
heim's fossa). 



440 UPPER EXTREMITY. 

At the lower border of the pectoralis minor the long thoracic is 
given off; this branch passes downward close to the lower border of 
this muscle, lying beneath the edge of the pectoralis major, and ram- 
ifies upon the side of the chest. 

Still lower, and close to the posterior wall of the axilla, the artery 
gives off the subscapular, a large branch which descends upon the 
posterior wall of the axilla, along the outer border of the subscapularis 
muscle; it is accompanied by the large subscapular nerve, and enters 
and supplies the latissimus dorsi. External to this branch is given 
off the posterior circumflex, which passes backward between the latissi- 
mus dorsi and subscapularis muscles together with the circumflex 
nerve; they wind around the surgical neck of the humerus beneath 
the deltoid, which they supply. The axillary vessels and adjoining 
nerves, etc., in the upper, or inner, part of the axillary space, are 
located close to the anterior wall, and in the lower, or outer, part of 
the axilla they are found close to the humerus, resting upon the 
tendon of the latissimus dorsi and beneath the edge of the coraco- 
brachialis. Branches of the axillary artery ramify upon the anterior 
and posterior walls of the axillary space, and, descending upon the 
inner wall, side of the chest, posteriorly, is the long thoracic nerve, 
which supplies the serratus magnus; the middle of the axilla is, 
therefore, free for incisions for abscess, etc.; if it is desired to ex- 
tirpate completely the axillary contents, it is well to commence by 
making a clean dissection of the main vessels and nerves. 

THE ARM. 

Upon the front of the arm there is seen a prominent spindle- 
shaped mass, which consists of the belly of the biceps and, joined to 
its inner side, the coraco-brachialis muscle. Occup}dng the inner side 
and back of the arm is a thick mass of muscle, the triceps. Upon the 
outer side, above, covering over the shoulder-joint, is a large mass of 
muscle, the deltoid. Beneath the deltoid, between it and the surgical 
neck of the humerus, the circumflex nerve and the circumflex arteries 
are found. The circumflex nerve, although well protected by the mass 
of deltoid muscle, on account of its relation with the neck of the 
humerus is often injured by blows and falls upon the shoulder, with 
a resulting disability of the deltoid. 

Vessels of Arm. The Brachial Artery. — In the depression 
corresponding to the inner margin of the biceps and coraco-brachialis, 



ARM. 



441 



beneath the deep fascia, lies the brachial artery. The brachial artery 
is the continuation of the axillary; it passes down along the inner side 
of the arm in the space between the anterior muscular mass, biceps, etc., 
and the inner muscular mass, triceps; externally and behind, the 
artery rests against the humerus, and below the bend of the elbow it 
divides into the radial and ulnar. 

The linear guide to the artery with the arm abducted is a line 
drawn from the coracoid process to a point upon the front of the 
elbow, midway between the condyles; the muscular guide is the inner 
edge of the biceps and the coraco-brachialis muscles. 

The brachial artery is covered by the integument and deep fascia, 



CEPH/1L 
VEIN 



BRACHIAL 
ARTERY. 

MEDIAE 
filttVE. 

BAC/L- 

/C VElrf. 



MUS.SPI 




Fig. 184. — Section through Middle of Right Arm. 



and is accompanied by two veins, venae comites, which lie directly 
upon the vessel and anastomose with each other by numerous trans- 
verse branches. Above the median nerve lies to the outer side of the 
artery, crosses the artery about its middle, and below lies to its 
inner side; the ulnar and internal cutaneous nerves lie to the inner 
side of the artery, the ulnar resting upon the inner head of the 
triceps and gradually getting farther away from the artery as it 
descends to reach the back of the internal condyle. Behind the 
artery, in the upper part of the arm, lies the musculo-spiral nerve. 

The basilic vein runs parallel with the brachial artery, lying 
superficial to it and rather to its inner side. One may meet this vein 



442 UPPER EXTREMITY. 

in making the incision to expose the brachial artery. In the lower 
half of the arm this vein is separated from the artery by the deep 
fascia, but about the middle of the arm it pierces the deep fascia, and 
thus gets into closer relation with the artery. In the upper part of 
the arm the basilic vein joins the Tense comites to form the axillary 
vein. Along the outer side of the arm, superficial to the deep fascia, 
runs the cephalic vein; above this vein is found in the groove between 
the pectoralis major and the deltoid, and, after piercing the costo- 
coracoid membrane, passes across the first part of the axillary artery 
to empty into the axillary vein. 

At the Elbow, upon the front aspect of the arm, there is a tri- 
angular space with its apex directed downward toward the hand; the 
inner border of the space is formed by the pronator radii teres, passing 
obliquely downward and outward from the internal condyle; the outer 
border is formed by the spinator longus, and the floor of the space by 
the brachialis anticus and supinator brevis. 

In this space are found the tendon of the biceps, the brachial 
artery and its accompanying veins, the median and the musculo-spiral 
nerves, and the bifurcation of the brachial artery into the radial and 
ulnar, which occurs about one inch below the bend of the elbow. In 
this space the median nerve is about half an inch to the inner side of 
the brachial artery, owing to the latter's verging outward, away from 
the nerve, toward the middle line. 

The musculo-spiral nerve lies in the outer part of the space upon 
the supinator brevis, and is covered by the overlapping edge of the 
supinator longus. This region is covered by the skin, superficial and 
deep fascia. The skin of this region has a marked tendency to retract 
when cut, and this should be remembered in marking out the flaps for 
exarticulation at the elbow-joint. Lying just beneath the skin upon 
the deep fascia is the median cephalic vein externally, and the median 
basilic internally. The latter, the median basilic, is separated from 
the brachial artery, not only by the deep fascia, but also by a fibrous 
expansion which is given off from the biceps tendon to the deep 
fascia of the forearm. The median cephalic is the vein selected by 
preference for intravenous infusion. 

The Eadial Artery. — From its origin below the bend of the 
elbow the radial passes somewhat outward and then downward upon 
the outer side of the anterior aspect of the forearm; it lies superficial, 
though partly covered by the overlapping edge of the supinator longus. 
In its course it rests upon the tendon of the biceps, the supinator 



ARM. 443 

brevis, the radial origin of the flexor sublimis digitorum, the pronator 
radii teres, the flexor longus pollicis, and the pronator quadratus. The 
lower part of the artery, above the wrist, lies beneath the integument 
and the deep fascia, to the outer side of the tendon of the flexor carpi 
radialis, between it and the tendon of the supinator longus. 

In the upper part of the forearm the artery is accompanied by 
the radial branch of the musculo-spiral nerve, which lies to its outer 
side. Usually two vena? comites accompany the artery. 

At the wrist the radial artery curves around the outer side of 
the joint, lying beneath the extensor tendons of the thumb and resting 
upon the external lateral ligament; it then passes across the posterior 
surface of the scaphoid and trapezium, and then forward, through the 
opening in the first dorsal interosseous muscle, into the palm of the 
hand. 

In the hand the radial artery is situated deep and passes from 
without inward, resting upon the bases of the metacarpal bones and 
the anterior interosseous muscles, covered by all the structures of the 
hand: tendons, nerves, superficial arch, etc. Upon reaching the inner 
side of the hand it anastomoses with the communicating branch from 
the ulnar, and in this way completes the deep palmar arch. The deep 
palmar ar