THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
LOS ANGELES
GIFT
Mrs . Snedaker
f
SURGICAL TREATMENT
A Practical Treatise
on the Therapy of Surgical Diseases for the Use of
Practitioners and Students of Surgery
BY
JAMES PETER WARBASSE, M.D,
Fellow of the American College of Surgeons
American Medical Association
American Academy of Medicine
New York Academy of Medicine
Surgeon to the Wyckoff Heights Hospital, Brooklyn, New York
Formerly Attending Surgeon
to the Methodist Episcopal Hospital, Brooklyn, New York
IN THREE VOLUMES
WITH 2400 ILLUSTRATIONS
VOLUME II
PHILADELPHIA AND LONDON
W. B. SAUNDERS COMPANY
1920
Copyright, 1918, By W. B. Saunders Company
Reprinted June, 1919
Ill-printed September, 1919
Heprinted April, 1920
PRINTED IN AMERICA
wa-
00
CONTENTS
PAGE
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 17
The Scalp 17
The Skull 26
Operations upon the Skull 26
Diseases of the Cranial Bones 41
Intracranial Injuries and Diseases 42
Concussion of the Brain 52
Contusion of the Brain 52
Compression of the Brain 53
Intracranial Hemorrhage 54
Wounds of Intracranial Structures 61
Diseases of Meninges and Ependyma 65
Inflammations of the Brain 73
Tumors of Meninges and Brain 75
Operations on Hypophysis of Brain 82
Encephalocele 92
Hydrocephalus 94
Epilepsy 99
Traumatic Psychoses and Insanity 102
Intracranial Operations upon Fifth Nerve (Trigeminal) 105
Intracranial Operations on Auditory Nerve no
Injuries and Diseases of Face 115
The Eye 115
Diseases of Eyelids 119
Wounds of Eyeball 121
Diseases of Conjunctiva 121
Diseases of Cornea 124
Diseases of Sclera 128
Diseases of Iris 129
Diseases of Ciliary Body 130
Diseases of Choroid 130
Diseases of Crystalline Lens 132
Diseases of Vitreous 134
Diseases of Retina 134
Diseases of Optic Nerve 135
Disorders of Orbital Muscles 135
Diseases of Lacrimal Apparatus 136
Diseases of Orbit 137
Operations on the Eye 138
Operations on the Eyelids 138
Operations on the Conjunctiva 149
Operations on the Cornea 152
Operations on the Iris 154
Operations on the Sclera 156
Operations on the Globe 157
Operations for Cataract 165
Operations upon the Eye Muscles 174
Operations on the Lacrimal Apparatus 177
The Nose 179
Injuries of the Nose 183
Infections of Nasal Cavities 186
Malformations of Nasal Septum 188
Empyema of the Antrum 195
Empyema of the Ethmoid Sinuses 197
Empyema of the Sphenoid Sinuses 198
Empyema of the Frontal Sinus 199
11
782^09
12 CONTENTS
PAGE
Nasopharynx and Fauces 205
Retropharyngeal Abscess 205
Diphtheria 207
Adenoids of Nasopharynx 208
Tonsils 212
Larynx and Trachea 217
Malformations 218
Infuries 219
Inflammations 220
Tuberculosis of Larynx 222
Tumors 223
Foreign Bodies in Larynx, Trachea and Bronchi 224
Operations on Larynx, Trachea and Bronchi 226
The Mouth 244
Inflammation of Lips and Mouth 246
Epithelioma of Lower Lip 247
Diseases of Soft Palate and Uvula 255
Cleft-palate 257
Harelip 266
The Teeth and Gums 274
Caries of Teeth 275
Alveolar Abscess, Pyorrhea Alveolaris, Gingivitis 277
Extraction of Teeth 278
Tooth Grafting 279
Tumors of Gums and Teeth 280
The Jaws 280
Deformities of Jaws 280
Periostitis and Osteomyelitis of Jaws 283
Tumors of Jaws 286
The Tongue 286
Congenital Defects of Tongue 286
Injuries of Tongue 287
Inflammation of Tongue 288
Ulcers of Tongue 289
Tumors of Tongue 292
Removal of Tongue for Carcinoma 293
The Ear 299
The External Ear 303
The External Auditory Canal 304
The Middle Ear 306
Chronic Suppurative Otitis Media 308
Radical Mastoid Operation 312
Operation for Acute Mastoiditis 317
Intracranial Complications of Infections of Temporal Bone 318
Labyrinthine Disease 319
THE SPINE 322
Contusions and Concussion of Spinal Cord 324
Stab Wounds and Bullet Wounds of Spine 325
Osteomyelitis, Spondylitis 326
Tuberculosis of Spine 327
Tumors of Spine and Cord 338
Operations on Posterior Nerve Roots 344
Spina Bifida 349
Lumbago 350
Kyphosis 351
Scoliosis 352
Diseases of Sacro-iliac Joint 355
Coccygodynia 357
THE NECK 360
Wounds and Injuries 360
Infective Processes 361
Diseases of Lymphatics of Neck 363
Operations on Tonsil and Pharynx through Neck 367
Tuberculous Lymph Glands of Neck 368
Tumors of Neck 372
Torticollis 373
CONTENTS 13
PAGE
Salivary Glands 377
Parotid Salivary Fistula 377
Thyroid Gland 380
Inflammations 380
Malignant Tumors 381
Goiter (Struma) 381
Hyperthyroidism 389
Hypothyroidism 394
Thymus Gland 394
Carotid Gland 395
THE THORAX 396
Chest Wall 397
Inflammation of Chest Wall 398
The Pleura 399
Wounds of Pleura 399
Hemothorax 400
Hydrothorax 401
Pyothorax (Empyema) 402
Tubercular Hydrothorax and Pyothorax 413
The Lungs ' . . 413
Wounds of Lungs 413
Abscess of Lung 414
Tuberculosis of Lungs 416
Bronchiectasis 419
Rigidity of Chest 421
The Pericardium 422
Serous Effusion in Pericardium 422
Exposure of Pericardium and Heart 424
The Heart 424
Paracentesis of Heart 425
Exposure by Plastic Flap 426
Cardiorrhaphy 427
Wounds of Heart 428
Foreign Bodies in Heart 429
Heart Massage for Cardiac Syncope 430
The Esophagus 430
Wounds 431
Inflammations and Ulceration 432
Congenital Stenosis 433
Stricture 433
Dilatations 438
Fistula 439
Foreign Bodies 440
Esophagismus 442
External Cervical Esophagotomy 442
Partial Cervical Esophagectomy 443
The Mediastina 444
Tumors of Thorax 444
Operations through Mediastinae and Pleurae 446
Operations on the Lungs 453
Exposure of Lungs 453
Pneumotomy, Pneumectomy 456
Operations on Mediastina 458
Anterior Exposure of Mediastina 458
Posterior Exposure of Mediastina 459
Resection of Thoracic Esophagus 463
Thoracic Exposure of Diaphragm 467
THE BREAST 471
Contusions and Wounds, Congenital Anomalies 472
Hypertrophy 472
Diseases of Nipples 473
Mastitis 473
Tuberculosis of Breast 475
Benign Tumors 475
Cysts 476
Carcinoma 477
The Male Breast 49 7
14 CONTENTS
PAGE
THE ABDOMEN 498
General Principles 498
Regions of Abdomen 499
Structures of Abdominal Wall 500
Landmarks of Abdomen 503
Abdominal Section 504
Incisions for Opening Abdomen 504
Median Abdominal Section 510
Ilio-inguinal Abdominal Section 510
Oblique Postmuscular Abdominal Section 511
Vertical Postmuscular Abdominal Section 512
Low Median Abdominal Section 513
Oblique Subcostal Abdominal Section 513
Retraction, Sponging 515
Protection of Peritoneum 515
Leaving Instruments in Abdomen 516
Closure of Abdominal Wound 516
Dressing Abdominal Wound 519
Methods of Dealing with Adhesions 520
Methods of Dealing with Hemorrhage 523
Methods of Securing Drainage 524
Postoperative Treatment of Abdominal Cases 529
The Abdominal Wall 535
Wounds of Abdominal Wall 535
Infections of Abdominal Wall 536
Diseases of Umbilicus 537
Tumors of Abdominal Wall 538
Excessive Abdominal Fat 538
Relaxed and Pendulous Abdomen 540
The Peritoneum 541
Injuries 542
Foreign Bodies in Peritoneal Sac 544
Peritonitis 546
Paralytic Ileus 552
Ascites 557
Retroperitoneal Disease 563
Preparation of Patients for Operations on Alimentary Canal 564
The Intestines 565
Contusions 565
Rupture 566
Perforating Wounds 567
Wounds of Mesentery 568
Infections of Intestinal Canal 569
Ulcers and Perforations of Intestines 576
Tumors of Intestines 582
Intestinal Obstruction 595
Diverticula 603
Intussusception 604
Chronic Intestinal Obstruction 610
Chronic Intestinal Stasis 610
Acute Intestinal Stasis 614
Acute Dilatation of Stomach 615
Enteroptosis 616
Closure of Intestinal Fistula 616
The Omentum 620
Enemata 620
Operations on Intestines 621
Intestinal Suture 628
Intestinal Resection 636
Intestinal Anastomosis 646
Intestinal Exclusion 677
Operations for Closing Lumen 681
Enterostomy 683
Jejunostomy 695
The Stomach 698
Gastric Lavage 700
CONTENTS 15
PAGE
Inflammations 702
Carcinoma of Stomach 703
Hour-glass Stomach 706
Gastroptosis 710
Dilatation of Stomach 713
Cardipspasm 716
Pyloric Stenosis 717
Ulcer of Stomach 720
Hemorrhage of Stomach 727
Operations on Stomach 730
Gastrotomy 730
Gastrostomy 730
Pylorodiosis 737
Pyloroplasty 740
Gastroduodenostomy 747
Pylorectomy 747
Resection of Pyloric End of Stomach 751
Radical Operation for Cancer of Pyloric End of Stomach 756
Resection of Cardia for Carcinoma 756
Resection of Gastric Ulcer 759
Partial Gastrectomy 759
Total Gastrectomy 761
Gastro-enterostomy 762
Exclusion of Pylorus 771
Reconstruction of Wall of Gastro-intestinal Tract 773
Treatment of Shock in Gastric Operation 776
The Pancreas 778
Wounds 779
Approach 779
Drainage 780
Pancreatitis 780
Tumors 782
Pancreatic Calculi 783
The Spleen 784
Hemolytic Jaundice, Pernicious Anemia, Biliary Cirrhosis 785
Leukemia 786
Wandering Spleen 786
Operations on Spleen 787
INDEX OF NAMES 789
INDEX OF SUBJECTS 793
SURGICAL TREATMENT
REGIONAL SURGERY
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
SCALP
In the treatment of injuries and diseases of the scalp, there are certain
peculiarities of structure to be considered. The scalp is loosely connected
to the bone by elastic connective tissue, which renders it freely movable and
easily detached, excepting in infancy and old age. Its blood supply is so
rich that healing is easily secured. The chief arteries are the supraorbital,
temporal,- and occipital; and in making large flaps these vessels should be
considered. The capillaries, anastomosing venules, and arterioles are so
numerous as to give the scalp almost an angiocavernous or spongy character.
The veins communicate through the minute openings in the skull with the
intracranial vessels so freely that infections in the scalp always threaten the
venous sinuses of the brain. The structure of the scalp is so firm and so
related to the vessels that when the latter are divided they do not collapse
but their mouths tend to remain open and bleed.
The lymphatics empty into the lymph chains of the neck. The nerve
supply is largely sensory, giving rise often to neuralgias if irritated by scar
tissue. The motor nerves are to the occipitofrontalis, temporal, and small
muscles of the ear. The nerve to the frontalis from the facial should be
guarded from injury. The external periosteum of the skull has the power to
generate bone even in adults. It is adherent with especial firmness at the
suture lines. The deepness of the hair follicles and glands of the scalp
renders perfect cleansing by mechanical means impossible. lodin in alcohol
or other penetrating antiseptic solution must be used for cleansing.
Contusions. — Contusions of the scalp require the treatment already given
for contusions in general, unless associated with hematoma, open wound,
or fracture of the skull. The vessels of the scalp are so easily torn and the
scalp is so easily lifted up that more or less extravasation of blood accom-
panies contusions. To prevent or minimize this, cold and pressure are of
service. Cold water, an ice-bag, or alcohol may be combined with a gently
compressing bandage to the contused area immediately after the accident.
Hematoma of the Scalp. — The first essential in the treatment is to recog-
nize the nature of the condition. When the scalp is lifted up by a bloody
effusion, the softened center and the abruptly indurated circumference should
not obtain for the patient an operation directed to the cure of a depressed
fracture which does not exist. During its development a hematoma may
be checked in its progress by the use of cold and pressure. The cold should
not be of too low a degree. Having reached its maximum size and the back-
pressure having stopped the bleeding, there is little to do but await the ab-
sorption of the blood. The active circulation of the scalp makes such ab-
sorption rapid, and usually the hematoma will have disappeared within a
VOL. II— 2 * 17
18 SURGICAL TREATMENT
week or ten days. The absorption may be hastened by warm applications.
This treatment is not called for unless for cosmetic reasons.
If a hematoma has not been absorbed in two weeks, it is good treatment
to incise it. This should be done with a narrow-bladed knife, making a
puncture at its base at the lowest point. If the blood does not flow out
freely, a canula may be inserted through the wound, and the contents of the
swelling washed out with sterile water. Aspiration is not satisfactory because
of the thick consistency of the blood. Such an operation should be done
with the same aseptic care as any other operation upon the skull or brain,
because the surgeon cannot know but that a fracture communicates with the
hematoma. The pressure of a firm dressing for a few days will cause the
scalp to adhere again to the skull. An infected hematoma demands free
incision and drainage.
Accidental Wounds of the Scalp. — No open wound of the scalp should
be regarded as unimportant. The aim of treatment should be to prevent
cellulitis and suppuration and to minimize scar. Often wounds which look
like incised wounds are contused wounds with ragged and devitalized tissue
beneath. All scalp wounds should be freely exposed so that the nature and
extent of the wound can be seen. Blood, dirt and hair should be removed
until the wound is clean. The best cleansing for a scalp wound which con-
tains foreign matter is accomplished with warm water and soap, or peroxid of
hydrogen, followed by sterile water. The hair immediately around the
wound should be shaved, and the remaining hair parted away from it.
Ragged edges should be trimmed away. Clotted blood should be washed
out. Every particle of foreign material which can be seen should be re-
moved either by irrigation, with a scrubbing brush, or picked out with forceps.
After cleansing and drying a dirty wound it should be swabbed throughout
with 3 per cent, iodin in alcohol, or a chlorin antiseptic should be applied.
Wounds which are not seriously soiled need not be treated with a chemical
antiseptic. At the time of treating the wound the skull may be examined
for fracture.
Every accidental scalp wound is an infected wound; whether it will
suppurate or not is a fortuitous matter which the surgeon cannot predeter-
mine. The best guarantee against suppuration is the antiseptic treatment.
Drainage is advisable in all cases of large ragged wounds. This may be
secured with a small rubber tube, a roll of rubber dam, or any other drainage
material. Even in small wounds drainage for the first two days is wise.
In small wounds, I like to use a small bundle of silkworm-gut sutures for
drainage. Pockets often demand counter openings. The drainage should
be adequate. A scalp wound properly cleansed, antisepticized, and drained,
represents in a high degree the possibilities of good surgery; a scalp wound
improperly cared for, covered with hair and matted blood, and its extent
undetermined, represents one of the worst forms of surgical neglect.
The control of hemorrhage in small wounds is simple. In larger wounds,
as a result of the cleansing and trimming of the edges, bleeding may be awak-
ened. It may be controlled temporarily by pressure made by an assistant
with a pad of gauze; or the bleeding edges may be covered with gauze and
lightly clamped with T-shaped or ring-clamps. In extensive wounds the
bleeding may be checked by the elastic bandage around the head. Time
should not be wasted clamping and ligating bleeding points, for if this is
once begun it means ligating the whole of the edges (see Operative Control
of Hemorrhage of Scalp, page 20). If the facilities for stopping the hemor-
rhage by the above means are not at hand, temporary mass-ligatures may
be applied with a needle. The permanent control of bleeding in scalp wounds
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
19
is accomplished by the sutures which close the wound and the pressure of the
dressing. The only vessels entitled to separate ligatures are the main trunks
of the frontal, temporal, posterior auricular, and occipital arteries; and even
these can be controlled by the wound suture. The inexperienced surgeon
will be seen wasting time, and blood, clamping and ligating bleeding points
prior to suturing the wound, when the sutures which he will ultimately
apply would accomplish all of the hemostasis that can be secured by the time-
consuming process of multiple ligations.
For suturing wounds of the scalp, interrupted sutures of silkworm-gut
or silk are preferable. They should be tied tightly enough to check bleed-
ing. In the forehead a subcuticular suture of wire, or other stiff material
FIG. 700. — TOURNIQUET OF RUBBER TUBING FOR CONTROL OF BLEEDING OF SCALP.
The tubing is applied over tapes and caught with a heavy clamp.
is most effective, as it avoids the multiple puncture wounds of the skin.
The superficial subcuticular should be preceded by a deep buried suture
of catgut which controls bleeding and closes the deep parts.
Bleeding appearing between sutures may be controlled by still another
suture. Union takes place quickly. The wound should be dressed daily
for the first four days in order to discover infection. Undrained infection and
stitch-hole abscess call for the removal of sutures. Drainage is usually
continued from two to four days, and the sutures removed in five or ten
days, unless the presence of infection demands that the drainage be continued
longer and the sutures removed earlier.
20
SURGICAL TREATMENT
Operative Wounds of the Scalp. — In the wounds of the scalp, made by
the surgeon as a step in an operation, the conditions are different from those
of accidental wounds. A wide area of the scalp should be shaved of hair.
In operations upon the skull or brain, either a half or, better, the whole of
the scalp should be shaved. The shaving and cleansing with soap and warm
water should be thorough. This should be done twenty-four hours before
the operation. The scalp should then be washed with alcohol, and covered
with a dry gauze cap. Just before the operation the dry scalp should be
treated with tincture of iodin or other skin disinfectant. In the absence of
such, scrubbing and treatment with an antiseptic solution may be used (see
Preparation of the Skin for Operation, Vol. I, page 177).
To render the operation as free from blood as possible, a rubber elastic
tourniquet should be applied. For this purpose the ordinary rubber bandage
FIG. 701. — TOURNIQUET OF RUBBER TUBING FOR CONTROL OF BLEEDING OF SCALP.
Tapes tied to prevent displacement of tubing. A sterile cloth may be placed under
the tubing and tapes and folded downward when the operation is to proceed. Either of
the tapes may be dispensed with, or the positions of the tapes may be altered to accom-
modate the site of operation.
or rubber tubing may be used. To apply this, all being ready for operation,
a sterile cloth or square of gauze is laid smoothly over the scalp. Then a
strip of sterile tape or muslin bandage, about 100 cm. (40 inches) long is
placed over this, running anteroposteriorly in the middle line and having
its middle at the forehead. A similar piece is placed transversely across
the head (Fig. 700). The rubber bandage is then tightly applied in the form
of a cord around the head over these, passing around 2 or 3 times just
above the ears and the eyebrows, and its ends fixed by a clamp. The two
ends of the tape or bandage are then gathered up and tied over the scalp in
the most convenient place, the object of this being to prevent the hemostatic
bandage from slipping downward. An opening is cut in the cloth at the site of
operation, and the lower ends of the cloth so distributed as to cover the ears
and adjacent parts (Fig. 701). Gushing used a tubular rubber, which was
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
21
fitted to the patient's head the day before the operation, provided with a
tape to prevent slipping, and the ends fixed. This is ready sterilized, and can
be snapped on just before the operation.
Instead of using a rubber tourniquet around the head, broad clamps
may be applied to the bleeding edge of the scalp wound. W. P. Carr
devised a useful appliance for this purpose. It is a clamp with a light spring,
and with a crescent-shaped bite (Fig. 702). Such clamps may be applied
about the whole outer edge of the wound, and removed just before the suture
is applied.
L. Friedman (Surg. Gyn. and Obs., xx, 1915) devised a hemostat
having the principle of a safety pin, which is very useful (Fig. 703).
The metal bobbins of Kredel are also useful for local hemostasis. They are
made of soft pliable metal such as tin, lead or copper so that they may be
given the shape of the surface to which they are applied. They consist
FIG. 702. — CLAMP FOR TEMPORARY CONTROL OF BLEEDING FROM WOUNDS OF SCALP.
simply of a notched rod (Fig. 704) made in lengths of 5 cm. (2 inches) and
7 cm. (2% inches). Before making the scalp incision, a heavy silk suture is
passed through the scalp with a straight or slightly curved needle just beyond
the contemplated line of incision. The needle slides along the bone and then
emerges, embracing a distance about equal to the length of the rod to be
used. If the longer rod is to be employed the needle should emerge at half
the distance to be traversed and then reintroduced to make a loop. The
thread is tied over the bobbin, and the scalp thus compressed. A number of
these rods may be used. They are removed at the end of the operation.
A line of sutures of heavy catgut alone may be used. The sutures are
passed down to the bone with a curved needle. Each stitch takes about
2 cm. (% inch) of scalp, and overlaps about half of the preceding suture.
This is a running suture, placed about 1.3 cm. (^ inch) beyond the proposed
line of suture. The suture should not only pass around parallel with the
22
SURGICAL TREATMENT
FIG. 703. — HEMOSTATIC SAFETY-PIN OF FRIEDMAN FOR CONTROLLING BLEEDING IN THE
SCALP.
If necessary a temporary suture of silk may be inserted at the angles left open between the
pins.
FIG. 704. — METAL RODS FOR SCALP HEMOSTASIS.
A heavy silk suture is passed through the scalp, over the rod, and tied.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 23
contemplated incision, but should cross the base of the flap also, thus com-
pletely surrounding it. At the end of the operation the suture is quickly
removed by cutting the thread.
Avulsion of the Scalp. — This accident, occurring most commonly among
women operatives in factories, should be treated by first controlling the
hemorrhage from the main arteries if they are bleeding. Usually when the
surgeon sees the patient, bleeding has stopped. If the avulsion is a partial
one, the wound should be cleansed as described above for accidental scalp
wounds, the hair shaved, and the flap sutured back in place. If the scalp
or a part of the scalp has been completely detached, it should be cleansed in
warm saline, shaved, kept warm all the time, and, as soon as the wound can
be made ready, sutured back in place. If the scalp or a portion of the scalp
has been irreplacably damaged, the wound should be cleansed and covered
with strips of rubber dam or other porous material over which a copious
wet gauze dressing is applied. A piece of scalp which is destined to become
necrotic should not be left. The head should be kept warm and protected
by the dressing. To prevent the remaining scalp sagging over the eyes, it
may be necessary to fasten it with a few sutures to the frontal periosteum.
Usually the condition of the patient does not justify any more operation
than the above at the first dressing in cases of complete avulsion. At the
earliest time possible, steps to cover the denuded area with epithelium should
be made. This may be accomplished by turning up flaps from the back of
the neck or elsewhere; skin grafts may be used; or scalp flaps may be donated
by members of the patient's family (see Plastic Operations, Vol. III).
The granulating surface should not be left too long uncovered by epithe-
lium, as the more time that elapses the poorer becomes the nourishment of
the surface on account of the deposit of scar tissue. With good care,
healing in the worst of these cases may be expected. Treatment by skin-
grafting or skin transplantation is imperative. Large areas cannot be expect-
ed to become covered by epithelium growing in from the periphery. If the
surgeon cannot make grafts or transplants grow to the denuded area, he
should not be satisfied with an alternative; he should put the case in the
hands of some surgeon who can.
In these distressing cases there is no use of attempting to restore a com-
pletely avulsed and dirty scalp. A small piece may be cleansed and restored,
but a large piece cannot. Just as soon as granulations have formed, plastic
flaps should be applied. Flaps containing some fat are best. The Italian
method of taking flaps from the arm is highly advantageous. Thin skin
grafts should not be used over a large area, as the skull needs a thick covering,
and, unless it has it, nervous disturbances will develop. The best results
are secured, by turning up flaps from the periphery and adding to these
flaps transferred from the arm.
In complete avulsion of the scalp, after checking hemorrhage, it is well to
apply hot boric acid compresses. From three to five days later, skin grafting
should be done. It is best to take the skin from the patient herself. One-
third or one-half of the area may be grafted, preferably one or the other sides
so that an ungrafted side is left to lie on. A week or ten days later the other
side may be grafted.
If an area of denuded bone develops, granulations may be made to grow
upon it by boring holes in the bone. Each hole becomes an island of granu-
lations.
Infections of the Scalp. — Cellulitis easily takes place in the loose cellular
tissue under the scalp. It is for this reason that every scalp wound should
be watched carefully, and sutures removed upon the earliest appearance
24 SURGICAL TREATMENT
of infection. There should be no hesitation in opening up widely a wound
which shows infection. Unless this is done, the cellulitis is prone to extend,
it may be, over the whole skull. Treatment must be aimed to check its
progress. An area of cellulitis of an undrained part of the scalp should be
freely incised, and copious wet dressings kept applied (see Cellulitis, Vol. I,
page 264).
Abscess should be prevented by combating cellulitis and providing free
drainage before an abscess occurs. Wherever an abscess develops it should
be incised and drained. The hair should be kept shaved from the infected
area. Indeed, as soon as a spreading infection appears the scalp should be
shaved. These infective processes are amenable to treatment by suction
hyperemia, but free incision and drainage should be the main reliance.
Other reasons for vigorous treatment of scalp infections are because of the
danger of infection of the intracranial sinuses and meninges through the
communicating veins and because of the strong tendency to caries and
necrosis of the underlying skull. For these reasons cellulitis of the scalp
should be thought of as a serious disease, and should receive the best surgical
attention.
Erysipelas is prevented by the measures above described. Copious
wet dressings combined with the induction of artificial hyperemia by suction
or bandage are the most effective treatment. The disease runs a course of
about nine days, during which time the general as well as the local condition
of the patient should receive attention (see Erysipelas, Vol. I, page 262).
Tumors of the Scalp. — These tumors are similar to those encountered
elsewhere in the integument (see Tumors of Skin, Vol. I, page 840).
Sebaceous cysts (wen) should be removed for cosmetic reasons or when
they become objects of annoyance(see Cystoma, Vol. I, page 325; Steatoma,
Vol. I, page 845). Dermoid tumors develop at the sites of closure of congenital
clefts, and require removal because their pressure often produces rarefication
and absorption of bone. In removing these growths the lining epithelium, or
enveloping epithelium, of the cystic tumor should be removed or destroyed.
Such growths in the orbit or temporal fossa may require resection of bone to
accomplish their removal. These tumors should be removed early in life to
obviate the damages which their pressure would inflict upon the growing
parts.
Lipomata and fibromata may be important because of their confusion with
other conditions. They are easily excised. For treatment of keloids (see
Vol. I, page 843; and Vol. III). Fibroneuroma (plexiform neuroma, ele-
phantiasis nervorum, multiple neurofibromatosis) is observed most fre-
quently in the temporofrontal region, but wherever it occurs it should
be excised as soon as possible. When the tumor has become larger, its
extirpation becomes more difficult because of its size, vascularity and spongy
character. If the tumor is allowed to grow it may become too extensive
for safe removal, or several operations may be required.
Pericranial pneumatocele, the air tumor caused by a defect in the wall of the
mastoid or frontal sinuses, permitting air to lift up the pericranium and scalp
into an air-filled sac, should not be confused with transient emphysema of the
scalp due to fracture of the sinuses or with infection with gas-forming bac-
teria. The method of treating this condition, which would suggest itself
to the surgeon, is incision of the sac, breaking down any ridges of new bone,
destroying epithelium which may be present in the sac, turning in an osteo-
plastic flap over the bone -defect, curetting or irritating the lining of the sac,
and holding the parts together by firm pressure uutil healing has taken place.
Sinus pericranii is the condition in which there is a tumor under the scalp,
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 25
caused by the formation of a sac of blood, which communicates through a
defect of the skull with an intracranial venous sinus and empties or fills from
the sinus as the intracranial pressure diminishes or increases. The treatment
which would naturally suggest itself to the surgeon would be the exposure and
removal of the sac under the scalp, suture, ligation or crushing of the com-
municating outlet, and closing the bone-opening by an osteoplastic flap. No
such operation should be done if there is present some disease which causes
increase of intracranial tension which may be the etiologic factor in forcing
out blood and dilating an emissary vein. Harvey Gushing cites cases
in which the swelling subsided after decompression operation for brain tumor.
Spurious meningocele is a collection of cerebrospinal fluid under the scalp,
communicating with the subdural space through a skull defect due to fracture
or disease. In the acute cases, occurring in children, any bony displacement
which is present should be corrected, and the fluid may be expected to be
absorbed. The chronic cases are analogous to true meningocele and should
be treated as such (see Encephalocele, page 92).
Aneurism is usually traumatic and involves one of the large afferent
vessels of the scalp. The treatment is simple ligation (see Aneurism, Vol. I,
page 380). Arteriovenous aneurism is best treated by ligating all of the ves-
sels which have any communication with the arteriovenous anastomosis, and
the extirpation of the diseased veins. In a recent case, simply the ligation
suffices. When the disease is of long standing and a tumor exists, it is best to
turn back a flap, uncovering the disease, ligate all vessels tributary to the
tumor, extirpate the diseased vessels and close the wound (see Arterioven-
ous Aneurism, Vol. I, page 393). The old treatments by galvanopuncture
and pressure are not to be recommended. Cirsoid aneurism should be treated
by ligation, if possible, of all of the vessels passing into the diseased area,
and destruction by the actual cautery of the diseased arterioles and capil-
laries. For the treatment to be successful the ligations should be made in
sound parts of the vessels and the vessels of the diseased area should be extir-
pated (see Cirsoid Aneurism, Vol. I, page 400). In a number of cases of this
sort, I have been compelled to operate a second and even a third time be-
cause of failure to destroy all of the diseased vessels passing into the cavern-
ous mass. These cases bleed most profusely. In a case involving the
supra-orbital vessels, success was attained only by turning down a forehead
flap, double-ligating all of the vessels, excising the cirsoid mass as a tumor,
and destroying the supraorbital foramen.
Nevus is amenable to treatment by excision of the diseased area, and cover-
ing the resultant wound by plastic flaps or skin grafts (see Nevus, Vol. I,
page 325).
Angioma of the scalp is best treated by excision of the cavernous mass of
vessels by turning back a skin flap and ligating all tributaries in sound tissue
(see Angioma, Vol. I, page 325). Old cavernous angiomata, which have
developed large communications through the skull with the intracranial
sinuses, are serious conditions. If not removed there is a strong tendency
to pressure destruction of the bone and ultimate wide anastomosis with the
sinuses. Extirpation of these tumors, even with the utmost care means a
great loss of blood. Notwithstanding the danger of serious hemorrhage,
the best surgery demands their removal. Depending upon the shape and
size, either a U-shaped flap should be turned back from the tumor, or an
elliptical incision made about it. The ligation of all vessels in the scalp
around the spongy tumor is not so difficult, but when the separation of the
tumor from the bone is attempted, the hemorrhage can be checked only by
pressure. This last stage of the operation must be done expeditiously, and
26 SURGICAL TREATMENT
hemostatic pressure maintained for as many days as necessary. The pressure
does not need to be great, but it does need to be constant and well secured. A
good plan is to have the circumference of the tumor ligated and freed; it is
then grasped with heavy pedicle clamps, and, with a broad knife or large
curved scissors, cut free from the skull, while immediately a piece of rubber
dam follows the incision and is pressed flatly against the skull with a gauze
pad. This gauze pad should be in readiness, of size slightly larger than the
base of the tumor, and for convenience it may have the rubber dam sewed to
its under surface. The advantage of introducing an impervious material is
to prevent pulling out the clots when the dressing is changed. The dressing
should be held down by a bandage which makes dependable pressure. If a
U-flap has been employed the pressure should be wholly beneath it, not upon
it. After a few days, when hemostasis has been assured, the wound may be
sutured. Large openings through the bone should be closed by crushing them
with a chisel in such a way as to drive the edges of the bone into the opening.
THE SKULL
The successful treatment of injuries and diseases of the skull requires
an understanding of its anatomical peculiarities. The extreme thinness of
the infant's skull and the absence of diploe are important. The surgeon
should bear in mind that the thickness of the adult skull varies much in
different regions of the head and also in different individuals. Also the
density of the tables varies: some are hard like ivory, others are soft and
cancellous. The character of the diploe varies not only in thickness but
also in the size of the blood spaces; in some the spaces are so small as to
render the diploe scarcely distinguishable from the two tables; in others the
spaces are so large that bleeding from them may be difficult to control. The
periosteum (pericranium) is more important than that of other bones, because
its power to regenerate bone persists even in adult life, and because the con-
tinuity of the covering of the brain should be maintained as complete as
possible. The interior lining of the cranium is important because its sur-
face is a serous membrane with which the brain articulates. The skull is
chiefly important because it constitutes the protective covering of the brain,
and is involved not only in its own diseases and injuries but requires to be
operated upon whenever the surgeon would expose or operate upon its
contents.
OPERATIONS UPON THE SKULL
Here will be described the common operations which are performed upon
the skull for the purpose of gaining access to the cranial chamber. The
treatment of the diseases which these operations are aimed to attack will
be given in their several places. The technic of operations upon the scalp,
which must precede attacks upon the skull, have been described (see Opera-
tive Wounds of the Scalp, page 20).
Instruments. — Besides the common instruments of surgery used in all
cutting operations upon bones, certain special instruments are employed in
operations upon the skull.
The tourniquet and other apparatus for controlling hemorrhage from the
scalp have been described (page 19). The ordinary periostea! elevators,
rongeur bone-cutting forceps, bayonet bone-lifting forceps, and wire saw,
are employed (see Operations on Bones, Vol. I, page 688).
Of the instruments for incising the skull, the trephine is the most impor-
tant. This instrument should be of the beveled pattern (Fig. 705) and_not
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
27
the straight cylindrical trephine. The former is less apt to do damage to the
meninges. A central button, carrying a pin is used to "center" the cut.
The pin should project just far enough to hold the instrument until the cir-
cular cut is well started. The pin is then removed. This should surely
be done before the pin has penetrated the skull. The cutting is done with
a boring wrist motion. After the outer table has been cut through, the
FIG. 705. — BEVELED TREPHINE.
The conical shape of this instrument prevents its too sudden penetration,
elevated as soon as the outer table has been cut.
The pin is
operation should proceed with caution. The pressure of the instrument should
be well under control. As the penetration of the inner table is approached,
the pressure should be made very light, and the rotating hand supported by
the other hand beneath it. By removing the trephine, and tapping gently
upon the circumference of the button with the handle, the percussion will
show if the skull has been penetrated at any place. The trephine should be
perpendicular to the inner table. Unless care is taken thus the cutting edge
FIG. 706. — BURR OF DOYEN CUTTING THROUGH SKULL.
This burr may be driven by a hand-brace or by electric power (Marion}.
may be operating upon bone in one place and meninges in another. When the
bone is cut through, the button is removed and placed in warm salt solution
if it is to be replaced later. Excessive hemorrhage from the diploe should
be checked by pressing in some bone-wax. If necessary this may be done
while the trephine is being used. For general use the trephine should be
about 2 cm. (% inch) in diameter.
28
SURGICAL TREATMENT
FIG. 707. — SPIRAL OSTEOTOME.
This instrument is driven by electric power. The button at the end prevents injury of the
meninges.
FIG. 708. — BURRS OF HUDSON.
These burrs may be used with the hand power brace or with electric power.
29
Other instruments for penetrating the skull are the burr and the circular
craniotome.
The burr of Doyen is most useful as it does not cut the dura (Fig. 706).
For making linear cuts between primary openings several instruments and
methods are used (see Operations on Bones, Vol. I, page 688).
The appliances driven by electric engines are being more and more
employed. The spiral osteotome devised by M. H. Cryer is a most useful
FIG. 709. — LINEAR BONE-CUTTING FORCEPS.
device (Fig. 707). It may be attached to any dental or surgical engine. For
cutting the skull, a button runs along under the skull and protects the
meninges.
The burrs invented by W. H. Hudson (Fig. 708) are valuable for cranial
surgery because they minimize the danger of injuring the meninges. Hudson
invented a most effective forceps for linear craniotomy (Fig. 709).
The bone drill bores a hole 8 mm. (%g inch) in diameter and has a guard
by which the depth of the hole is regulated. A number of these holes may
FIG. 710. — SIMPLE BRACE, WITH BONE-CUTTING BURR, DRIVEN BY HAND POWER.
be made rapidly in the line of the bone division, and connected by cutting
with the linear bone-cutting forceps or wire saw. The hand brace (Fig. 710)
is a most effective instrument for operating the drills and burrs.
The bone-cutting forceps of Montenovesi and Dahlgren are effective.
The wire saw of Gigfi is used by passing it through two trephine openings and
cutting the intervening bone. Inasmuch as the saw operates when taut
in a straight line there is danger of wounding the dura if used where the skull
30
SURGICAL TREATMENT
is much curved or through too long a distance. When it is used the dura
should first be separated from the bone by passing a spatula or dural elevator
into the openings. The saw is then passed and the dura protected by a
spatula in each opening while the saw is operated. The wire saw has the
advantage that it allows an oblique cut in making an osteoplastic flap so that
when the flap is replaced bone rests upon bone (Fig. 711).
FIG. 711. — OBLIQUE DIVISION OF PART OF OSTEOPLASTIC SKULL FLAP.
This obliquity prevents depression when the flap is replaced.
The simple, bladed saw is also employed for making linear cuts. For this
purpose are used the hand saw of Doyen (Fig. 712) or the circular saw driven
by an engine. For driving the burr or circular saw an electric motor is
most effective. V-shaped and U-shaped chisels are still used by some sur-
geons, but they possess the disadvantage of causing concussion. With the
exception of the trephine, instruments should be preferred which cut the
inner table from within outward.
FIG. 712. — HAND SAW OF DOYEN FOR MAKING LINEAR BONE INCISIONS.
The guard regulates the depth of the cut.
Osteoplastic Craniotomy. — The temporoparietal region most commonly
requires operation. The technic of the typical osteoplastic operation for
exposure of the brain in this region will be described.
Preparation of the patient should be according to the methods already
described. The shaving and cleansing of the scalp should have been
done on the preceding day, although many operators have this done just
before the operation (see Operative Wounds of the Scalp, page 20).
The patient should come to the operating room with the scalp covered with a
protective dressing. A final preparation of the scalp should be done after
the patient is placed on the table. In the absence of iodin, chlorin, or other
skin-penetrating antiseptic, alcohol and bichlorid solution are used.
Landmarks should be identified. The location of the lesion and the line
where the incision is to be made may be marked on tincture of iodin with
a white starch pencil, or with methylene blue solution, or carbol-fuchsin.
The protective cloths and the hemostatic tourniquet should be applied when
everything is in readiness for the operation to begin. All of the environs
of the field of operation should be covered with protective sheets. The
anesthetist should be excluded from the field of operation by a screen or by
his own carefulness.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 31
The administration of the anesthetic in cerebral operations requires a high
degree of skill because of the effects of manipulation of the cranial contents
upon the cardiac and respiratory functions. In serious cases the blood-
pressure should be taken before the operation and recorded during the opera-
tion. The choice of anesthetic must rest upon the rules already laid down
(see Anesthetics, Vol. I, page 165). The sensitiveness of the scalp is not
acute. In many conditions, such as intracranial hemorrhage, in which the
sensibilities are obtunded, no anesthetic at all is required, in other cases
it suffices to give a preliminary injection of morphin and to use an anesthetic
during the division of the scalp and skull, but not while the meninges and
brain are being operated upon. Local anesthesia is applicable in some cases.
In operations done in two stages, the secondary turning down of the flap
and operation on the cranial contents require no anesthetic.
The anesthetist is so close to the field of operation that he must use his
surgical sense to prevent transmitting infection. A screen to separate the
scalp and the face is used; if not the anesthetic mask should be covered with
a couple of layers of sterilized gauze, and should be as small as possible.
If ether is given, the small drop-method mask should be used. Some sur-
geons prefer ether given by the pharyngeal tube.
The position on the table should be well under control. The head should lie
on flat sand-bags, with the face rotated toward the well side. The neck
should be straight. The table should be so constructed that the patient's
head can quickly be extended or flexed upon the neck.
For operations in the occipital region the head may lie latterly, or, the
patient may lie prone with the head projecting over the end of the table
and supported by a special head rest.
The incisions for turning down a flap of skull and scalp in the parieto-
temporal region should be in the form of a horseshoe with the opening
downward to receive the temporal and middle meningeal arteries. The size
and position of the flap varies, of course, with the region to be exposed and
the object of the exposure. The lateral aspect of the brain, i.e., the motor
area and the convolutions anterior and posterior to it, is exposed by a
horseshoe-shaped incision, the anterior end of which begins at the middle of
the zygoma and the posterior end lies above the external auditory meatus.
The whole incision lies within the temporal fossa. This incision is carried
down through the scalp to the bone. Any bleeding vessels are caught. At
its mesial arc the soft parts are pressed aside anteriorly and posteriorly.
The periosteum should be pressed back external to the flap for about i cm.
along the whole line.
If the trephine is used an opening is made at the internal anterior part
of the incision, and another about 5 cm. (2 inches) posterior to it at the inter-
nal posterior part of the incision. The buttons should be removed. The
dura should not be wounded. With a dural spatula, made in the shape of a
thin, smooth teaspoon handle, the dura should be separated from the skull
between these two openings. A wire saw should be passed into one opening
and out of the other, and the dura pressed away from the saw by means of a
spatula inserted in either opening. The saw should cut through the inter-
vening bone in an oblique direction toward the median line, so that the
upper margin of the bone flap shall have a lip which shall prevent the bone
pressing upon the brain when the flap is replaced.
The two arms of the flap, from either trephine opening downward are
best cut by means of the bone-cutting forceps, care being taken to separate
the dura from the skull without wounding it. The posterior incision should
be cut first, leaving the possibility of wounding the middle meningeal artery
32 SURGICAL TREATMENT
for the last. In making these two bone cuts, the scalp outside of the flap
should be retracted away from the cut, in order not to separate the scalp
and bone of the flap. When the flap has thus been cut, an elevator is inserted
at the top, and as the flap is pried up the dura is gently detached with a
spatula. At last the bone breaks across the base of the flap. If the middle
meningeal artery is torn and bleeds, it should be ligated by making a small
opening in the dura just below and passing a ligature around it in a curved
needle. If the mesial cut with the trephine or saw is made so high that the
longitudinal sinus is opened, or if the expansions of the lateral sinuses
are wounded, bleeding may be controlled easily by gently packing in a bit of
gauze. To expose the brain, the dura mater is then incised and cut parallel
to the bone incision.
The dura flap is made the same shape as the bone flap, but it should be
about 6 mm. (% inch) smaller, so that there shall be a margin outside for
suturing.
The most satisfactory instrument for cutting the bone Hap is the circular
saw, driven by an electric motor. The chisel and mallet are not desirable
because of the concussion and possible injury of the dura. The wire saw
of Gigli if passed through trephine openings is usually satisfactory, but in a
thick skull the saws break, time is lost in introducing them, and adherent
dura is torn. Cutting a line with the biting forceps is slow if the bone is
thick. The depth of the cut can be regulated by an adjustable shoe in
the circular saw. This saw may be supplied with washers to regulate the
depth to which the saw will cut (see Operations on Bones).
FIG. 713. — MEASURE FOR DETERMINING THICKNESS OF SKULL.
The thickness of the skull is best measured, through the holes bored on
the line of incision, by the instrument devised by Doyen for that purpose
(Fig. 713).
In operating upon the brain the cerebral topography should be marked
with carbol-fuchsin or other stain. The lines of Chipault (Fig. 714)
are most satisfactory (see Cerebral Localization, page 43).
With the motor engine, a cutter bores holes at the corners of the flap and
along the sides. Between the adjoining holes the thickness of the skull
should be uniform. The saw should be adjusted to cut a certain thickness,
and all of the bone between the holes having that thickness should be cut.
Then the saw should be adjusted to the next thickness and the bone having
that thickness cut. By slanting the saw so that it does not cut at a right
angle, thinner bone may be cut without changing the saw. Bleeding from
bone is controlled by bone- wax. The uncut parts of the inner table are divided
with an osteotome and mallet. The flap is then pried up and fractured at
the base (Fig. 716).
For cutting small flaps, a large number of holes may be bored with the
motor burr, and the intervening bone cut with rongeur or other bone-cutting
forceps.
If it is desired to perform an operation in two stages, the flap may be replaced
before the dura is opened, and a dressing applied. This is often advis-
able in serious operations, or in operations when at this juncture there is a
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 33
FIG. 714. — HEAD PREPARED FOR CRANIAL OPERATION.
Lines of Chipault marked for localization.
FIG. 715. — CUTTING OSTEOPLASTIC SKULL FLAP.
Hemostasis has been secured by rubber tubing compression. The scalp has been in-
cised. Holes through the skull have been made with the burr in order to determine the
thickness of the bone. The skull is being cut by the electric-motor-driven circular saw,
provided with a washer to regulate the depth of the cut.
VOL. II— 3
34
SURGICAL TREATMENT
decided fall of blood-pressure. In doing this the tourniquet should be re-
moved, and bleeding from the scalp controlled either by suturing the wound
or by a compressing dressing. After a few days the second stage of the opera-
tion may be undertaken.
PlG. 7l6. OSTEOPLASTIC CRANIOTOMY.
The flap of the skull, having been cut through on three sides, is pried up and fractured
across the base. A pad of gauze should be placed under the levers to protect the scalp.
In order to incise the dura safely so that pial and arachnoid vessels shall
not be cut, a grooved director should be passed beneath it or it should be cut
with scissors having a probe on one blade. Vessels in the dura which bleed
or are to be divided are best closed by passing a fine ligature in a needle.
Vessels crossing the line of incision should be tied thus in two places and cut
between.
FIG. 717. — TEMPORAL OSTEOPLASTIC CRANIOTOMY.
The flap of bone and scalp has been turned down. The dura has been incised as a
flap and turned down. Note free margin of dura. This margin permits suturing the
flap of dura back in place at the close of the operation. Vessels in the dura have been
caught with needle and thread and tied before they were cut.
If it is desired to expose the brain further in any direction, the rongeur
forceps may be used, and then the dura cut in a radiating direction from the
flap. Bleeding from the cortex of the brain is best controlled by gently
laying a piece of gauze on the vessel. Adrenalin may be added. Clamps
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
35
should not be used. Larger vessels may be surrounded by a fine ligature in
a needle. The dura should be cut as a flap and turned back (Fig. 717).
Having dealt with the intracranial condition, the wound is closed, unless
a tumor which cannot be removed is discovered. In the latter event, a
decompression operation may be indicated, and a part or all of the bone in
FIG 718. — METHOD OF APPLYING DRAINAGE IN CONNECTION WITH OSTEOPLASTIC
CRANIOTOMY.
FIG. 719. — OSTEOPLASTIC CRANIOTOMY COMPLETED.
Wound closed with drainage.
the flap should be removed. Ordinarily the bone flap should be replaced.
To do this, the dura is sutured with fine chromicized catgut. The bone-
scalp flap is then pressed back into place, and the scalp sutured (see page 18).
The first part of the dressing should be applied and the tourniquet removed.
The suture and the pressure of the dressing are depended upon to prevent
36
SURGICAL TREA TMENT
bleeding. Over the trephine openings or wherever there is much separation,
the periosteum also should receive a few buried sutures.
If drainage is necessary, as it is in some cases, especially in which a little
packing must be left to check bleeding from a sinus, the gauze or wicking
may be lead out directly through the wound (Fig. 718), but it is often better
to carry it out obliquely through a special wound made outside of the flap.
This drainage should be enveloped in rubber protective to prevent adhesions.
It may be removed at the end of forty-eight hours (Fig. 719).
Temporal operations are performed for exploration for hemorrhage, for
purposes of decompression, for the removal of tumors, for abscess of the
temporal lobes, and for other conditions in the middle fossa or temporal
FIG. 720. — INTERMUSCULAR TEMPORAL CRANIOTOMY.
This is the operation done for decompression. A smaller flap of scalp should be turned
down than is here shown. The dura is shown exposed but no: yet incised.
regions of the brain. The temporal muscle and the strong temporal fascia
furnish sufficient protection for the brain so that the preservation of the
bone is not necessary. For exposing the temporal region, a curved incision
is made, making an arc somewhat parallel to the superior border of the temporal
fossa but lying below it, and terminating at the front of the upper border of
the zygoma and on the same level behind the ear. This flap of scalp is
turned down exposing the temporal fascia. The fascia is divided in a direc-
tion parallel with the fibers of the muscle and the incision deepened to the
bone by blunt separation of the fibers. The periosteum is incised. The
muscle is retracted laterally along with the periosteum. The trephine is
applied carefully because of the thinness of the bone. From the trephine
opening, with the bone-cutting forceps, the exposure is enlarged in any
direction to the desired degree (Fig. 720). The opening in the dura should
be made in such a way that the dura can be sutured back in place if
necessary.
After dealing with the brain condition, the dura should be sutured (unless
decompression is desired), the muscle with the underlying periosteum sutured
over the opening, the temporal fascia closed by a running stitch, and the scalp-
flap sewed back in place. Osteoplastic temporal operations are described
above.
Suboccipital operations are done for the exposure of the cerebellum, the
fourth ventricle, auditory nerve and basilar regions of the brain. The heavy
muscular covering of this region makes it unnecessary to preserve the bone.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
37
The tourniquet for the control of hemorrhage cannot well be used, and
bleeding vessels must be cared for as they are exposed.
The position of the patient is important. The head must be held well
forward; this is the first essential. All things being considered the lateral
position is to be chosen. C. H. Frazier devised an attachment for holding
the patient to the table by the shoulders. In order to give the best exposure
and minimize venous bleeding, it is desirable that the lower part of the body
be lowered (Fig. 721). H. Gushing operates with the patient's face down-
ward, by supporting the forehead and malar prominences upon an extension
beyond the end of the table, and the shoulders and upper chest upon a special
rest.
FIG. 721. — DEVICE FOR HOLDING PATIENT ON TABLE FOR EXPOSURE OF OCCIPITAL REGION,
PERMITTING ELEVATION OF HEAD.
Note frame for screen between anesthetist and field of operation.
For most operations for conditions other than tumor, a unilateral opera-
tion suffices. The incision should begin at the tip of the mastoid process
and pass outward parallel to the superior curved line, and 2 cm. above it,
to the external occipital protuberance, and thence downward in the median
line for about 8 cm. (3 inches), more or less, depending upon the thickness
of the tissues (Fig. 722). This incision should include only skin, scalp and
superficial fascia. They should be dissected free for 3 cm., and then the deep
fascia and muscles divided down to the bone just below the superior curved
line, leaving enough tissue for suture. This triangular musculocutaneous flap
should be dissected away from the bone and strongly retracted. The trephine
is applied midway between the mastoid process and the middle line. This
opening may then be enlarged with the rongeur forceps in all directions, as far
as the mastoid process, the median line, the lateral sinus and the foramen
magnum. Such an opening will usually allow access sufficiently to displace
the hemisphere for exposure of the auditory nerve.
The bleeding in this operation will be considerable unless hemostasis
keeps pace with the incisions. The large openings in this part of the skull
38
SURGICAL TREATMENT
transmit emissary veins which may require to be dealt with by plugging
the openings with bone-wax. Crushing the bone will stop bleeding from
these bony sinuses. At the conclusion of the operation the dura is sutured,
and the musculocutaneous flap sewed back in place.
For operations upon tumors and whenever necessary to give a degree
of displacement which cannot be secured by a unilateral operation, the bilat-
eral operation is done. Inasmuch as this takes more tissue and involves more
loss of blood than the one-sided operation it possesses disadvantages; but it
does give better access in many of the conditions requiring operation by
this route. The operation really amounts to two unilateral operations. A
unilateral operation may be continued into a bilateral one whenever indicated.
Or the latter may be planned from the beginning. In the last case an incision
is carried from one mastoid process to the other just above the superior curved
lines. This is intersected by a median incision down to the spinous processes
of the upper vertebrae (Fig. 723). The two flaps are turned down and the
FIG. 722. — INCISION FOR UNILATERAL SUBOCCIPITAL CRANIOTOMY.
skull opened on either side, upward to the lateral sinuses, across the
middle line avoiding the torcular Herophilii, and downward into the posterior
part of the foramen magnum. The dura may then be opened, and the
medioccipital sinus ligated. This is the method of H. Gushing.
For exposing the occipital lobes and the cerebellum, it is customary to
remove the bone; but the osteoplastic flap operation may be done. The bone
in this region is often very thick. To expose both occipital lobes of the
cerebrum and both lobes of the cerebellum, the upper border of the flap should
be about 4 cm. (i^ inches) above the lateral sinus, the sides should extend
downward and inward just behind the posterior border of the mastoid
thickening, and the base should be broken across just above the foramen
magnum. If the bone is thick it is not safe to attempt to fracture the base
of the flap until the bone has been cut to weaken it where the fracture is
desired. If this is not done there is danger of breaking the base into the fora-
men magnum. J. H. Kenyon (Annals of Surg., Jan., 1915) described a prac-
tical method. A longitudinal incision is made in the median line from
the external occipital protuberance downward 5 or 8 cm. (2 or 3 inches).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
39
This goes down to the bone. An elevator is passed into the wound and the soft
parts separated from the bone on either side along the line of the desired
fracture. A motor drill then bores holes along the line to weaken the base
FIG. 723. — BILATERAL SUBOCCIPITAL CRANIOTOMY.
FIG. 724. — UNILATERAL OCCIPITAL CRANIOTOMY
Osteoplastic occipital flap turned down to expose cerebellopontine angle. The bone
on three sides has been cut and fractured at the base of the flap. The dura is exposed.
of the flap. The same is done at the lower end of each lateral incision.
The bone is then easily broken (Fig. 724). The cutting of the dural flap
is not difficult. The occipital sinus and the falx cerebri are doubly ligated
and cut between.
40
SURGICAL TREATMENT
FIG. 725. — BILATERAL OSTEOPLASTIC OCCIPITAL CRANIOTOMY. FIRST STAGE.
Osteoplastic occipital flap turned down. Holes have" been bored with a drill and the
circular motor saw used to cut the bone between them. The base line of fracture has been
weakened by boring holes at the lower ends of the lateral incision and through a median
incision. The dura is exposed.
FIG. 726. — BILATERAL OSTEOPLASTIC OCCIPITAL CRANIOTOMY. SECOND STAGE.
The bone flap has been turned down. The sinus or large vessels in the dura are tied
by passing a ligature with a needle, and a flap of dura cut and turned down. Note free
margin of dura.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 41
For exposing the cerebellopontine angle by an osteoplastic flap the same
method is used. An incision is carried upward from the posterior border of
the mastoid to a point about 2.5 cm. (i inch) above the lateral sinus. An-
other incision about i cm. (% inch) to the same side of the median line is carried
upward from below the occipital ridge to the same height. The two are
connected by a transverse incision at their upper ends. The base of this flap
should be 12 mm. (% inch) above the foramen magnum and should be bored
before it is broken (Fig. 725) (see Suboccipital Craniotomy, page 36). The
treatment of the dura and the exposure of the brain are the same as for tem-
poral craniotomy (Fig. 726).
DISEASES OF THE CRANIAL BONES
There are certain diseases of the skull for which there is little treatment
but which should be borne in mind because of their relations to the treatment
of other conditions.
Atrophy of the bone may result from local or general nutritive disturbances.
Such is the senile atrophy which may result in cranial defects.
Pressure, either from intracranial or extracranial tumors, may cause
thinning of the bone and finally perforation. Natural decompression may be
caused in this manner. The atrophy of rickets, giving rise to craniotabes,
should be treated by the measures already given (Vol. I, page 32). Children
suffering with this disease should have the position of the head upon the
pillow frequently changed to prevent distortion of the skull.
The hypertrophies, acromegaly, gigantism, osteomalacia, and osteitis
deformans, have been discussed. Leontiasis ossea has in some cases called
for removal of masses of bone where pressure demanded such operation.
Infective Diseases of the Cranial Bones. — Acute -periostitis and osteitis
of the bones of the skull should, if possible, be prevented, by the free drainage
of infections of the scalp. Abscess under the scalp, whether the result of
infected wound, hematoma or contusion, should be freely opened. Unless
this is done there is danger of infection of the bone. Infection of the bone,
arising from extension of pericranial infection or developing as a primary
osteomyelitis (Pott's puffy swelling), may secondarily involve the peri-
cranial structures or give rise to meningitis, brain abscess or infection of the
cerebral sinuses. Because of the danger of intracranial infection, osteo-
myelitis should be drained by trephining down to the dura. If free drainage
external to the dura can be maintained there is little danger of subdural
infection.
Necrosis calls for the removal of enough bone to provide free drainage;
then, when the extent of the disease has declared itself, all dead bone should
be removed. Care should be taken to uncover and remove the dead bone in
cases in which the inner table is more widely diseased than the outer. The
wound after operation for infected bone should be left open and packed with
gauze. When granulations have developed and the infection has subsided
measures may be taken to close the wound (see Operations on Bones,
Vol. I, page 688). Even though a considerable bony defect exists, it need
not necessarily be operated upon, as the tough scar tissue which grows in it
furnishes adequate protection for the brain.
Tuberculosis of the skull, most commonly observed in children and
especially in connection with the temporal bone, should be treated by general
hygiene. Abscesses should be aspirated. Sinuses should be laid open and
dead bone uncovered and removed (see Tuberculosis, Vol. I, page 276).
Syphilis of the cranium should be treated by active constitutional
42 SURGICAL TREATMENT
measures. Constitutional treatment usually should be pushed to tolera-
tion. Where necrosis exists, free drainage should be secured and dead bone
removed. If the patient's general resistance is poor, care should be taken in
making new wounds lest they become infected and an acute cellulitis set up.
When the patient is brought well under the constitutional treatment, these
bony lesions heal often with striking rapidity (see Syphilis, Vol. I, page 283).
Tumors of the Cranial Bones. — These tumors are not notably different
in their treatment from tumors in other bones. The malignant tumors
should be removed; the benign tumors require no treatment unless pressure
or cosmetics demand it.
Osteoma of the small external variety requires no treatment, unless for
cosmetic reasons the patient desires its removal. When these tumors en-
croach upon the brain cavity, their removal is called for. They sometimes
develop in the accessory sinuses, such as the frontal sinus. In these cases
the tumor should be uncovered and removed. In their extirpation, the whole
tumor wall should be removed. Chisel, burr, and rongeur are the instru-
ments required.
Sarcoma presents serious difficulties. The diagnosis not being easy, the
only treatment that can be curative is often deferred until hope is passed.
Syphilitic osteitis and periosteitis, osteoma, and echinococcus cyst must be
quickly excluded. By making a wide excision in the early stage of the growth,
it should be possible to remove it. Rarely does the surgeon have such
an opportunity: when he does he should grasp it quickly. The myleogenous
sarcomata occur in the skull, and should offer a fairly hopeful prognosis if
dealt with radically. In dealing with sarcoma, the surgeon should examine
carefully to discover whether it may be a metastatic growth or the local
manifestation of a general disease as is the case in myeloma.
Carcinoma invades the skull either by direct extension from an adjacent
growth or by metastasis, and is, therefore, hopeless in most cases. When
the invasion is from an epithelioma of the skin, there is often a possibility of
its removal, and the disease should be eradicated by one of the methods
already given (see Tumors, Vol. I, page 323).
Deformities of the Skull. — The deformities due to fractures, rickets,
hypertrophies and atrophies of the bone are discussed above. Deformities
associated with tumor require the, treatment of that disease. In the case
of any deformity, which gives rise to increase of intracranial pressure and
which is not amenable to treatment, the symptoms may be relieved by
decompression.
In oxycephaly ("tower head," "steeple skull") if the intracranial pressure
is above normal and gives rise to distress, subtemporal decompression gives
relief. The operation may be done first on the right side and then, if neces-
sary, on the left side. Patients with this condition, suffering with disturbed
vision, vertigo, neuralgia and other signs of pressure are decidedly relieved
by operation. Operation is only indicated for the relief of pressure.
INTRACRANIAL INJURIES AND DISEASES
General Principles of Treatment. — In the treatment of intracranial
injuries and diseases, their close relation to the delicate vital organs gives
them extraordinary importance. The surgeon should be familiar with
craniocerebral topography. As he looks at the outside of the skull, he should
be able to picture in his mind, the structures which lie within and their
relations to the skull (Fig. 727).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
43
The dura mater is a strong membrane, lining the skull and adherent to it. Its inner
surface is covered with smooth endothelium, which articulates with the pia-arachnoid
covering of the brain. The dura carries between its layers the great venous sinuses.
The pia mater is a delicate transparent membrane which closely covers the brain,
dipping down into all its sulci and following every convolution. The arachnoid lies external
to the pia, does not dip down into the sulci but bridges across them; it is a diaphanous
membrane, supporting the external cerebral vessels.
The brain lies and hangs, supported and surrounded by subarachnoid fluid, blood-vessels
and sinuses. It encloses the fluid-containing ventricles. All these are contained in an
Transverse sinu
Cavernous sinus
First div. trifacial nerve
Second div. trifacial nerve
Third div. trifacial nerv
Anterior fossa
Middle!JmeningeaJ artery
Middle fossa
Gasserian
ganglion
Sensory root
of trificial
Facial and audi-
tory nerves
Sup. petrosal
sinus
Groove for sup. long, sinus
Cribriform plate of ethmoid
Sella turcica
Orbital plate of frontal
Optic foramen
Lesser wing of sphenoid
Sphenoidal fissure
Foramen rotundum
Carotid groove
Foramen ovale
Foramen
spinosum
Foramen
lacerum med.
-Roof of semicir-
cular canals
Seat of Gasserian
gang.
Internal auditory
meatus
Formal lac.
posted us
Sigmoid sinus
Internal jugular vein
Inf. petrosal sinus
)ccipital bone: posterior
fossa
Lateral sinus
Foramen magnum
Occipital sinus
Torcular herophili
Superior longitudinal
sinus
FIG. 727. — BASE OF SKULL.
Showing vessels and nerves on left side and bony openings on right side.
unyielding case. Both the cerebral fluid and the blood can escape from the inelastic
cranium into extracranial channels with which they communicate, thus maintaining an
equable intracranial pressure. Such a fluctuation takes place physiologically as the mass
of blood and the blood-pressure in the cranium are influenced by respiration and cardiac
pulsation. The exposed brain is observed to pulsate with these two movements.
The brain receives its nourishment chiefly through the two carotid arteries. Not
withstanding the free anastomosis with the other vessels, through the circle of Willis,
occlusion of an internal carotid, or especially of a common carotid, is apt to cause uni-
lateral softening of the brain. The occlusion of both carotids, if rapid, is apt to cause
fatal cerebral anemia. Slow and gradual occlusion of the vessels need not destroy life
(Fig. 728).
44
SURGICAL TREATMENT
The motor area of the cortex of the brain, from which originate the impulses to the
muscular system of the body, occupies a narrow strip of the outer surface of the gyrus
centralis anterior, and extends to the depth of the central fissure (fissure of Rolando).
The area extends upward to the median fissure of the cerebrum and slightly over onto
the mesial surface of the paracentral lobe. The lower limit of the motor area ends some-
what short of the fissure of Sylvius. The fibers from the motor cortex pass downward
through the pyramidal tract. They degenerate throughout their whole extent after de-
struction of their cortical cells, and muscular paralysis results.
Superior long, sinus
Lateral sinus
Straight sinus
FIG. 728. — SINUSES OF BRAIN, SHOWN BY TRANSVERSE VERTICAL SECTION.
The straight sinus is seen at the junction of the four lobes.
FIG. 729. — BRAIN SURFACE TOPOGRAPHY.
The cortical areas, concerned in speech, lie about the lower end of this motor area.
The posterior part of the gyrus frontalis inferior is regarded as the motor center for speech.
In right-handed people, the center for the recognition of spoken words lies in the gyrus
temporalis superior of the left temporal lobe, below and behind the center for general
audition. The center for the recognition of written words, or the visual reading center, is
located in the outskirts of the visuopsychic field in the gyrus angularis. The writing
center is in the posterior part of the gyrus frontalis medius, anterior to the motor area which
controls the hands and fingers (Fig. 729).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
45
The sensory area of the cortex is situated posterior to the motor area. The motor
area extends to the depths of the central fissure anteriorly; the sensory area extends to the
depths of the central fissure posteriorly. The sensory field, besides occupying the anterior
portion of the gyrus centralis posterior, which is hidden in the central fissure, also occupies
about the anterior half of the exposed external part of the gyrus. This is the area of com-
mon sensation, cutaneous sense, tactile sense, and muscular sense. The centripetal fibers
to this area pass by way of the posterior part of the internal capsule and the thalamus.
The fields of special sensation lie posteriorly to and below this, where the sensations
become more complex and involved with association. The sensation of pain and of tempera-
ture probably are located in the intermediate postcentral zone. The center for the recog-
nition of objects and the stereognostic sense are situated in the parietal lobe. The visual
sensory center is located in the occipital lobe especially on its mesial surface in the calcarine
region. The auditory sensations are received in the gyrus temporalis superior. Olfactory
sensations are believed to be received in the pyriform lobe or the adjacent areas (Fig. 730).
FISSURE OF
FISSURE or
SYLVIUS
FIG. 730. — CORTICAL FUNCTION TOPOGRAPHY OF BRAIN.
Craniocerebral topography determines the position of the parts of the brain with refer-
ence to the exterior of the head.
Cranial Landmarks
Glabella. — Nasal eminence of the frontal bone in the median line midway between super-
ciliary arches.
Nasion. — Median point of junction of nasal and frontal bones.
Inion. — External occipital protuberance.
Bregma. — Anterior fontanelle at junction of coronal, frontal, and sagittal sutures.
Condyloid Point. — Outer end of condyle of inferior maxilla.
M idzygomatic Point. — Middle of horizontal upper border of zygoma.
Midsagiltal Point. — Middle of median line between nasion and inion, usually lying per-
pendicularly above external auditory meatus.
Lambda. — Posterior fontanel at junction of lambdoid and sagittal sutures, situated S
to 10 cm. (3^ to 4 inches-) behind the superior Rolandic point and 6 or 7 cm. (2^102^4
inches) above the inion.
Stephanion. — Point of intersection of coronal suture and superior temporal ridge.
Auricular Point. — Centre of external auditory meatus.
Supra-auricular Point. — Point at root of zygoma vertically above auricular point.
Nasolambdoidal Line. — An imaginary line beginning at the nasofrontal groove, passing
backward 6 mm. (% inch) above the external auditory meatus, and ending i cm. (% inch;
above the lambda or 7 cm. (2% inches) above the inion. This line lies on a level with the
lower part of the inferior frontal convolution of Broca, 4 to 6 cm. (i^fe to 22s inches) of the
posterior limb of the fissure of Sylvius, and the base of the angular gyrus.
Coronal Suture. — Suture between frontal and parietal bone, on a line from bregma to
midzygomatic point, lying 2.5 to 3.8 cm. (i to 1^2 inches) anterior to fissure of Rolando.
46
SURGICAL TREATMENT
Sagittal Suture. — Median suture between parietal bones.
Squamous Suture. — Suture between parietal bone and squamosa.
Lambdoid Suture. — Suture between parietal and occipital bones.
The supra-orbital arch is the upper margin of the orbit. The superciliary ridge is, the
first eminence above the supra-orbital arch. The frontal eminence is the second prominence
above the supra-orbital arch. The internal angular process is the inner end of the supra-
orbital arch; the external angular process is the external end. The retro-orbital tubercle is
an apophysis on the posterior border of the upper part of the frontal process of the malar
bone, lying just below the fronto-malar suture.
Superior Rolandic Point. — A point 55 per cent, of distance from nasion to inion in
median line. This is the upper end of the Rolandic fissure.
Sylvian Point. — Point at which Sylvian fissure reaches the convexity of the hemisphere
2.9 to 3.2 cm. (i% to \Y± inches) directly behind the external angular process (Fig. 731).
On the naso-inial line, 5.6 per cent, equals 1.3 to 2 cm. (H to %inch). The superior
Rolandic point is i to 2 cm. posterior to the centre of the naso-inial line. It is 2 or 3 cm.
posterior to the bregma. The presence of the parasinoidal sinuses renders this region very
difficult of access. In large heads it is about 18 cm. and in small heads about 17 cm. poste-
rior to the nasion in the median line.
— „... MID-SA&ITTAL PT.
i ^SUP. ROLANDIC PT
INION
FIG. 731. — RELATIONS OF BRAIN AND SKULL.
Showing cranial landmark points, brain fissures, and middle tneningeal 'artery.
The lower end of the fissure of Rolando is 9.5 cm (3^4 inches) below the upper end,on a
line passing downward and forward at an angle of from 65 to 75 degrees, with the median
line. It is 7 cm. (2% inches) above the condyloid point on a line perpendicular to the upper
border of the zygoma, or 5.5 cm. (2^ inches) above the zygoma. It lies generally about i
cm. above the Sylvian line.
The fissure of Rolando may be located by connecting the two points above,,described
If the line is continued downward it should cross the midzygomatic point. The fissure lies
entirely under the parientalbone. The superior Rolandic point is 4 to 5 cm. (i-Ke to 2
inches) and the inferior Kolandic point about 3 cm. (ijKe inches) posterior to the tem-
poroparietal suture.
The fissure of Sylvius lies in the direction of a line connecting the external angular process
of the frontal bone and a point 77 per cent, of the distance from the nason to the inion. fiThis
line crosses a point at the junction of the middle and lower thirds of a line connecting the
condyloid point and the midsagittal point.
The Sylvian point, or bifurcation of the fissure, is opposite the antero-inferiorangleof the
parietal bone. This point is found by carrying a straight line from the fronto malar junc-
tion horizontally backward for 3.1 to 3.5 cm. (1^4 to i% inches), and from this point ver-
tically upward for 6 to 12 mm. (^4 to £2 inch).
The Sylvian line is found by carrying a straight line from the Sylvian point backward
and upward to a point 1.2 to 1.8 cm. (^ to % inch) below the most prominent point of the
parietal eminence. This marks the horizontal or posterior limb of the fissure of Sylvius;
it is 7.5 to 10 cm. (3 to 4 inches) long. From the Sylvian point, the fissure runs backward
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
47
and slightly upward; at first it follows the squamous suture; and thence it passes backward
and upward to a point below the parietal eminence. The ascending limb passes upward
and forward from the point of bifurcation. The anterior limb runs from the same point
forward in the direction of the squamous suture.
The floor of the middle fossa of the skull lies on a level with the upper border of the
zygoma. The motor area lies entirely under the parietal bone, on the top of the brain
rather than on the side. A meridian line from the midsagittal point, passing downward
and forward at an angle of 60 degrees, to the midzygomatic point lies in the direction and
shows the position of the middle of the precentral convolution. The temporal lobe is
covered by the squamous portion of the temporal bone. The Sylvian point is opposite the
island of Reil. The middle meningeal artery curves forward and upward from the foramen
spinosum across the front of the temporal lobe, lying against the anterior part of the squa-
mous portion of the temporal bone, grooving the antero-inferior angle of the parietal
bone, and crossing close to the Sylvian point (Fig. 732).
MIDDLE MENINCEAL
ARTERY
FIG. 732. — SHOWING RELATIONS OF LATERAL VENTRICLE, ISLAND OF REIL, SINUSES AND
MIDDLE MENINGEAL ARTERY.
The superior longitudinal sinus may be outlined by drawing two straight lines, each
starting at the middle of the nasofrontal suture, where is located the foramen cecum, and
diverging as they pass backward on either side of the sagittal suture, the left one ending
S mm. (Y\§ inch) to the left of the inion, the right ending 10 mm. (% inch) to the right of
the inion.
The lateral sinuses, in their transverse portion, form a slight curve, convexity upward,
from the external occipital protuberance to a point back of the external auditory meatus
The highest point reached by the sinus is at the mastoparietal suture, 1.5 to 2.5 cm. (%
to i inch) above a line drawn from the inion to the center of the external auditory meatus,
and slightly external to the center of this line. The sigmoid portion of the sinus begins
back of the ear on a level with the upper border of the external auditory meatus, and passes
in a curve, with its convexity forward, over the mastoid process to its apex, lying 10 to 12
mm. (Jf6 to % inch) behind theexternal auditory meatus and extending 5 mm. (3{6 inch)
48
SURGICAL TREATMENT
below it. The sigmoid portion of the sinus lies at a depth of about 7 mm. (% inch) from
the external surface of the mastoid process. This distance is very variable.
The lateral ventricle may be located by taking a point 3.1 cm. (i j£ inches) above and the
same distance behind the external auditory meatus. The ventricle lies a distance of from
5 to 6.3 cm. (2 to 2% inches) from the surface. It is located by Chipault as lying oppo-
site the junction of the third and fourth tenths of the lambdoidal line. F. Hartley
found that the ventricle is reached at a distance from the surface of the brain equal to
one-third of the transverse diameter of the whole brain at this point. The diameter of the
whole head is taken with calipers; from this is subtracted the thickness of the scalp and
skull, multiplied by two; one-third of the remainder gives the desired distance. A needle
passed horizontally enters the ventricle at this distance, the descending horn of the ventri-
cle may be reached by passing a needle through the middle temporosphenoidal convolution
directly above the external auditory meatus. The posterior horn is reached by passing the
needle through the middle temporosphenoidal convolution in a line with the posterior bor-
der of the mastoid process. (Fig. 732).
Craniocerebral Localization. — Chipault's method is most commonly employed. It is
based on relations of the parts of the brain to the skull as determined by averaging the
measurements of a large number of skulls. The objection to the method is that it requires
working out for each case the percentage distances between the nasion and inion and divid-
ing the primary and secondary lines into tenths. It is applicable to skulls of all sizes,
shapes, and ages (Fig. 733).
N—
733. — CRANIOCEREBRAL TOPOGRAPHY BY CHIPAULT'S LINES.
N, Nasion; S, Sylvian point; R", inferior Rolandic point; A, external angular process.
A median line is drawn from nasion to inion (median naso-inial line). This line is
divided by certain percentage points. The precentral point is marked at 45 per cent, of the
distance from nasion to inion. The Rolandic point is marked at 55 per cent, of the distance.
The Sykian point is marked at 70 per cent, of the distance. The lambdoidal point, or
superior temporosphenoidal point, is marked at 80 per cent, of the distance. The lateral
sinus point is marked at 95 per cent, of the distance.
Thus if the median distance over the scalp between nasion and inion is 30 cm., then the
precentral point would be 4;Koo of that distance, o 13.5 cm. from the nasion; the Rolandic
point 5?foo °f 3°, or 16.5 cm. from the nasion; the Sylvian point 7Koo of 30, or 21 cm.
from the nasion; the lambdoidal point 8%oo of ?o, or 24 cm. from the nasion; and the
lateral sinus point, 9^foo of 30, or 28.5 cm. from the nasion. If the med an nasoinial line
were 12 inches long, the precentral point would be 4;Koo of 12, or 5.4 inches from the
nasion.
The three primary lines of Chipault are the Sylvian line from the retro-orbital tubercle (.4)
to the Sylvian point, the lambdoidal line from the retro-orbital to the lambdoid point, and
the lateral sinus line from the retro-orbital tubercle to the lateral sinus point. Chipault
divides these three primary lines into tenths of their length. Thus, if the Sylvian line is
22 cm. long, it is divided into 10 parts, each 2.2 cm. long.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
49
The two secondary lines of Chipault are the precentral line, which passes from the point
between the second and third tenths of the Sylvian line to the precentral point on the naso-
inial line, and the Rolandic line, which passes from the point between the third and fourth
tenths of the Sylvian line to the Rolandic point on the naso-inial line. The precentral line
commences at the bifurcation of the Sylvian fissure, follows the ascending limb of the fissure
and in its two upper thirds lies over the precentral fissure. The Rolandic line begins below
at the lower extremity of the Rolandic fissure and follows it throughout.
The two secondary lines are marked off in tenths. The tenths on the primary lines are
numbered from the front backward; on the secondary lines, from below upward.
The inferior frontal fissure begins at the junction of third and fourth tenths of the pre-
central line. The anterior branch of the middle meningeal artery crosses the second tenth
of the three primary lines. The lateral ventricle is opposite the junction of the third and
fourth tenths of the lambdoidal line.
The technic of applying this method of measurements in operations on the brain is not
difficult. The scalp should be shaved and the necessary lines and landmarks marked on the
scalp with silver nitrate or with a marking pencil. To mark a point on the sicull for identi-
fication, a sharp-pointed instrument is passed through the scalp, and with a few taps of a
mallet a puncture is made in the outer tables of the skull, which can be seen when the scalp is
turned back and the skull exposed. Only the area to be sought need be marked on the
skull. The only lines that require to be marked are those which have to do withjthe local-
ization of that area.
FIG. 734. — CRANIOCEREBRAL TOPOGRAPHY BY REID'S LINES.
Reid's method of craniocerebral localization has three primary lines. The baseline (AB)
is drawn horizontally from the lowest part of the infra-orbital border through the center of the
external auditory meatus, and thence backward (Fig. 734). The anterior perpendicular line
(DE) is drawn from the pre-auricular point (a depression on the base line between the con-
dyle and the tragus), at right angles to the base line, and ends at the median line above.
The posterior perpendicular line (FG) begins at the base line at a point vertically above the
posterior limit of the mastoid process and passes upward vertically to the median line. The
Sylvian fissure (HJ) extends from a point 3.1 cm. (i^ inches behind the external angular
process to a point 1.8 cm. (% inch) below the most prominent point on the parietal emi-
nence. The ascending limb of the Sylvian fissure (IK) may be marked out by drawing a verti-
cal line, beginning at the Sylvian line 1.8 cm. (% inch posterior to its anterior end, and pass-
ing upward for 2.5 cm. (i inch). The Rolandic fissure (LF) is represented by a line beginning
at the upper end of the posterior perpendicular line and passing diagonally downward and
forward to the point where the Sylvian line crosses the anterior perpendicular line. The
sigmoidj[portion of the lateral sinus (M) lies at a point on the base line 1.8 cm. (%inch) pos-
terior to the center of the external auditory meatus. The transverse portion of the lateral
sinus (N) lies at a point 2.5 cm. (i inch) posterior to the center of the external auditory
meatus and 6 mm. (Y± inch) above the base line. The mastoid antrum (0) lies at a point
opposite the intersection of a vertical line passing along the posterior wall of the external
VOL. II— 4
50
SURGICAL TREATMENT
auditory meatus and a horizontal line along the upper border of the meatus. The latera
ventricle (P) is opposite a point 3.8 cm. (i^ inches) above the external auditory meatus.
The anterior branch of the middle meningeal artery (R) lies under the bone at a point 3.8 cm.
(i^£ inches) posterior to the external angular process, and 3.8 cm. (i^ inches) above
the zygomatic arch. The posterior branch of the middle meningeal artery is found at a point
4.4 cm. (i^'inches) posterior to the external angular process, and 6 mm. (% inch) above
the zygomatic arch.
The usual site of cerebral abscess (S) is the temporosphenoidal lobe at a point 1.8 cm.
(% inch) above the base line, on a line drawn vertically along the posterior border of the
external auditory meatus. The usual site of cerebellar abscess ( T) is opposite a point 3.8 cm.
(i^-i inches) behind the center of the external auditory meatus, and 6 mm. (% inch) below
the base line. These figures are all calculated upon the basis of an average adult skull.
Kronlein's method of craniocerebral localization employs three parallel vertical, two
parallel horizontal lines and two oblique lines (Fig. 735). The inferior horizontal line (CB)
passes through the inferior border of the orbit and the superior border of the external
auditory meatus. The superior horizontal line (UH) is parallel with the inferior line and
passes through the upper border of the orbit. The anterior vertical line (ZS) passes through
the midzygomatic point. The middle vertical line (CR) passes through the condyloid point.
. 735. — CRANIOCEREBRAL TOPOGRAPHY BY KORNLEIN'S LINES.
The posterior \verticallline (MR') passes through the most posterior part of the posterior
border of the mastoid process. The Rolandic line (SR') begins at the point of intersection
of the superior horizontal and anterior vertical lines and ends at the point of intersection
of the posterior^ vertical and median lines. The inferior extremity of the Rolandic fis-
sure (/?) lies opposite the point where this line crosses the middle vertical line. The
Sylvian line (SS') is found by bisecting the angle formed by the Rolandic line and the
superior horizontal line, the Sylvian fissure extending from the apex of the bisected triangle
to the point on [the posterior vertical line where the bisecting line crosses it. The main
trunk of the middle meningeal artery crosses the anterior vertical line just above the inferior
horizontal line; the anterior branch lies at the intersection of the superior horizontal and
anterior vertical lines; the posterior branch runs along just below the superior horizontal
line between the anterior and posterior vertical lines. Otic abscess is explored for in the
area bounded by the middle and posterior vertical lines and the upper and lower horizontal
lines.
For determining these various lines and points, instruments made of
flexible metallic bands have been devised. The differences in human brains
and skulls give a small margin of error. The surgeon should be familiar with
the appearance of the surface of the brain so that he shall recognize the impor-
tant fissures and convolutions. The fissure of Sylvius is easily identified. If
necessity demands it the motor centers of the paracentral convolution may
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 51
be determined by testing their electric reaction. A fine platinum wire elec-
trode with a blunt end is used for this purpose. It is covered with a glass
handle, between which and the tip it is twisted into a spiral to obviate the
danger of pressure which might wound the pia-arachnoid (Fig. 736). A
faradic current should be used which is just strong enough to cause muscle
fibers to contract. (It may be tested on some exposed muscle such as the
temporal.) If there is cerebiospinal fluid under the arachnoid, it should be
evacuated by a puncture at a sulcus so that the membrane shall lie close to the
brain. The patient should not be deeply narcotized. A negative pole is
applied to the peripheral region innervated by the cerebral area to be tested.
The platinum electrode is lightly applied to the cortex. This test will posi-
tively give contraction of the muscle receiving its nerve supply from the
faradized cortical cells unless there is degeneration of the nerves passing
through the pyramidal tract.
FIG. 736. — ELECTRODE FOR TESTING ELECTRIC REACTION OF MOTOR AREA AND MOTOR
NERVES WHILE OPERATING.
The pia-arachnoid being exposed, when it becomes necessary to incise
the cortex for exploration, for the removal of a tumor, or for the extirpation
of a cortical area, the cortical meningeal vessels should be ligated on either
side of the incision. It is best that the incision should not cross a sulcus.
For ligatures, very fine catgut is preferable. The dissection should be done
mostly with blunt instruments, but not with the fingers.
Bulging of the brain may be prevented by elevation of the head, by seeing
that there is no impediment to respiration, or by making punctures of the
arachnoid at sulci to permit the escape of cerebrospinal fluid. Lumbar
puncture to remove fluid may be called for during an operation. It is a
simple procedure, and the fact of the skull being open does not seem to add
to its hazard. It should not be practised in cases of brain tumor situated
below the tentorium, because of the danger of fatal disturbance in the basilar
centres. In the case of tumors above the tentorium, the gradual withdrawal
of fluid may be of help during the course of an operation for decompression
or removal of the tumor. The puncture should not be made until the dura
is exposed and ready to be opened. In suboccipital explorations, if high
intracranial pressure is found, the dura should be incised low down near the
foramen magnum, and the posterior cisterna opened to permit the escape
of fluid. This procedure makes lumbar puncture unnecessary.
The loss of a considerable amount of brain substance need not create
serious disturbance, particularly if areas which have no specially localizing
function are removed. Frazer has removed as much as one-third or one-
half of one cerebellar hemisphere without causing any apparent disturbance
of brain function. The function of the missing part is apparently assumed
by the remaining hemisphere. Such operations are necessary in some in-
stances to expose the cerebellopontine space; and often hernia cerebri
or uncontrollable extrusion of brain tissue can be treated only by removal of
brain substance.
The advantage of outward dislocation of the brain is always to be borne in
mind in intracranial operations. It is possible, by making an osteoplastic
flap on one side of the skull, to perform an operation through a smaller
opening on the opposite side by virtue of dislocating the brain partially
52 SL'RGICAL TREATMENT
through the larger opening. Such a procedure allows freer access to tumors
and permits wider exploration by giving more room within the cranium
because some of the cranial contents are extruded through the opening.
To lessen the danger of meningitis, in cases in which the subarachnoid
space is exposed to infection, hexamethylenamin may be administered inter-
nally as it finds its way to the cerebrospinal fluid. It may be given for this
purpose as a preliminary to operations involving the meninges.
CONCUSSION OF THE BRAIN
Concussion of the brain is the disturbance which results from sudden
traumatism which has not produced discoverable anatomic changes. Satis-
factory treatment of this condition revolves around diagnosis. When, after
a traumatism to the head, fracture, intracranial hemorrhage, and laceration
has been ruled out, and only concussion remains, the treatment is simple.
The patient should be kept quiet and recumbent in bed. This is the main
thing. The bowels should be moved by a laxative or enema. The diet
should be fluid. Tradition calls for an ice-cap or other temperature lower-
ing application to the head. I do not know that this does any good.
Serious heart weakness and lowering of blood-pressure call for their appro-
priate treatment. They are due, perhaps, to an inhibitory effect of the
traumatism upon the basilar centers, and are to be treated the same as shock.
Having excluded hemorrhage, the head should be lowered. In the absence of
such an appliance as Crile's pneumatic suit, the surface tension may be in-
creased and the depleted internal vessels filled by bandaging the limbs from
their extremities up to the trunk. Abdominal pressure has also proved of
service in emptying the dilated veins of the splanchnic area.
In true concussion, the stupor tends to subside. If it does not do so
after a few hours or days, the surgeon may know that he has to deal with some
other condition. Irritability, restlessness, or convulsive movements mean
the addition of pressure or laceration, which should be met by their appro-
priate treatment. The patient should be watched for localizing symptoms.
After consciousness has returned and the grave symptoms have subsided,
the patient should be kept quiet, a light diet prescribed, and freedom from
responsibility enjoined until the symptoms of headache, vertigo, and muscular
weakness have gone.
The muscular unbalance, headache, and circulatory and nervous dis-
turbance which sometimes persist, are probably due to vasomotor depression,
and may be relieved by alternate hot and cold douching. The douches may
be given for hah' a minute each at a temperature of 45°C. (ii3°F.) and i4°C.
(59°?.), ending always with the cold.
CONTUSION OF THE BRAIN
Contusion of the brain is that condition, following sudden traumatism
to the head, in which there are added to the concussion anatomic changes
which are discoverable in the nature of minute hemorrhages, damage to
blood-vessels, producing extravasation of blood elements, and slight lacera-
tions or cellular separations caused either by the primary traumatism or by
the extravasated materials, all of which are not gross enough to be described
as cerebral hemorrhage or laceration. The treatment is that of concussion.
Usually this suffices, and after a period of several weeks the patient goes on
to recovery. Continuous improvement even though slow calls for no addi-
tional treatment. These patients often desire to be up and about and toje-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 53
turn to work prematurely. So long as there is headache, vertigo, muscular
weakness, or evidence of abnormal cerebral pressure as shown by slow pulse
and venous stasis of the retina, rest and quiet should be insisted upon.
In cases which do not improve, localizing symptoms should be sought.
If the signs of cerebral pressure persist, the lumbar puncture which is em-
ployed to determine the presence or absence of blood in the cerebrospinal
fluid, may draw off enough fluid to have a curative effect.
If the evidences of pressure are positive and unabated, in the absence of
localizing symptoms, the skull may be trephined in the temporal fossa
between the separated fibers of the temporal muscle. Upon incising the
dura, clear or bloody cerebrospinal or edematous fluid may be found. The
liberation of this will often suffice to effect a cure. If after trephining upon
one side, a bulging of the dura, indicating pressure, is found, and if after
incising the dura no excess of fluid is discovered, the opening should be
enlarged with the rongeur in search of clot. None being found, the wound
should be closed, and the effects of the decompression awaited. No improve-
ment appearing, a similar operation should be done upon the opposite side.
Often when no lesion is discovered, the operation will sufficiently reduce the
pressure to turn the balance in the favor of recovery.
COMPRESSION OF THE BRAIN
Whether compression of the brain is due to foreign body, depressed
fracture, tumor, blood-clot, excess of cerebrospinal fluid, extensive venous
occlusion, or edema, the treatment consists in either (i) removal of the
compressing factor, (2) reducing the amount of normal fluids in the skull,
or (3) making more room for the cerebral contents by removing some of the
skull. All of these are aimed to prevent the ultimate fatal anemia of the
cardiac and respiratory centers in the medulla. The skull-box itself is
unyielding; the brain is incompressible as water; any cerebral content,
over and above that which is normal, must either destroy brain substance
and replace it, or it must cause the extrusion from the skull-box, through
some of its numerous openings, of cerebrospinal fluid, blood or brain sub-
stance. When the pressure reaches a certain point, greater than that of
the blood-pressure, blood is squeezed out of the intracranial vessels. When
this pressure begins to produce anemia of the vital medullary centers, and
the vasoregulator mechanism has done all it can to keep up the blood-
pressure in the vessels, if the pressure outside of the vessels increases, death
takes place. The rise of systemic blood-pressure in case of increased intra-
cranial pressure is an essential and salutary vasoregulator function. Brain
compression is a mechanical condition which must be met by mechanical
treatment, but not by lowering the systemic blood-pressure.
Accessible clot, abscess, tumor, or other compressing agent should be
removed. Edematous fluid, which is producing serious pressure, should be
evacuated. In the presence of edema, noninfective meningitis and certain
other inaccessible or irremovable compression factors, the amount of normal
fluid in the skull may be reduced and more room secured by lumbar puncture.
Decompression operations accomplish the same result. There is no merit in
reducing the amount of circulating fluid by means of bleeding or inhibiting
the fluid intake. The operative expedients may always be resorted to as
temporary measures of relief in an impending emergency.
The withdrawal of cerebrospinal fluid by lumbar puncture under these
circumstances is by no means free from danger. A number of fatalities
have attended this simple operation. After the withdrawal of spinal fluid,
54 SURGICAL TREATMENT
the intracranial pressure may become much greater than the intraspinal
pressure, the brain may be forced down against the foramen magnum so
strongly that immediately fatal anemia of the medulla, or compression of the
fourth ventricle and fatal edema of the medulla, may occur. This danger
seems to be obviated if a decompression operation upon the skull has been
done before the puncture is made.
Blood-letting was once much resorted to, especially in compression due to
intracranial hemorrhage. It is rarely of value. The natural physiologic
mechanism for regulating blood-pressure had usually better be depended
upon. Death in cerebral compression is ultimately due to a failure of the
pressure-maintaining mechanism, and when this last stage is approached the
patient needs his blood. The exceptional conditions under which phlebotomy
may be practised belong in the province of the internist.
Decompression of the brain is an operation which has proved of much
value and is finding a constantly increasing field of application, especially in
tumors of the brain. For cerebral compression the operation is best done in
the temporal region (see Temporal Craniotomy, page 36). The temporal
muscle should be preserved, by separating its fibers, in order to prevent
hernia cerebri, and to afford protection to the brain. In right-handed per-
sons the operation should be done on the right side. Here the squamous
wing of the temporal bone covers a fairly silent cortical area. The trephine
opening should be made posterior to the middle meningeal artery and below
its posterior branch. It should be remembered that the lower end of the
fissure of Rolando lies just above the squamous (temporoparietal) suture
from 4 to 7 (average 5.5 cm.) above the zygoma. The opening may be
enlarged in all directions, but it should not go above this inferior Rolandic
point. The posterior branch of the middle meningeal artery will be found in
the dura, and need not give trouble. The size of the opening made must
vary with the degree of bulging encountered. Usually an opening about 5
cm. (2 inches) in diameter is made. The dura should be incised so that it
shall not restrain the brain, and not be sutured. Some surgeons remove it.
The muscle and temporal fascia should be sewed in layers. No drainage
should be required or used lest it be responsible for hernia cerebri. A uni-
lateral operation usually suffices. Later, if necessary decompression may
be done upon the other side.
In subtentorial lesions, especially in tumors of the cerebellum, the sub-
occipital operation is done (see Suboccipital Craniotomy, page 36). This
gives the protection of the suboccipital muscles. The general principles of
the operation are the same as those of the temporal operations. Here, for
decompression purposes, the bilateral procedure is, perhaps, more efficacious
than the unilateral operation. In compressing disease, situated below the
tentorium, it may be hoped that suboccipital decompression will reliev • the
pressure which causes occlusion of the exit from the fourth ventricle, if such
occlusive pressure be present.
INTRACRANIAL HEMORRHAGE
The treatment of intracranial hemorrhage may be either expectant or
operative. Small hemorrhages which are not causing serious compression,
which do not involve important areas, which will not leave irritating adhe-
sions, or which are inaccessible, may be left to be absorbed. Hemorrhages
which are producing serious pressure, which are paralyzing important organs,
which are apt to leave epilepsy-engendering patches of adhesions, should be
exposed and the clot removed if it is accessible. It should be remembered
that clot itself does not destroy at once the brain structure. It produces
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 55
anemia by pressure; and intracerebral clot causes a separation of structures.
If clot is at once removed, restoration of brain function may be expected.
Extradural Hemorrhage. — The treatment of extradural hemorrhage
should be operative exposure of the clot, removal of the same, and stanching
of the bleeding as soon as the diagnosis is made. Most of these hemorrhages
are from the trunk of the middle meningeal artery or one of its main branches,
and operation in the temporal region is called for. The best approach is by
trephining between the separated fibers of the temporal muscle (see Temporal
Craniotomy, page 36). If the first opening does not discover the clot, a
subsequent opening in the next most probable site should be made. This is
better than turning down an osteoplastic flap, unless the site of the trouble
is positively known. The middle meningeal, it should be remembered, after
entering the skull through the foramen spinosum, passes outward and curves
upward, grooving the bone under the temporal fossa. It reaches the squa-
mous wing of the temporal bone just in front of the condyloid point, passes
upward and forward, and bifurcates about two fingers' breadth above the
zygoma and a thumb's breadth behind the frontal process of the malar bone.
Its branches spread out over the whole temporal region, and hemorrhage
may be looked for anywhere within this zone. In trephining for meningeal
hemorrhage the first point may be the temporal fossa about 2.5 or 4 cm.
(r or i^ inches) above the midzygomatic point. A second place is 5 cm.
(2 inches) above the midzygomatic point. A third place of choice is the
posterior temporal region in a vertical line from the posterior border of the
mastoid process on the same horizontal as the first opening. It should be
borne in mind that the middle meningeal may be ruptured at the foramen
spinosum by fracture of the base, and that hemorrhage may involve the base
as well as the lateral region. Commonly it will be found that a fracture has
caused the rupture of the vessel and the site of rupture can be located by
the fracture. The pressure in this vessel is so great that unless operation is
done a fatal amount of clot will be produced in most cases.
Rupture of veins or sinuses may also be responsible for extradural hem-
orrhage. The surgeon should have in mind the possibility of the hemorrhage
being located on the side opposite that which received the blow, and, indeed,
the possibility of bilateral hemorrhage. Because of the hemorrhage usually
being below the motor area, no localizing symptoms are present to serve as
a guide; but in many cases, if the patient is carefully watched, twitching of
the face or upper extremity may be observed as the upper edge of the clot
advances. These focal indications may sometimes be confused, and facial
symptoms may be due to motor area disturbance or to basilar fracture
affecting the facial nerve.
Hemorrhage occurring beneath an osteoplastic flap after the closure of a
craniotomy wound is not uncommon, and calls for reopening of the wound.
It should be borne in mind that concussion commonly accompanies this
hemorrhage, the latter coming on after the symptoms of the former have
abated. The development of pressure symptoms under these circumstances
is quite characteristic. Impediment to the return flow of blood from the
eye appears early, and can be discovered in a tortuosity of the veins and
edema of the eye-ground, usually first on the affected side.
When the hemorrhage is found, the trephine opening should be enlarged
sufficiently to allow the removal of the clot and the checking of the hemor-
rhage. Often it will be found that upon the removal of the pressure the
bleeding becomes aggravated. The torn vessel may be closed temporarily
with gauze packing while a new trephine opening is made or the rongeur
applied to expose the place to be ligated.
56 SURGICAL TREATMENT
Ligation of the middle meningeal artery is the first thing to be done in a
steadily progressing hemorrhage of known meningeal origin. The skull
should be exposed as in temporal craniotomy (page 30). The trephine
should be applied about 2.5 cm. (i inch) above the midzygomatic point.
The vessel curves forward below and upward in front of the middle of this
opening. The removal of the button will usually reveal the artery. If it is
not here, by pressing away the dura, and enlarging the opening downward,
it will be found. The branch which passes posteriorly comes off just below
and behind this, and the ligation of this branch may be required. In trephin-
ing over the artery care must be taken as the vessel often lies deeply imbedded
in the bone. If, as the trephine approaches the dura, there is a sudden gush
of arterial blood, the division of the bone should be quickly completed, the
button lifted out, and the wounded vessel seized in the dura with mouse-tooth
forceps. Then the dura may be pressed back from the bone, and the opening
enlarged with the rongeur sufficiently to permit carrying a ligature around
the vessel by means of a small curved needle.
Subdural Hemorrhage. — Hemorrhage occurring within the cranium as a
result of traumatism is usually subdural, between the dura and pia-arachnoid.
Such hemorrhage comes from the bone when the dura also is torn, as is apt
to be the case in fractures of the base where the dura is closely adherent.
The bleeding may also come from arachnoid or cortical vessels with or with-
out fracture. Unlike the extradural hemorrhage, the blood passes freely
through the subdural space. Often the delicate arachnoid at the base gives
way or is torn and permits the blood to mingle with the cerebrospinal fluid
about the cord. The bleeding is usually from small veins and tends to be
self-limiting. The proportion of cases in which the hemorrhage is slight and
unrecognized, and in which recovery takes place without operation is greater
than we have any statistics to show. It is the graver cases which require
operation.
After traumatism and symptoms of concussion, if recovery is not as
prompt as from concussion alone, and if symptoms of pressure supervene,
subdural hemorrhage, in the absence of something else more positive, may
be assumed to exist. Commonly the hemorrhage is basilar. If there are
no localizing symptoms to guide the surgeon, operation should be aimed to
drain the subdural space near the base. Operation is done when the positive
evidences of pressure are present. If no focal symptoms are present, per-
haps, one or the other sides may show lateral symptoms. Venous stasis in
the eye-ground will often point to the side which is suffering compression.
If there is no guide but the general symptoms of compression from subdural
hemorrhage, the place of choice for craniotomy is low in the right temporal
fossa (see Temporal Craniotomy, page 30). The trephine opening should
be made as low as the retraction of the fibers of the temporal muscle will
permit, 1.3 to 2.5 cm. (% to i inch) above the zygoma, in a vertical line above
the condyle of the inferior maxilla. The opening may be enlarged as re-
quired. Upon incision the dura and discovering hemorrhage, clots should
be irrigated away. If the source of the bleeding seems to have been the
near vicinity, and the hemorrhage is represented by a coagulum which is
removed, the wounds may be closed without drainage. If, as is usually the
case, the blood has diffused itself in the subdural space, drainage by means
of wick or gauze rolled in an impervious sheath (cigarette drain) should be
inserted. The rest of the wound is closed. On account of the usual neces-
sity for drainage, the low, intramuscular, temporal operation has the ad-
vantage of giving good drainage and offering the least danger of hernia
cerebri.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 57
The temporal craniotomy affords very satisfactory drainage if the hemor-
rhage comes from the middle fossa of the base. The temporal lobes can be
lifted up and the base drained. A bilateral operation is called for if the
drainage secured from one side is inadequate, or if the evidences of subdural
hemorrhage are strong and the hemorrhage is not discovered by the first
operation. Suboccipital craniotomy gives the best drainage in fractures of
the posterior fossa of the skull and in subtentorial hemorrhages (see Suboccipi-
tal Craniotomy, page 36). When the pressure symptoms are localized the
operation should be applied to expose the hemorrhage wherever it is.
Checking of subdural hemorrhage is not a matter of moment. The seat
of bleeding can rarely be discovered. It is almost invariably venous and
from small vessels with but little pressure. It may be left to take care of
itself. The main thing is to relieve the intracranial compression. If drain-
age is provided to carry off the blood as fast as it accumulates, the bleeding
need not give concern. It will stop.
The cases which always require operation are those with distinct focal
symptoms. Here, if the clot is accessible, it should be removed; if it is at
the base, drainage as near to it as possible should be provided. Operation
should also be done though the symptoms are not localized, if the compres-
sion is, steadily progressing toward the danger point, the stupor becoming
deeper, and the pulse slower. My own practice has tended to watch these
cases as the pulse rate went down from 80 or 90 per minute, incidental to the
concussion, to 65, 60, and 55, indicative of pressure. I have usually oper-
ated before the pulse reached 50.
In mild nonlocalizing cases, or in cases before operation, the patient
should be kept quiet in bed with the head slightly elevated. If the general
condition remains fairly good, if the stupor does not deepen but seems to
abate, if the pulse rate does not grow progressively slower, operation may be
deferred. If, after three days, improvement does not show itself, but the
symptoms of pressure continue unabated, operation is advisable. Operation
will be of most service, if it is to be done at all, when it is done not too late.
After paralytic symptoms have developed, and clot has become organized
and provoked adhesions, permanent damage has been done which operation
can not relieve.
Pachymeningitis Hemorrhagica. — This condition is associated with the
deposit of a membrane in the subdural space, presumably made of blood clot.
The indications for operation are variable. There may be progressive demen-
tia, convulsive attacks, headache, and signs of intracranial pressure. The
diseased area should be uncovered by craniotomy, and the deposit removed.
Subarachnoid Hemorrhage.— Subarachnoid bleeding is usually the result
of contusion of the brain. It is commonly associated with laceration of the
brain, or with fracture and subdural hemorrhage. When near the medulla
it is usually fatal. Over the hemispheres, where it exists alone, it may reveal
itself by pressure symptoms. These are apt to be preceded by symptoms of
irritation. Such hemorrhage should be uncovered by trephining. The
overlying meshwork of arachnoid should be incised, and the clot, if thick,
washed out by means of a gentle stream of warm saline solution. If the clot
is not thick, the decompression alone should suffice.
Hemorrhage into the Brain Substance. — Bleeding into the substance of the
brain may be the result of traumatism or disease. It may occur in the cortex
of the cerebrum, deep in the brain substance, in the basilar ganglia, or in the
cerebellum. The points of hemorrhage may be single or multiple. From
the standpoint of treatment, it is chiefly the single hemorrhages with which
the surgeon is concerned — those which require attention because of compres-
58 SURGICAL TREATMENT
sion. Here, as in the other intracranial hemorrhages, operation is called for
chiefly to relieve pressure. If death does not result from pressure, in most
cases the clot will either be absorbed or degenerate into a cyst. Small hem-
orrhages are serious only when they involve important regions; otherwise
they are absorbed and leave little trace of their existence.
Hemorrhages connected with a wound, such as made by a bullet, a stab
wound, or associated with depressed fracture, if sufficient to give even slight
symptoms of compression, should be evacuated. Usually this is best done
by following the track of the wound. If further damage to important areas
would be entailed, some other course of approach through a silent area may
be selected. Hemorrhage in a vascular tumor, such as gliosarcoma, should
receive treatment by decompression, and if possible by drainage or removal of
the tumor.
The same rules which are applied to the treatment of subdural hemor-
rhages apply to brain hemorrhages. If the location of the clot is known and
it is approachable, it should be exposed and drained, provided that it is pro-
ducing serious pressure. If such a clot cannot be reached, the condition
should be treated as a brain tumor, and a decompression operation done.
Spontaneous cerebral apoplexy, the hemorrhage due to disease of the
blood-vessels occurring especially in the aged and giving rise to the so-called
"stroke of apoplexy," usually comes from a rupture of one of the small
branches of the middle cerebral artery. The indications for surgical treat-
ment are those of pressure. In most cases some localizing symptoms are
present which show the side of the brain involved. The differences of the
eyes, the differences in muscular tone between the limbs of the two sides, and
the lines of the face showing muscular flaccidity on one side or the other usu-
ally suffice for lateral localization. Medical treatment offers much for the
prophylaxis of this disease but little for its treatment. Surgery can do much
for this condition which in every respect is a surgical lesion.
The blood coagulates quickly, and the hemorrhage usually is ended in a
short time. The progressive symptoms which continue are most probably
the gradual changes, such as the development of a zone of edema, due to the
pressure. It is doubtful if the routine measures to lower blood-pressure in
these cases are of value; it is certain that they often do harm. The use of
drugs which act as vasodilators, bleeding, the constriction of limbs to confine
the blood in the extremities, none of these things have proved to be of definite
service. The high blood-pressure is a result of the apoplexy; it is essential to
overcome the compression anemia of the basilar centers; a fatal anemia of
these centers occurs unless the systemic blood-pressure is maintained suffi-
ciently high to overcome the increased intracerebral pressure which is caused
by the presence of the clot. The rational treatment of this condition must
be worked out not by combating the natural life-saving mechanism for
regulating the systemic blood-pressure, but by relieving the increased intra-
cranial pressure due to the presence of a foreign body.
Given a case of spontaneous apoplexy with stupor or coma, flaccidity of
the muscles of one side of the body, a high blood-pressure in response to an
abnormal intracranial pressure, and the other characteristic signs of a hemor-
rhage in the internal capsule on the side of the brain opposite to that of the
paralyzed muscles, the surgeon may expose the brain and relieve the pressure
by draining the clot focus. Usually no anesthetic is required. The head
should be shaved. A temporal craniotomy should be done between the
retracted fibers of the temporal muscle (page 36). This is done through a
vertical incision above and anterior to the external ear. The temporal fascia is
exposed and incised in the same direction. The fibers of the temporal muscle
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
59
are separated, but not cut, and the squamous portion of the temporal bone
and the adjacent parietal bone are exposed. The skull should be opened by
trephine or burr just below or above the squamous suture, and the opening
enlarged to about 3 or 4 cm. (i^ inches) in diameter. The dura is opened
by a crucial incision. This is all done rapidly and should consume but a few
minutes. An opening should be made sufficiently large to expose the region
of the lower end of the fissure of Rolando, the lower ends of the two central
convolutions, and the fissure of Sylvius. The brain will often show edema
or other local evidence of injection and hemorrhage. If not, it should be
entered at the prominent rounded eminence of the lower end of the posterior
central convolution just behind the lower end of the Rolandic fissure and
above the Sylvian fissure. This point is horizontally above the external
auditory meatus, about 5.5 cm. (varying from 4 to 7 cm.) above the zygoma.
The opening in the dura should be as small as possible. A trocar and canula
of small size should be entered in a downward and inward direction. It
should pass sufficiently above the fissure of Sylvius to avoid the island of
Reil (Fig. 737). By inserting the instrument in the middle of a convolution,
FIG. 737. — SPONTANEOUS CEREBRAL APOPLEXY.
Showing transverse vertical section of brain. Trocar and cannula passed inward and
downward to tap clot. This is the point of election for tapping the usual capsular clot
through fthe postcentral gyrus. The instrument is entered high enough to pass above the
island of Reil.
no vessels are injured. The apoplectic clot should be encountered within
5 cm. (2 inches) of the surface. A soft roll of rubber tissue, to serve as a
drainage tube should be inserted through the canula. The dura, fascia, and
muscle should be sutured snugly about the tube with chromicized catgut.
Every precaution should be taken to prevent hernia cerebri. The clot may
be expected to extrude itself through the tube.
If the lower end of the postcentral convolution cannot be located, the
puncture may be made somewhere posterior to a line erected horizontally
above the external auditory meatus, from the zygomatic line, and above the
Sylvian fissure. That means from 4 to 7 cm. above the zygoma, depending
upon the size of the brain. The puncture should be made at the convexity
of a convolution.
Some surgeons draw apart the borders of the operculum at the junction
of the Sylvian fissure and a continuation of a line from the Rolandic fissure.
The island of Reil is in the depths of this fissure. A trocar is inserted into
60 SURGICAL TREATMENT
the island, penetrating the white matter of the island, the claustrum and
the globus pallidus. Blood is encountered at a depth of from i to 3 cm.
(% to i Y± inches).
Because of the intracranial pressure, there may be troublesome bulging
of the brain after the dura is opened. This may be overcome by elevating
the head of the table. Lumbar puncture may be required. As soon as the
dura is opened, the decompression should show itself in improvement in the
patient's general condition. The results of these operations have not been
collected sufficiently to place the operation upon a definite surgical basis.
Most of them have been done too late when, as a result of laryngeal paralysis,
inhalation pneumonia has been engrafted. Others have been attempted
when the compression had exhausted the vasoregulator centers. But it can
be safely predicted that as a result of the experimental work which is now
being done the operation will become an accepted surgical procedure.
In exceptional cases, in which there was abnormally high blood-pressure
before the apoplexy, in a plethoric individual, if the patient is seen immedi-
ately while the hemorrhage is going on, there is, perhaps, some value in
phlebotomy, or in throwing a bandage about the bases of the arms and legs
to shut off the venous return and confine as much blood in the limbs as possi-
ble for a short period. An injection of nitroglycerin during the bleeding may
be of service. Elevation of the head is surely called for. But these expedi-
ents must be applied quickly as the hemorrhage is soon over. Whatever is
done to reduce the blood-pressure, it is absolutely essential that the blood-
pressure shall rise again sufficiently to overcome the extravascular pressure
in the skull.
The pre-apoplectic stage belongs to the province of medical therapy.
Treatment of that stage is vastly more important than the treatment of
apoplexy, for it deals with a yet undamaged brain.
Intracranial Hemorrhage in the Newborn. — This condition follows in-
juries sustained in utero or at birth. Usually they are the result of prolonged
or instrumental labor. They commonly occur in the first born of women
who are advanced in years. Traumatism and congestion are, perhaps, both
causative factors. The hemorrhage may be unilateral or bilateral, and is
usually subdural. It is important that the clot shall be removed by opera-
tion. Unless it is removed, if the child survive, the clot produces pressure
which destroys cortical cells, and adhesions remain as a permanent cause of
irritation. Spastic paralysis, "birth palsy," hemianopsia, epilepsy and
mental defectiveness are some of the permanent results of failure to give
these cases the benefit of operative treatment.
The indications for operation are that the child at first suffers with re-
spiratory difficulty or irregularity often amounting to asphyxia; it displays
the symptoms of intracranial pressure; there may be slowing of the pulse,
prominence of the fontanels, dilatation of the veins of the skull and eye; the
child does not suckle well, and has to be fed with a spoon or dropper; there
may be twitching or convulsive movements, which may be unilateral.
There are no localizing muscular paralyses because the motor impulses have
not yet become cortical.
The operation should be conducted on the same principles as with an
adult. These cases are by no means hopeless. The elasticity of the infant's
skull permits it to accommodate a large clot. The operation need not cause
any more traumatism than it suffers in labor. Localization may be impossi-
ble, but it may often be decided by some lateral differences in venous con-
gestion. It is important in operation that the body heat shall be conserved
by hot-water bottles, and that blood shall be saved as much as possible. The
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 61
operation should be done as soon as the diagnosis is made. If the clot is not
found on one side it may be looked for on the other.
The child's head should be shaved, and its limbs and trunk enveloped in
warm blankets containing hot-water bags. Unless there is stupor, light
general anesthesia is used. Hemostasis is secured by a light elastic band
about the head (see Scalp, Hemostasis, page 19). An incision, the shape
of a horseshoe is made, base downward, just within the limits of the parietal
bone. The bone is freed for a short distance at its upper border by cutting
the interosseous membrane. With a director or an elevator under the bone,
it is divided in a line corresponding to the scalp incision. The bone may be
cut with scissors, a knife or cutting forceps. The scalp-bone flap should be
turned down. Clot will show through the dura by its dark color. The dura
should be divided some distance from the bone margin, the flap turned down,
and the clot washed away with warm saline solution. In older cases an ad-
herent fibrinous mass may be found, which should be peeled off and removed.
The dura should be nicely approximated with fine chromicized catgut, and
the skull and scalp sutured back in place. (See Injuries of the Newborn,
Vol. III).
WOUNDS OF INTRACRANIAL STRUCTURES
Wounds of the meninges usually require treatment in connection with
depressed fractures and operative procedures. All hemorrhage should be
checked before the wounds are closed. This is important because even
slight bleeding is prone to continue until a considerable clot has formed.
Wounds of the pia-arachnoid, if large enough to gap and expose brain sub-
stance, should be sutured with extremely fine catgut.
Still more important is the suturing of wounds of the dura mater. Such
wounds in the presence of skull defects, if not closed effectively, are prone
to be followed by extrusion of the brain or hernia cerebri. If they are not
smoothly closed so as to present an even endothelial surface to the pia-
arachnoid, adhesions which obliterate the subdural space are apt to form.
Such adhesions are a prolific source of irritation to the cells of the underlying
cortex and prone to be causative factors in the development of epileptic
attacks. It sometimes happens that the dura is torn and ragged. Under
such circumstances it should not be trimmed off in the wasteful manner that
other tissues are treated. All that is viable must be preserved. The dura
is but slightly elastic. Sometimes the bulging brain prevents good apposi-
tion, and it is advisable to perform a lumbar puncture to relieve the pressure.
By applying a slight plastic operation dural defects may often be closed.
Adjacent fascia or periosteum may be turned in. Hydrocele or hernial sac
or transplanted fascia with its fatty layer may be employed. To strengthen
a dural defect under a bony defect, an osteoplastic operation should be done,
applying solid bone over the weak place. This can often be accomplished
by turning down a patch constituted of the outer table of the skull and
periosteum, applied with the periosteum toward the brain. Or bone may
be transplanted from the tibia, scapula or rib.
In emergency work when haste was necessary, I have with much satis-
faction closed defects in the dura by weaving the opening across in two direc-
tions with chromicized catgut over a piece of fascia.
Wounds of the brain require treatment applied chiefly to the skull and
meninges. Hemorrhage has been discussed. Such wounds fall together by
their own consistency. The brain cannot be sutured. Brain substance
which is lacerated and torn loose should be removed. Brain tissue which is
torn and extruded through a skull wound should be removed. It often
62 SURGICAL TREATMENT
becomes necessary to remove brain tissue in order to close a rent in the dura.
No hesitation need be had to make such sacrifice; the motor area is the only
part of the cortex which need receive conservative consideration.
Stab wounds of the brain are important on account of the danger of (i)
hemorrhage; (2) infection; (3) foreign matter carried into the cranium; and
(4) subsequent irritating adhesions. A certain amount of hemorrhage will
invariably be present. If it gives any symptoms whatever, it should be
exposed and dealt with; this for the reason not only of the hemorrhage, but
also because of the three other dangers associated with the wound. These
wounds may heal without infection, provided the scalp wound is properly
cared for; but upon the first appearance of symptoms of infection, the wound
should be opened. If the symptoms point to intracranial infection, a button of
bone should be taken out. This should include the bone wound. The
opening should be enlarged if necessary to uncover and drain meningeal
infection. The development of abscess should receive the treatment else-
where described (page 73). If the wound has been inflicted with a blunt-
pointed instrument which has obviously carried in foreign matter, it should
be trephined and as much of the offensive substance as is accessible removed.
Any one or all of these complications are prone to give rise to adhesions. A
clot with a mild localized infection creates the conditions most prone to pro-
duce subsequent trouble. If to this are added spicules of bone and bits of
hair, a mass of scar tissue may result, capable of predetermining an epileptic
destiny. For all of these reasons it is clear that but a very slight excuse
should call for the excision of enough bone to remove clot, check hemorrhage,
eliminate foreign matter, and provide drainage, thereby minimizing the dan-
gers of pressure, infection, and subsequent cortical irritation.
Whatever is done, at least the scalp for several centimeters around the
wound should be shaved and cleansed, a drain should be carried down to the
bone, and through it, if possible, a copious wet antiseptic dressing applied,
and the patient kept quietly in bed.
Bullet wounds of the brain should be treated according to the rules already
given for the treatment of bullet wounds (Vol. I, page 222) and of wounds of
the brain in general. Practically the same rules apply as are given for stab
wounds. The peculiar feature of many of these injuries is that the bullet
lodges within t.ie cranium. The treatment here becomes one of a tentative
nature. By no means should an attempt be made to locate the bullet by
means of a probe. If it is suspected that the ball lies just beneath the skull,
there is far less hazard in doing a systematic trephining than in the most
careful introduction of a probe. Quite invariably a probe fails to locate
a bullet, and only serves to carry in more infection. But a trephine opening
may be of some use. One of the pernicious activities of obsolete surgery was
the probing of the brain for bullets.
In most injuries of this sort, the scalp should be shaved about the wound,
cleansed, and dressed with a copious wet antiseptic dressing after the intro-
duction of a small drainage tube just to the bone opening. If there is a
wound of exit, it also should receive the same treatment. If the bullet is
lodged within the cranium, in most cases it may be left undisturbed. It
usually sinks to the base of the skull laterally, becomes surrounded by a
fibrous envelope, and does no appreciable harm. Next to leaving the bullet
alone, the most important thing is to determine its location by means of
x-ray pictures taken at right angles to one another.
If the ball happens to lie near the surface of the brain where it can be
reached without harm, particularly if it occupies some position from which
focal disturbances would arise, it should be removed either through a tre-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 63
phine opening or by turning down an osteoplastic flap. If the bullet is
hidden in brain tissue, the operation should not be attempted until the most
accurate measurements and guides have been made whereby the surgeon
shall be able to find it with the least amount of trauma tism. The cortex
should be entered through the middle of a convolution because of tae greater
abundance of vessels at the sulci. A fine needle should locate the bullet. A
telephone attachment will add to its delicacy. It should be extracted with
the least possible traumatism. The motor area of the cortex should )e
avoided, if possible, in such operations.
Hemorrhage, infection, and abscess are discussed elsewhere. An abscess
developing in connection with the bullet gives an opportunity in the treatment
of the former to remove the latter.
Foreign bodies in the brain require the same general treatment as bul-
lets. Jagged and irregular bodies do more damage, carry in more surface
dirt, and are more prone to be associated with infection; consequently such
wounds must be especially asepticised down to the meninges, and the early
localization of the body and its removal are more urgently demanded.
Removal of pieces of bone and other foreign matter and drainage down to
the meninges are imperative.
Injuries of intracranial nerves give rise to scar formations which require
treatment for the relief of neuralgia, paralyses, and other disabilities. Frac-
tures of the base of the skull are the chief causes of injury to these nerves.
The sixth nerve (the abducens) is sometimes injured by fractures of the
base as it lies in its groove on the basilar surface of the sphenoid bone. Its
paralysis causes internal strabismus in the eye of the affected side. There is
no treatment directly applicable to the nerve. Time and correcting exercises
of the eye often suffice to effect a cure (see Strabismus, page 135).
The fifth nerve (the trigeminus) is often injured by fractures and diseases
at the base of tae skull. Such injury may involve the Gasserian ganglion or
its roots, but most commonly the superior maxillary nerve at the foramen
rotundum, the vidian in the Vidian canal, or the inferior maxillary at the fora-
men ovale. Such injury may compress the nerve or involve it in scar tissue,
for the relief of which some of the methods of treatment elsewhere described
are called for (see Neuralgia of Trifacial Nerve, Vol. I, page 86 5; Operations
on the Gasserian Ganglion, Vol. II, page 106).
The seventh nerve (facial and auditory) is often injured by fractures of the
petrous portion of the temporal bone, by clot, tumor or inflammatory disease
in t'nat region. Such injury occurs to the facial nerve at the internal auditory
meatus, in the canal of Fallopius, or at tie stylomastoid foramen. The
portio intermedia of Wrisoerg, connecting facial and auditory, may also be
involved. The auditory nerve may be injured with the facial or it may be the
seat of separate disease. The determination of the location of injury of these
nerves, and its extent, is one of the delights of exact anatomic knowledge.
Whether the indications for treatment are muscular paralysis, neuralgia,
convulsive tic, or tinnitus aurium, much can often be done to bring relief
(see Paralysis of the Facial Nerve, Vol. I, page 881; Neuralgia of the Facial
Nerve, Vol. I, page 877; Spasm of the Facial Nerve, Vol. I, page 888; In-
juries of the Auditory Nerve, Vol. I, page 890; Intracranial Operations on
the Seventh Nerve, Vol. II, page no).
Injuries of the brain have been discussed under the heads of " Concussion,"
"Contusion," "Compression," "Intracranial Hemorrhage," "Wounds," and
"Fractures of the Skull." There is no distinction between the treatment of
injuries of the cerebrum and cerebellum excepting that in the former the
integrity of the motor area is to be conserved by all means.
64 SURGICAL TREATMENT
Injuries of the pons and medulla are usually immediately fatal. Slight
injuries by wounds, foreign bodies, or blood clots, which are not at once fatal,
demand that the head shall be kept quiet and the blood-pressure equable.
Injuries of the meningeal sinuses occur in fractures of the skull, in con-
nection with wounds of the brain and meninges, and in operations upon the
head. The blood-pressure in these venous sinuses is very low. Hemorrhage
from small wounds is easily controlled by pressure. If a bit of gauze is
placed at the sinus wound the pressure sufficient to stop the bleeding need
not be great enough to do any injury to the adjacent brain. In some cases,
if there is a sufficiently free exposure, the wound in the sinus may be sutured.
In operating in the presence of a wounded sinus, the surgeon, having in mind
the ease with which the bleeding can be stopped by pressure when he is ready
to apply it, may proceed with the operation. These sinuses, being held open
by their non-collapsible surroundings, do not tend to spontaneous hemostasis
as other vessels do ; and the first business of the surgeon is to check the bleed-
ing. A minute pad of gauze may be held against the rent by a retractor.
It should not be forgotten and left in the wound. If the sinus has not been
closed by suture or by the pressure of other structures, a narrow strip of
gauze may be packed against it and the end brought out through a convenient
place in the scalp. At the end of forty-eight hours this may be removed,
and hemostasis expected.
The parasinoidal sinuses especially may be injured in the operation of
craniotomy. When a large rent is made in the roof of a sinus, gauze may
be packed directly into it. A clot forms and obliterates its lumen. The
only sinus thrombosis which need be feared is that which is associated with
infection.
Hernia Cerebri. — Hernia cerebri is a protrusion of the brain through an
opening in the dura and cranium, and is due to increased intracranial pres-
sure. In operating upon the brain or skull and in treating injuries of these
parts, it should be borne in mind that any increase of intracranial pressure
will tend to produce protrusion. Congestion within the cranium, whether
from traumatism, infection, low position of the head, respiratory obstruction
due to narcosis, or any other cause, in the absence of dura and skull covering,
will always cause cerebral hernia. When these coverings are removed and
a brain is exposed in the presence of congestion, tumor, clot or excess of
cerebrospinal fluid, protrusion may be expected to take place.
Two things are important to keep in mind in the treatment of these condi-
tions: (i) If the brain is uncovered in the presence of normal intracranial
tension, the normal atmospheric pressure will balance it and prevent hernia;
(2) when the brain protrudes, it is conclusive that there is abnormal intra-
cranial tension, the treatment of which should not be aimed toward sup-
pression of the protrusion but toward reduction of the pressure. To attempt
the reduction of extruded brain in the presence of pressure increases the
pressure, and is bad surgery. In acute conditions, the protrusion may be
due to some of the causes, above enumerated, which produce congestion.
Thus, in operating for compound depressed fracture, it will often be found
that the traumatism produces local congestion and edema sufficient to cause
cerebral hernia if the dura has been opened. In order to overcome this
temporary condition so that the dura may be sewed, the patient's respiration
should be made easy and equable, numerous punctures may be made in the
arachnoid to permit the escape of some fluid, the head may be elevated, and
if these expedients do not suffice some fluid may be drawn off by lumbar
puncture.
It is seen that the treatment of hernia cerebri is a treatment of the causa-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 65
tive force from behind rather than of the hernia itself, that it is a salutary
condition, and that so long as the brain is protected by a good covering of
scalp the disease is not a serious one. If the causative factor cannot be
removed it is better surgery to leave a well-covered hernia than to expose it
and attempt replacement or excision of the herniated tissue. If the causa-
tive factor disappears, the herniated portion may be expected to recede
within the skull. An exception will be found in the cases in which the hernia
has existed for a considerable time; here when the pressure becomes normal
the extrusion is apt to persist.
Fungus cerebri is a hernia in which there is an absence of all brain cover-
ing— meninges, skull and scalp are deficient. This is due to unhealed wounds
of all the coverings, or to ulceration of the coverings of a hernia cerebri. In-
fection of the exposed brain is usually present. The increase of pressure
which provokes the extrusion is often kept up by the infection and traumatic
congestion. This localized pressure continues so long as the causes are pres-
ent. If portions of the brain are excised or slough away, further infection
and congestion keep up the extrusion. Unless the condition is controlled,
fatal meningitis is sure to develop.
An attempt should be made to secure a scalp covering in order to stop
the infection. This is accomplished by shaving and cleansing the scalp, dry-
ing it with alcohol, and applying tincture of iodin or phenol followed by
tincture of iodin or other antiseptic.
At the operation the vessels of the scalp should be controlled by a tourni-
quet. The scalp for a wide distance about the field of operation should be
painted with tincture of iodin or other skin disinfectant. Crevices which
cannot be reached by the iodin should be sterilized by the sharp point
of the actual cautery. The extruded brain tissue should then be cut away,
the scalp dissected free, and the area covered by a plastic operation of the
scalp (see Plastic Operations, Vol. III). If sterilization has been secured, the
operation should succeed.
DISEASES OF MENINGES AND EPENDYMA
Extradural Infections. — Pachymeningitis externa usually springs from
disease of the bone and requires the treatment necessary for the bone disease.
Collections of pus between the dura and skull should promptly be evacuated
lest they produce subdural infection. Often these lesions are syphilitic and
require both operation and medication. When the infection is secondary to
middle-ear disease prompt operation may prevent the infection passing
through the dura. The sensitiveness of the dura gives much pain when pus
presses it away from the bone, and this symptom is often the call for opera-
tion. Even when pus is not present, an infection which has reached the dura
should have free drainage outward. Pachymeningitis has no especial sur-
gical significance except as a part of an extradural or subdural infection.
Syphilitic pachymeningitis may be from extension from the bone or a
distinct gummatous deposit. The constitutional treatment should be applied
and the thickening excised if necessary.
Extradural infection of otic origin often gives rise to a collection of pus
between the bone and dura. The causative ear disease should be operated
upon (see Suppurative Otitis Media, page 306; Mastoid Operations, page
310). The suppurative process should be followed to the place where it
penetrated the skull. Here the inner table should be cut away widely
enough to expose freely the extradural focus. Drainage should be provided.
Leptomeningitis (Subdural Meningitis).- — There are many varieties of
VOL. II— 5
66 SURGICAL TREATMENT
subdural meningeal infection, all involving the pia-arachnoid. The surgeon
is most concerned with the treatment of those which tend to be localized or
which have a known focus of origin. Such a meningitis following, for exam-
ple, an infected compound fracture of the skull presents some difficult prob-
lems. As soon as the signs of meningeal infection are elicited, local drainage
should be secured by reopening the wound. When the dura is reached, if it
had been previously opened, no hesitation should be had to reopen it, care
first being taken to sterilize its outer surface with phenol or iodin and to use
newly sterilized instruments in opening it. A seropurulent discharge found
in the subdural space discloses the meningitis. If upon approaching the
dura from the outside the dura is found not to have been wounded, its open-
ing is still called for if the evidences of meningitis are positive. Still further
assurance is afforded by the appearance of thickening and inflammation of
the dura. If there is bulging of the dura the evidence of meningitis is still
stronger. The same aseptic precautions against infecting uninfected menin-
ges should be taken, and the dura opened. Drainage should be secured by
rubber tubing or wick.
Whether to proceed further with the operation is a difficult question. It
often appears that the meningeal involvement extends downward to some
more dependent region which should be opened if the best possible drainage is
to be secured. Thus a secondary opening may be required in the temporal or
occipital regions. Death in these cases is due to pressure and sepsis. The
pressure is usually the most serious factor; and it is best overcome
by drainage.
The infecting agents in meningitis are so variable that the treatment
must be modified much according to the nature of the infection. The pyo-
genic organisms, such as the various Staphylococci, and Streptococci, and the
Bacillus pyogenes fetidus call for drainage at once. Organisms such as the
Pneutnococcus, Bacillus typhosus, Bacillus Pfeifferi, Bacillus anthracis, and
Bacillus tuberculosis must be met by other general indications. But in any
infection, drainage is called for if the symptoms of compression progress
toward the danger point. The natural tendency of meningitis is to gravitate
toward the base, and here drainage will be found most effective. The ante-
rior and middle fossae of the skull may be drained by lateral operations. The
posterior fossa requires suboccipital craniotomy. Here, after making a good-
sized trephine opening, the cerebellum should be lifted up and a wick drain
passed forward and inward toward the basilar cistern. Operation on both
sides is often called for. These operations are indicated in the meningitis
caused by infection through fractures of the base of the skull.
The posterior temporal and parietal regions and the occipital region above
the tenlorium cerebelli may be drained low down by a trephine opening just
above the superior curved line, sufficiently high to escape the lateral sinus —
2 cm. (^4 inch) above the posterior inferior angle of the parietal bone; or
midway between the parieto-occipital suture and the superior curved line on
the occipital bone, midway between its lateral and superior angles.
Meningitis of otic origin usually follows suppurative otitis media. It may
be serous or purulent. Infection reaches the meninges by way of the roof of
the middle ear, the roof of the mastoid, through the posterior wall of the
petrous portion, through the internal auditory meatus, or by way of the
aquaeductus vestibuli. The tendency of this infection is toward the base of
the brain. Prophylactic treatment is of first consequence. The presence of
an infective process in the middle ear always threatens intracranial infection,
and it should be healed as soon as possible (see Otitis Media, page 306).
Even when meningitis has developed, the suppurative focus in the ear should
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 67
be freely exposed. Similar puncture done for diagnostic purposes, by reliev-
ing pressure is often of therapeutic value.
The important treatment of these cases is the operative exposure of the
infected meninges. Usually this is best done by continuing the ear operation
through the skull, if possible, following the track of the infection (see Sup-
purative Otitis Media, page 306; Mastoid Operations, page 310). Upon
following the infection to the dura, the dura should be opened and drainage
established by means of wick or soft-rubber tubing. This operation may lead
to opening the skull in the angle between the lateral and superior petrosal
sinuses on the posterior surface of the petrous portion, or in front of the supe-
rior petrosal sinus on the anterior surface of the petrous portion, or at the
petrososquamous junction. In the first event the posterior fossa of the base is
entered, in the second event the middle fossa is entered. It is, therefore,
important to follow the route by which the infection passed from the ear to
the meninges in order that the infected fossa shall be drained. If the lateral
operation does not give adequate drainage, a suboccipital craniotomy may
be required.
Epidemic cerebrospinal meningitis, due to the Diplococcus intracellu-
laris meningitidis, must be differentiated from meningococcic, streptococcic,
pneumococcic, influenzal, and tuberculous meningitis, before treatment can
properly be inaugurated. Persons who have been in contact with the dis-
ease should be suspected as "carriers," and their nasal secretions exam-
ined. Children who have been exposed to known cases should be immun-
ized with a vaccine of the specific organism. Antimeningococcic serum is
also of value.
The treatment of the disease was placed on an effective scientific basis by
Abraham Flexner. Fluid is drawn from the spinal canal; if it is cloudy, the
serum of Flexner is injected at once. The injection is best not made with a
syringe, but by the gravity method. The dose for an adult is 20 to 40 c.c.,
and for babies and children 3 to 20 c.c. The dose should be 5 or 10 c.c. less
than the amount of cerebrospinal fluid withdrawn. In severe cases the anti-
meningococcic serum should be injected every twelve hours, preceded always
by the withdrawal of a greater amount of spinal fluid. In milder cases the
injection may be made once daily for four days. If the cases show a tend-
ency to become chronic, an autogenous vaccine should be made and given in
doses of 250,000,000 to 1,000,000,000 bacteria every five days.
There are certain purely surgical aspects to this disease. In the absence
of the Flexner serum and in advanced cases with pressure due to the accumu-
lation of inflammatory products, surgical drainage is called for. Lumbar
puncture will usually remove enough fluid to give temporary improvement,
but ultimately the accumulation of fluid in the lateral ventricles is apt to
demand attention. Obstruction to the escape of fluid from the ventricles is
often caused by intracranial pressure alone. When the excess of fluid in the
arachnoid and subdural spaces is evacuated, the ventricles drained, and the
spinal fluid tapped, an equalization of pressure may be secured. This equal-
ization of pressure cannot be attained in advanced cases unless all three of
these reservoirs are tapped; because, while normally they all communicate,
under the conditions entailed by pressure, meningeal adhesions, and exudate,
their intercommunications are shut off. Therefore, it is often necessary to
combine these operations. The disease is self limiting; and death is due to
pressure, causing anemia of the vital basilar centers.
Whether the skull operation shall be a suboccipital craniotomy or a lateral
craniotomy must be determined by the conditions present. Tapping the
ventricles in the posterior temporal region gives an opportunity to secure
68 SURGICAL TREATMENT
some subdural drainage; but, as Ballance has shown, the best subdural
drainage is to be secured by bilateral suboccipital craniotomy and the careful
lifting of the brain and placing wick drains forward and inward to the basilar
cisterns.
As a general plan of procedure for the relief of pressure in these cases it is
best to do first a lumbar puncture. If pronounced relief is secured, the opera-
tion may be repeated so long as it is effective. The next step should be
tapping the ventricles (see Operations for Drainage of the Ventricles, page
95). The ventricular tapping may be repeated as is required. The com-
bination of lumbar and ventricular drainage may be sufficient to secure relief
of pressure while the infection is subsiding. As a last resort, suboccipital
drainage combined with decompression is called for.
These are desperate cases. Anesthesia is rarely required because the
patients are usually in a comatose state. These lines of treatment described
for epidemic cerebrospinal meningitis are equally applicable to all forms of
meningitis in which the relief of pressure is called for (see Operative Treat-
ment of Meningitis, below).
Noninfective Meningeal Effusion. — This condition is comparable to the
nonmicrobic effusions found in other serous membranes. The causes to be
combatted are various; in some cases an unrecognized or healed infection
may be the cause. The presence of irritating toxic materials, which are often
the products of infections in other parts, may be a cause. Surgical treatment
is called for to combat compression. When the compression is overcome,
and hygienic treatment has eliminated the causative factor, the patient is
cured.
Lumbar puncture has been shown by Quincke to be the most valuable
operation. If there is free communication between the ventricles and the
spinal canal the operation may be expected to be curative. Unfortunately,
in some of the cases the exit from the ventricles is closed, and a condition of
hydrocephalus exists. After repeated lumbar puncture communication may
be established; but if the pressure symptoms persist unabated or assume a
serious character, drainage of the ventricles should be done (see Operations
for Drainage of the Ventricles, page 95). In some cases the obstruction is
due to the intracranial pressure and its release by any expedient may be cura-
tive. A temporal operation for decompression may be done if necessary.
Tuberculous Meningitis. — The surgical treatment called for in this dis-
ease is relief of the pressure. This should be done by lumbar puncture as in
the other meningitides. The operation relieves pressure and eliminates
toxins. Tapping of the ventricles is also indicated in cases in which pressure
symptoms are referable to the distention of ventricles. The general treat-
ment of the disease belongs to the province of medicine and hygiene (see
Tuberculosis, Vol. I, page 276).
Lumbar puncture prevents convulsions. From 20 to 30 c.c. of fluid may
be drawn off every second day. Tubercle bacillus will be found in the fluid
in a minor proportion of the cases. The fluid is rarely turbid.
Syphilitic Meningitis. — The vigorous treatment of syphilis in its early
stage should be looked to for the prevention of meningeal lues. Upon the
appearance of meningeal syphilis, which is usually within three or four years
of the original infection, antisyphilitic treatment should be pressed (see
Syphilis, Vol. I, page 283). A large proportion of these cases will be relieved
by this means. In other cases, particularly if treatment is not promptly in-
stituted, so much inflammatory tissue will have been deposited at the site of
the lesion that, despite active treatment, the symptoms of pressure will persist.
These call for operation.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 69
How long medical treatment should be used before operating, is a question
which the surgeon must answer for each case. If antisyphilitic treatment is
used for diagnostic purposes, it should not be continued longer than two
months without results. Some authorities advise continuing for three
months or even longer. It should be borne in mind that some forms of neo-
plasm are temporarily improved by mercury and iodid. If the case is one of
syphilis, improvement should be expected in two weeks. If there are decided
symptoms of pressure, if the pressure threatens permanent damage to impor-
tant nerves or organs, operation should be done if there is no abatement of
symptoms in two weeks — or even earlier if the pressure symptoms are
extreme. When early operations are done to relieve distressing symptoms,
the medical treatment may be continued after the operation.
The operation called for is that which treats the syphilitic deposit as a
tumor. If it can be localized it should be exposed and removed. Gummata
are sometimes found which are hard and unabsorbable. If it cannot be
localized, the dangers of compression should be relieved by a decompression
operation. Temporal decompression is preferred. By operating early the
blindness, which a choked disk presages, may be averted. Decompression
may usually be expected to relieve the severe headaches with which these
patients suffer. A pachymeningitis externa may be discovered. Operation
is called for also in localized conditions, such as give rise to Jacksonian epi-
lepsy, whether general compression symptoms are present or not.
Hydrocephalus should receive its special treatment. Distended ven-
tricles should be relieved by tapping rather than by decompression operations
upon the skull. If the latter are required they may be done later. Paraly-
sis of nerves later may require nerve grafting.
The Operative Treatment of Meningitis. — In meningitis operation is
capable of giving better results than any other treatment. It should not be
employed as a routine measure; but in the majority of cases, in which there
is a dangerous increase of intracranial pressure, due to an increased amount
of infected cerebrospinal fluid, operation is the important indication. It
should be borne in mind that the brain is unyielding and the skull is undilat-
able, and that when infection and inflammation increase the bulk of the fluid
secreted by the pia-arachnoid, the excess of fluid can only be accommodated
within the skull by compression of the blood-vessels, which causes anemia
of the brain and consequent disturbance of the vasomotor and respiratory
centers in the medulla. As a physiologic reaction the systemic blood-
pressure rises to overcome the intracranial pressure and to force blood through
the vessels of the brain. In this life-and-death struggle, the balance may
be turned in the patient's favor by operative relief of the intracranial pressure.
The normal amount of cerebrospinal fluid is about 60 to 80 c.c. (2 to 2%
ounces). The increase of cerebrospinal fluid, caused by bacterial infection,
gives rise also to the phenomena of infection. As the bacteria destroy the
dextrose in the cerebrospinal fluid at a rapid rate this phenomenon may be
utilized in determining the necessity for operation. Dextrose exists in
amounts of from 0.04 to 0.08 per cent. The absence of sugar may often be
detected by the chemical tests for dextrose before bacteria can be found.
This is of much importance in differentiating infective meningitis from other
conditions giving similar symptoms. The absence of the copper-reducing
substance can be discovered often twenty-four hours before bacteria can be
found in the spinal fluid. With the other means of diagnosis, such as the
clinical symptoms, the increase in cellular elements in the fluid, the excess of
globulin, and the presence of potassium salts, operation may be done early
enough to save life in a majority of cases which without operation would perish.
70 SURGICAL TREATMENT
The identification of the specific microbe is not so important as to relieve
pressure and provide drainage. The excess of fluid must be removed from
the cranium to make room for the life-giving blood, and make it possible
for nature to overcome the infection. As an exception, it may be stated
that, if the first examination of the cerebrospinal fluid shows the presence of
the diplococcus of meningitis or any other organism against which a serum
or bacterin is promptly effective, then the serum or bacterin should be used;
and if improvement does not quickly supervene, operation should be done.
A delay of not more than twenty-four or thirty-six hours should be allowed
for such treatment.
Irving S. Haynes (Archiv. of Pediatrics, Vol. xxx, No. 2, Feb., 1913) called
attention to the fact that opening of the skull in these cases ordinarily fails
because the brain is pressed into the opening and drainage defeated, and that
there is one location where it may be done without this occurrence. This
is the space between the two poles of the cerebellum and the medulla. The
cerebellomedullary angle in the cisterna magna lies close to the occipital
bone, and is easily accessible. This space is in free communication with all
the rest of the subarachnoid space about the brain and cord and with the
ventricles of the brain. It is a natural cavity into which the fluid flows as
it comes from its source in the ventricles.
The operation, as worked out by Haynes, is as follows: With the scalp
completely shaved, the patient is placed on the table, face downward. An
incision is carried in the middle line from the occipital protuberance to the
spinous process of the axis. This passes down to the bone. The periosteum
with the attached muscles is pressed outward on either side, exposing a space
4 or 5 cm. (i^ or 2 inches) long by 2.5 cm. (i inch) wide at the foramen
magnum. A trephine, i cm. (% inch) in diameter, is used to make an open-
ing in the skull in the median line about 2.5 cm. (i inch) above the margin
of the foramen magnum. The dura mater is carefully freed from the bone
toward the foramen magnum, and with a bone cutter, a line is cut on either
side from the outer part of the trephine opening to the outer part of the fora-
men magnum. These two lines should remove a truncated wedge of bone
about 7 mm. (% inch) wide above and 1.3 cm. (j^ inch) wide at the foramen
magnum. The dura should be protected carefully and separated from the
bone as the operation proceeds. The occipital sinus, lying in the median
line in the falx cerebelli, may be tied at its upper part and at the foramen
magnum. If there are two occipital sinuses, instead of one, the incision may
be made between them without ligating, or a longitudinal incision may be
made on either side of the usual occipital sinus. The incision through the
dura exposes the arachnoid which should be incised. This opening taps the
cisterna magna, and the fluid will spurt forth. The posterior poles of the
cerebellum are exposed, and in the notch between, the posterior surface of
the medulla is seen. A gauze drain enveloped in rubber tissue is placed in
the space, the deep parts closed with catgut, and the superficial wound with
silkworm-gut sutures.
Treatment by lumbar laminectomy, so far as results go, has, perhaps,
more to recommend it than occipital craniotomy. Laminectomy at the
third and fourth lumbar vertebrae is an operation which has been tried by
many surgeons with excellent results. The dura, having been exposed,
should be incised, and a cigarette drain placed at the dural opening. It
should be conducted out at the lower part of the wound, and the soft parts
closed about it (see Operations for Drainage of Ventricles, page 95).
Thrombosis of the Venous Sinuses of the Dura Mater. — Thrombosis of
a venous sinuses may be infective, traumatic, or spontaneous. It may be
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 71
complete or only partially occlude the lumen of the sinus. When it once
begins, its tendency is to become complete. Having become complete, there
arises a venous obstruction which is usually recognizable if one bring to bear
a knowledge of the anatomy of the veins which drain into the sinus and which
become obstructed by its occlusion.
Infective thrombosis is the most serious. It can often be anticipated and
preventive measures adopted. Usually it is an infection by extension from
a neighboring disease of cranial bone. Fortunately coagulation and throm-
bosis go ahead of the infection and form a protecting zone, otherwise pyemia
would result. Prophylaxis demands that all infective processes involving
the cranial bones or their sinuses should be regarded seriously. This applies
particularly to the regions lying close to the dural sinuses. The most im-
portant of these are the middle ear and the mastoid cells. A running ear
is a constant menace to life, and should be cured as speedily as possible.
The same may be said of chronic infections of the sphenoidal and frontal
sinuses. Indifference with regard to such chronic suppurations cannot be
too strongly condemned. This applies also to caries and necrosis of the
skull and to cellulitis and other infections of the scalp.
An infected thrombus should be exposed, and its center removed and
drained. In thrombosis, connected with ear infections, this can always be
done. In all cases of mastoid disease in which thrombosis is even suspected,
the mastoid cells should be exposed and freely laid open (see Mastoid Opera-
tions, page 310). The bone should be removed in the direction of the
infection and the dura exposed. If extradural abscess is found, it should be
uncovered by widely removing the overlying bone. The indurated wall of
the sinus will be exposed. The presence of clot shows itself by a thickening
of the sinus wall, by a sense of resistance, and by an absence of the normal
fluctuations of the sinus. The dura should be incised in the middle of the
induration, and the center of the clot removed. The outlying parts of the
thrombus should not be broken through but should be left to protect the blood-
stream from infection. Drainage by means of gauze or wick should be pro-
vided. The passability of subdural infection or abscess should be had in mind
and any sign leading to such a condition should be followed. When there is
doubt as to what lies beneath the exposed meninges, a small area may be
sterilized with iodin or phenol and a small incision or a puncture with an
aspirating needle made.
Opening and drainage of an infected thrombus should result in a sub-
sidence of symptoms. If marked cerebral symptoms persist unabated, menin-
gitis or brain abscess should be suspected, and further operative treatment
should be undertaken.
Thrombosis involves most commonly the posterior part of the inferior
petrosal sinus, where the mastoid vein enters it, or the lateral sinus. The
blood-current is forward in the direction of the internal jugular vein, which
receives the blood of the sinus a few centimeters anterior to the entrance of
the mastoid vein. When the thrombus has extended into the jugular vein it
can no longer be reached through the temporal bone; tenderness and pain will
be present along the vein; and often pressure symptoms will be observed in
the glossopharyngeal, vagus, and spinal accessory nerves. There is a strong
probability of infected clot being detached and swept downward into the
general circulation. So great is this danger in jugular thrombosis that the
operation of choice is ligation of the jugular in the lower part of the neck,
opening the vein above the ligature, and washing it through from the sinus
with saline solution. This is the operation recommended by Zanfel. It has
given a percentage of recoveries far exceeding any other method of treatment.
72 SURGICAL TREATMENT
Opening of the jugular alone does not suffice; the sinus should be opened in all
cases. As much of the clot as possible, lying centrad to the mastoid opening,
should be removed with forceps. The vein should then be irrigated through-
and-through. It should be remembered that from the lateral sinus or
from the base of the petrous portion, the inferior petrosal sinus, through
which irrigation is done, passes inward, downward, and forward to the jugu-
lar opening. Usually a clot will be found to have occluded the inferior
petrosal sinus anterior to the jugular opening, so that after the blood is washed
out of the vein between the thrombus and the ligature there is no more bleed-
ing. Both wounds should be drained.
Ear disease leading to the superior petrosal sinus should be followed up
and the sinus drained.
Thrombosis of the cavernous sinus is a still more serious condition because
of its greater inaccessibility and its intimate relation to important structures.
The signs of the disease calling for operative relief are characteristic. The
sight in the eye of the affected side, it may be assumed, is destroyed, so great
is the pressure-congestion in the obstructed veins. The adjacent sinuses are
prone to become involved. These are desperate cases. Death from pyemia
or meningitis is the usual result; any neighboring focus of infection should
be open freely and followed, if possible, to the infected dura. This should be
opened and drained as in thrombosis of the lateral or petrosal sinuses. If the
infection originated in the sphenoidal sinus of the sphenoid bone this should
be opened and drained (see Sphenoidal Sinus, page 198). Two routes have
been advocated for reaching .and draining the cavernous sinus ; the orbit and
the subtemporal route.
The surgeon is fully justified in sacrificing the already damaged eye. By
doing an enucleation and clearing out the orbit, the terminus of the cavernous
sinus is exposed. This is the ophthalmic vein. The artery enters the orbit
with the optic nerve through the optic foramen. The vein is large; it passes
through the inner extremity of the sphenoidal fissure and lies below the artery.
The vein may be opened, the anterior part of the thrombus removed and
drainage applied.
The sinus may be reached by the same route as is used for approach to the
Gasserian ganglion. Instead of carefully turning down an osteoplastic flap,
the quickest possible opening in the skull should be made. A generous
amount of bone should be removed. The sinus is reached by elevating the
dura along the anterior part of the floor of the middle fossa.
Infected thrombus of the superior longitudinal, lateral or occipital sinuses
occurs commonly from adjacent bone disease and should be treated by re-
moval of the overlying bone, removal of the center of the clot, and drainage.
Whatever is done in the operative way for infective thrombosis should
not detract from the importance of constitutional measures. The resist-
ance of the patient should be maintained, and if there is any doubt as to the
adequacy of the other treatment the resistance against bacteria should be
increased by the use of an appropriate vaccine (see Veins, Thrombosis,
Vol. I, page 454).
Thrombosis due to parasites other than bacteria requires the treatment
already laid down for infective thrombosis.
Noninfective thrombosis of the sinuses of the dura mater may be traumatic
or spontaneous. Traumatic thrombosis is usually the result of fracture or
operation. The treatment consists in keeping the patient quiet, the blood-
pressure equable, and preventing infection. Equalization of the circulation
must be looked for by the natural establishment of collateral compensation.
Spontaneous thrombosis of the non-infective type occurs in extremely debili-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 73
tated persons. The treatment should be a continuation of the treatment
of the causative disease.
Cerebrospinal sinuses develop at the base of the skull as a result of
fracture or disease and cause a continuous or intermittent discharge of
cerebrospinal fluid from the nose (cerebrospinal rhinorrhea) or ear. The
treatment consists in keeping the discharging cavity clean and free from
inflammation.
Arteriovenous aneurism occurs in connection with the cavernous sinus,
as a result of fracture of the base, wounding the internal carotid artery.
It produces pulsating exophthalmos. The treatment consists in ligation of
the internal carotid in the neck. This treatment can be expected to give
improvement but not a cure because of the collateral circulation in the circle
of Willis. Efforts to secure thrombosis in the sinus by ligation of the
ophthalmic vein have not met with success. Ligation of the common
carotid instead of the internal carotid has added much to the danger of soft-
ening of the brain and little to the expectation of cure. Ligation of both
internal carotids has been attended with high mortality. The ultimate
treatment consists in approaching the base of the brain through the temporal
fossa and dealing directly with the disease.
INFLAMMATIONS OF THE BRAIN
Acute Encephalitis. — This inflammation, by the local swelling and
edema which accompanies it, may call for decompression, or it may give
localizing symptoms sufficient to demand local exploration. It is sometimes
discovered in operations for acute compression, or in mastoid operations
with cerebral symptoms. Incision and drainage of the inflamed area may be
expected to be followed by relief. It is probable that such operations may
in some cases be responsible for preventing abscess formation, for an in-
flammation which has produced so much swelling as to call for operation
is associated with a degree of inflammatory infiltration not far from the
abscess stage.
Abscess of the Brain. — The treatment of cerebral or cerebellar abscess
is by incision and drainage as soon as the diagnosis can be made. While
it is true that some of these abscesses become walled off and chronic, and
exist for many years, as the autopsy findings among the insane have shown,
still the natural tendency of the disease is toward the destruction of life
or toward the production of serious mental derangements. Diagnosis is
often difficult, and the surgeon is referred to works dealing with diagnosis
because of the harm that may be done by misdirected operative attacks in
brain diseases. Diagnosis cannot always be positive, and operation must
often be done upon strong but inconclusive evidence.
Some of the chief indications for operation may be given. They are ob-
served usually in a patient with a chronic suppurative process in or adjacent
to the skull. Chronic otitis media is the most common source of infection.
Commonly in otitis the discharge abates; headache is apt to be severe;
vomiting may be expected; changes of position often produce dizziness; a
chill may be followed by a rise of temperature; the infection may be of a
milder grade and give only pressure symptoms with subnormal temperature
and slow pulse; drowsiness and stupor may be present, or irritability and
delirium, depending upon the location and degree of pressure; tenderness
upon percussion usually exists over the diseased area; focal symptoms point
to the location; pressure gives its peculiar symptoms; involvement of the
frontal lobes produces mental disturbances; dizziness, ataxia, and defective
74 SURGICAL TREATMENT
coordination point to the cerebellum. The juxtaposition of the causative
suppurative process is the most important guide to the location of the
abscess.
Differentiation must be made between abscess of the brain, encephalitis,
meningitis, infective sinus thrombosis, extradural abscess, ependymitis, and
tumor of the brain in the chronic cases.
Operation directed toward abscess, fortunately, is also applicable to
most of these. The prognosis in abscess without operation is very bad;
with operation it is also bad. The operation gives the best hope of recovery.
In the most experienced hands the mortality following operation is not below
50 per cent. Without operation all cases perish within a short time or after
a prolonged period of brain derangement. The dangers of the operation
are the infection of the meninges, fungus cerebri, and cerebritis.
Prevention is of the same importance here as in sinus thrombosis. The
care of suppurative processes in the accessory parts of the skuU is a surgical
obligation. The best hope for relief is early operation. Most of these
cases are sacrificed to the desire for positive diagnosis. It can rarely be made.
When that late stage is reached when the diagnosis is fairly clear, it is too
late.
Technic. — If there are localizing symptoms it is best to open the skull
over the area indicated. If the disease starts from a suppurative otitis,
and seems near the posterior temporal region, it is best to open the mastoid
cells freely and expose the dura as for sinus thrombosis of similar origin. In
such a case it is often possible to trace the course of an infection through the
bone and dura to the brain. Cases are sometimes found in which the main
abscess cavity communicates with the surface by a stem or fistula, the drain-
age of which is sufficient without doing any further injury to the brain tissue.
Operation by way of the ear and mastoid cells gives the best opportunity
to discover extradural abscess or sinus disease. It also affords the best
approach to the cerebellum.
If the location of the abscess is indicated in the temporal region, a tem-
poral craniotomy may be done as for decompression (see page 30). By
this route the brain may be inspected and punctured through an uninfected
region. If desired, the brain may be lifted up and the anterior surface of the
petrous portion inspected.
In either method of approach, it may seem wise as a result of having dis-
covered some other possible cause, to defer further operation. If necessary,
at a later tune, the wound may be reopened and the brain punctured. Upon
exposing the meninges, if abscess is present there will usually be observed
the bulging indicative of pressure.
For exploring the brain for abscess, the best instrument is a small-sized
trocar and canula or a hollow aspirating needle with a stilette. The needle
should be entered in such a way as to avoid sulci and important regions as
described in the operation for spontaneous apoplexy (see page 58), The
pus is sometimes thick and flows with difficulty. Having discovered an
abscess, a larger trocar and canula should be inserted, and through the
canula a rubber drainage tube may be passed and left in situ. As little
traumatism as possible should be inflicted. For this reason it is usually best
not to use irrigation. It is well to paint the meninges about the tube with
tincture of benzoin in order to cause occlusive adhesions. A copious moist
dressing should be applied and the patient should lie with the opening down-
ward. The drainage tube, therefore, should be just long enough to reach
the abscess. As the cavity drains and the pressure symptoms subside the
tube may be shortened and then removed.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 75
These patients are easily depressed, and the utmost care must be taken
during the operation to minimize shock. The minimum amount of anes-
thetic should be used, and everything should be in readiness to meet the
emergencies of cardiac and respiratory failure.
Tuberculosis of the brain and syphilis of the brain are treated under tumors.
TUMORS OF THE MENINGES AND BRAIN
Benign tumors of the meninges are peculiar in that they are superficial,
cause cortical compression, often give distinct localizing signs, and usually
are easily detached from the brain. The malignant meningeal growths are
apt to involve both brain and skull, and their removal is often difficult or
impossible.
Tumors of the brain proper are represented by most every known variety of growth.
The tumors of inflammatory origin are the most common. Tuberculosis of the brain is
prone to manifest itself in circumscribed inflammatory deposits especially in the cerebellum
of children. These so-called granulomata sometimes are amenable to surgical treatment.
Syphilis develops gummatous deposits which are even more resistant to antiluetic medica-
tion than is meningeal syphilis. The dense, circumscribed, inflammatory deposit so far as
symptoms and treatment are concerned is a tumor. It so often refuses to respond to con-
stitutional treatment that it must be regarded in the same category with fibroma.
The most common form of neoplasm requiring treatment is endothelioma. These
tumors usually originate in the endothelium of the meninges, are encapsulated, and call for
operation because of pressure. When removed, brain function is often restored. Glioma
and gliosarcoma are infiltrating tumors, removal of which is difficult because of their
infiltrating character. They sometimes require operation for the spontaneous apoplexies
which take place in them or for cystic degeneration. Carcinoma is usually metastatic
and inoperable. Cystoma may be relieved by drainage if due to degenerated clot or ab-
scess. Echinococcus and hydatid cysts require destruction of the lining of the sac.
Cysts developing in broken-down neoplasms require removal of the growth to effect a cure.
Other tumors of brain requiring treatment are those which are outgrowths from the
skull and meninges and metastatic deposits; also fibroma, lipoma, myxoma, teratoma,
psammoma and angioma.
The chief indications for operation are found in the general increase of intracranial
pressure and in localized disturbances of brain function. Headache, nausea and vomiting,
and venous congestion of the retina (choked disk) are the most important pressure indications.
Dizziness and vertigo are often present. The development of these is very slow, often
with remissions, and the signs of pressure which call for relief in acute lesions, such as
in hemorrhage, are not apt to be present.
Localizing indications are often present, and make it possible to discover and remove
the tumor. A tumor too small to give pressure may urgently manifest its position and call
for removal, whereas a much larger tumor may give only the signals of general pressure.
To determine where to operate for the removal of a tumor the surgeon must bring to bear
a good knowledge of brain function and localization (see Brain Localization, page 43).
Some of the important indications may be given. Tumors first produce irritation, then
paralysis from pressure. The zone of irritation precedes the paralysis, and later represents
its periphery.
Tumors of the motor area of the cortex manifest themselves by causing irritation leading
to focal epileptiform convulsive seizures referable to the muscle groups taking their innerva-
tion from the affected cells. As the pressure becomes greater, irritation gives place to
paralysis in the same groups. Tumors of the sensory field in the postcentral gyrus and
in the posterior sensory areas often cause convulsive seizures preceded by sensory aura
and ultimately followed by sensory paralysis.
Aphasia, word blindness, and speech defects indicate inhibition in the region of the left
angular gyrus. Gradually the motor area may be encroached upon. Tumors of the frontal
lobes are indicated by mental disturbances such as go on to insanity; the general pressure
symptoms are least marked. Involvement of an occipital lobe or its optic fibers leads to
blindness. The temporal lobe is a fairly silent area, but as a tumor grows it encroaches
upon the motor area, and on the left side upon the speech area. Involvement of the apex
of the temporal lobe causes disturbances of taste and smell.
Tumors of the base of the brain may cause pressure upon the motor and sensory paths
and paralysis. Involvement of the corpora quadrigemina cause failures of coordination.
Tumors of the crura cerebri, pons and other parts of the mid-brain are apt to cause
76 SURGICAL TREATMENT
obstruction to the ventricular outlet and result in hydrocephalus; they are difficult of
treatment.
Tumors of the cerebellum are not difficult of recognition. They soon cause enough
pressure to close the canal against the escape of fluid from the ventricles, and the pressure
symptoms of obstructive hydrocephalus appear. There is often suboccipital tenderness.
Tumors compressing the substance of the cerebellum give vertigo and disturbances of
coordination in the muscles of the same side. Tumors of the surface of the cerebellum are
apt to lie in the cerebellopontine recess and involve the acoustic nerve. Tumors of the
pituitary body cause suppression of the functions of the glandular part of that structure;
acromegaly and loss of procreative power may be present; and pressure on the optic
chiasm may cause rjemianopsia.
Tumors of the frontal, temporal, and right parietal lobes may give no sign of their
situation, and if they have been of slow growth may fail to be recognized. The distinction
between tumor of the brain and certain other conditions may be difficult. Chronic neph-
ritis, producing edema of the brain, compression, venous engorgement of the retina, and
convulsions, is often confused with tumor. The symptoms are of similar origin; perhaps,
similar decompressive treatment may be effective. Abscess of the brain, ependymitis,
and chronic meningitis may be operated upon for brain tumor, but operation in all of these
conditions is of value when called for by pressure.
Without operation the prognosis in tumor of the brain is very variable. The nature
of the growth and its situation are important factors. It is impossible to determine what
course the disease will pursue. Most cases are fatal. A gliosarcoma may steadily pro-
gress toward a fatal termination, and then suddenly break down in its center, and the
symptoms abate. Brain tumors have spontaneously disappeared. Another may give no
signs, and then suddenly develop acute and fatal pressure symptoms from hemorrhage in
its substance. An endothelioma may give no signs for many years until that degree of
pressure is reached when it closes a natural channel or shuts off the venous return from some
part and produces edema which itself becomes a sudden and fatal cause of compression.
Spontaneous decompression sometimes takes place (see Sinus Pericranii, page 24; and
Spurious Meningocele, page 25). Separation of fissures in infancy sometimes results from
tumor, and gives the decompression necessary to preserve life. A tumor should be re-
moved; but this is rarely possible. Most cases can be benefited and life prolonged by
palliative operations.
Active treatment is called for at once if tumor of the brain is recognized
or suspected. The distressing symptoms such as pain and convulsions are
to be met by means of analgesics and sedatives. Opium and coal-tar products
have value. Antisyphilitic treatment should be employed in all cases unless
there is a positive diagnosis of nonsyphilitic disease or unless syphilis is
positively excluded. This treatment should be pushed to its utmost. The
most important guide to the necessity for operation is the condition of the
eye-ground. Here intracranial pressure shows itself most palpably. Ve-
nous congestion, due to increased pressure against the return of blood from
the optic nerve, quickly manifests itself in choke disk, swelling of the retinal
veins, and limitations of the field of vision. This is the most important
guide, and examinations should be made frequently, preferably by the sur-
geon himself in order that he may be in closest touch with the progress of the
case. Tests of vision and especially of the size and shape of the field of
vision should be repeated and recorded.
If at the early examinations of the eye-ground, a condition of venous
congestion is found which is so great as to threaten the eyesight, time should
not be lost in testing antisyphilitic treatment but a decompression operation
should be done at once with the primary object of saving the eyesight. When
this has been accomplished the antiluetic measures may be applied. If there
is no great urgency indicated, antisyphilitic treatment should be continued
until in the judgment of the surgeon it has had a fair trial. If no results are
secured from it, it may be stopped after from six weeks to three months.
Judgment is required, for each individual case is different. It should be
remembered that in some nonsyphilitic tumors benefit is observed from
antisyphilitic measures; and on the other hand the symptoms of some old
gummata of the brain, with an abundant deposit of fibrous tissue, are
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 77
unaffected by such treatment. Furthermore the treatment may do harm
by disturbing digestion and increasing the nausea and vomiting already
present, and thus aggravate the symptoms. Having relieved any urgent
distress and given constitutional measures a fair trial the curative or pallia-
tive treatment of the tumor is called for.
Frazier warns against lumbar puncture, either as a diagnostic or curative
measure in brain tumor. A large number of fatalities have followed this
procedure, due to disturbances provoked in the basilar centers.
Curative treatment should be attempted whenever the location of the
tumor is known. To partly remove a malignant tumor is worse than useless.
Attempts to extirpate a diffuse growth have proved disastrous. Normal
brain tissue should rarely be removed; it may be incised and separated. The
tumors which are successfully removed are those which are encapsulated and
those which are small. Early operation is necessary for the best success.
The early cases which should not be neglected are those which give definite
focal symptoms, often associated with Jacksonian epilepsy. These should
not be temporized with, but should be operated upon at the place indicated
before general pressure symptoms have appeared. Better results are now
being secured as operative treatment is applied early as a curative measure
rather than as a last desperate resort. It is surprising and gratifying to
observe how cortical cells resume their function after the removal of a com-
pressing tumor which had caused paralysis. Shock need not be feared in
these operations if blood is not lost and if the brain is spared rough handling.
To plunge a finger into the brain to pluck out a tumor is brutal; it is not
surgical. By the use of the scalp tourniquet, by quickly controlling oozing
from the diploe, and by care in the treatment of the extradural vessels and
the sinuses, there need be no considerable loss of blood. Bloody operations
for the extirpation of brain tumor are serious.
Incision of the brain for the removal of a tumor should preferably be made
not through the motor area. A subcortical tumor, lying in this region should
be exposed by incision preferably posterior to the motor area.
The tumor being localized, the choice of making a trephine opening and
enlarging it with the rongeur or of turning down an osteoplastic flap must
rest upon the requirements of the individual case. The first can be most
quickly executed. In either an inverted U-shaped flap is best (see Opera-
tions on the Skull, page 26). Whichever operation is done, a good big
exposure should be made. The position of the patient has been discussed.
Ether, up to the present time, remains the anesthetic of choice. Horsley
keeps a stream of irrigation at 46°C. (ii5°F.) playing gently upon the exposed
brain to prevent cooling. Incisions through the cortex should be made at the
summit of a convolution in preference to near a sulcus. Pia-arachnoid
vessels should be ligated before cutting them. The field of operation should
be kept free from blood by attention to hemostasis. If a sinus has been
opened' and pressure applied to control bleeding, or if much blood has been
lost before opening the dura, or if there are evidences of beginning shock, it
is well to close the wound, and then after a few days reopen it and proceed
with the operation. Many surgeons advocate operating thus in two stages
in all cases.
In operating upon tumors connected with the cerebellum, Gushing lays
stress upon the advantage of outward dislocation of the brain to give more
room for access to the growth. By doing a bilateral suboccipital craniotomy,
room is made to permit the cerebellum to protude from the skull. If more
room is desired it may be secured by drawing off fluid from the lumbar
subarachnoid space (see Suboccipital Craniotomy, page 36).
78
SURGICAL TREATMENT
Krause applied suction apparatus as an aid in removing brain tumors, to
obviate the disadvantage of prying out the tumor, by pressure from behind
it. Glass cups of various sizes, ranging from 10 to 5.5 mm. (^ to 2 inches)
in diameter, are used. The cup is connected with a suction apparatus by
a soft rubber tube. The tumor having been exposed, the cup is applied to
it; and by making gentle traction upon the tumor and pressing back the
brain with pledgets of gauze, its removal
is accomplished with the least possible
bleeding and traumatism (Fig. 738).
Operations in two stages are often in-
dicated. The first operation consists in
turning down a large bone-scalp flap; and
when, because of loss of blood or other
depressing influence, the condition of the
patient is not good, the dura is not opened,
but the flap is replaced and held with a few
temporary sutures, and the wound dressed.
The closest watch should be kept for extra-
dural hemorrhage after this first stage of the
operation. After four or five days, when the
condition of the patient has improved, the
second stage of the operation is undertaken.
The sutures are removed, and the flap is
again turned down. This second operation
may be done without the use of a general
anesthetic. The dura may be incised and a
tumor may be removed from the substance
of the brain while the patient remains con-
scious and converses with the surgeon.
Traction upon the dura causes pain, but
simple incision is not painful.
Palliative operations are done in cases in which the growth cannot be
removed but in which symptoms demand relief — such as headache and ocular
congestion. Relief may be secured in these cases by giving the cranial
contents more room. The operation which accomplishes this is called
decompression.
Decompression consists in the removal of a part of the skull and dura
mater, and permitting the compressed cranial contents to expand beneath the
scalp. When an amount of cranial contents equal in bulk to that of the
tumor has extruded itself, intracranial pressure becomes normal, and thus
the symptoms of compression are relieved. If the tumor is of slow growth
the relief may last for a long time. If the tumor continues to grow slowly,
the plastic cranial contents will be extruded with pace equal to that of the
growth of the tumor. Such conditions sometimes go on for many years.
It has happened in a gratifyingly large proportion of cases that, after de-
compression the growth has ceased to enlarge; this has been either because
it has attained its maximum growth or because it had undergone degenera-
tion. In some cases, the increase in size of the growth after the operation
has been so slow that the progress of the protrusion has been scarcely per-
ceptible. In other cases the growth has gone on rather rapidly, causing a
large extrusion of brain beneath the scalp. In other cases the growth of the
tumor has seemed to be accentuated by the operation, and the progress to a
lethal end has been rapid. It is doubtful if the operation is worth while in
FIG. 738. — SUCTION RETRACTOR
FOR DRAWING OUT DELICATE AND
FRIABLE TUMORS IN TISSUES
WHERE METAL RETRACTORS ARE
CONTRAINDICATED AND THE
FINGERS CANNOT BE USED.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
79
cases with well-developed paralyses such as render life unhappy; or in cases
in which the tumor has caused an obstructive hydrocephalus.
Whatever happens, the operation is strongly justified in the majority of
cases. It gives relief to a brain, suffering from the effects of compression,
which if continued will produce pain, blindness and death. It can give relief
at least for a period. It should be done early. Patients thus relieved often
return to their work and enjoy many years of comfort. The operation is
practically without hazard in skillful hands. It is the expedient called for
in the great majority of cases of tumor of the brain. In some cases, after
decompression, focal symptoms appear and a second operation may be done
for the removal of the tumor.
The area from which bone and dura mater are removed should be on the
side upon which the tumor is located. The part of the brain which becomes
FlG. 739. SUBTEMPORAL DECOMPRESSION.
Showing relation of skull opening to the brain in subteniporal decompression operation.
The scalp-muscle flap is to be sewed back in place. Note free edge of dura which is des-
tined to cover the rough edge of bone as the brain bulges forth. This operation gives
larger access than when the fibers of the temporal muscle are separated but not cut; it
also leaves a weaker covering to the cerebral protrusion.
extruded suffers some derangement of function because of edema and tension,
and should be some silent area. If decompression upon one side does not
suffice, it may be done later upon the other side. The place of choice for
the operation is the lower temporal region, especially, of the right side.
This has the advantage that it exposes the silent temporal convolutions
below the motor area and adds the temporal muscle to the scalp for the
protection of the brain (see Temporal Craniotomy, page 30). The opera-
tion may be done in one or two stages under local anesthesia with 0.5 per cent.
novocain-adrenalin solution. If the operation is done with the patient in
the sitting position, no special method for hemostasis is necessary. Partial
general anesthesia is necessary only in very sensitive patients.
A scalp flap should be turned down. The temporal muscle should be
split and preserved. The size of the round or ovoid bony defect to be made
in the skull must vary with the amount of compression which appears to
80 SURGICAL TREATMENT
require relief. The opening should not extend above the lower end of the
central fissure. It should be extended downward as far as possible; that
will be nearly to the base of the skull. Usually it should be carried as far
forward and backward as the retraction of the split temporal muscle will
permit; that will be nearly to the anterior limit of the temporal fossa, and
posteriorly to the longitude of the mastoid process. No sharp bony points
should be left. The dura mater should be cut away just inside of the bony
opening, leaving a free edge of dura equal at least to the thickness of the bone
(Fig. 739). The meningeal artery should be ligated. When this has been
done and enough bone has been removed, the temporal muscle is allowed to
fall back in place. This occurs as soon as retraction is discontinued. The
FIG. 740. — SHOWING RESULT OF SUBTEMPORAL DECOMPRESSION.
Patient one year after operation. Note fulness of right temporal region.
temporal fascia and scalp should be sutured over the closed muscle. No
drainage should be used as it is apt to cause hernia or fungus cerebri (Fig.
740).
Tumors of the cerebellum or tumors situated below the tentorium should
be decompressed by suboccipital craniotomy (page 36), either unilateral
or bilateral, depending upon the location of the growth and the degree of
compression. In this operation also, after removing the desired amount
of bone and dura mater, the muscle should be sutured back in place. In
general, it is best to make a wide opening here, extending from the superior
curved line to the middle of the foramen magnum, and from mastoid to
mastoid (Figs. 741).
Cerebellopontine tumors, approached by the bilateral suboccipital
route, may best be removed in a one-stage operation. High tension should
be lowered by occipital puncture of the lateral cerebral ventricle. The
greatest gentleness should be practised. After extirpation of the tumor,
time should be taken to check all bleeding, the wound should be closed with
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 81
FIG. 741. — RESULT OF SUBOCCIPITAL DECOMPRESSION FOR TUMOR.
The hernia here is well protected by muscle. Note bulging in occipital region.
FIG. 742. — RESULT EIGHTEEN MONTHS AFTER DECOMPRESSION OPERATION FOR TUMOR
OF LEFT OCCIPITAL LOBE.
Showing large size of hernia of brain which may be attained in locations where the skull
opening is not covered by muscle.
VOL. II— 6
82 SURGICAL TREATMENT
care, and the patient should be left quietly on the table for some time
in the position in which he was operated upon while the parts become adjusted
to new conditions, and hemostasis becomes established.
The operation of decompression may be done as a preliminary to a later
curative operation. It was once the practice to decompress directly over
the tumor (Fig. 742) ; but the extensive cerebral protrusions which developed
beneath the scalp unsupported by muscle lead to the selection of the two
muscle-covered sites. As a result of the relief given by the operation, more
deliberate study of the localizing symptoms may be made, or in the course
of time more definite localizing signs may appear. The curative treatment
should always be kept in mind, and at the opportune time a curative opera-
tion done. Subsequent to decompression, if the tumor is located with suffi-
cient assurance to warrant an attempt at removal, if the place of approach
selected is not covered by muscle, then an osteoplastic flap should be
turned down so that there shall be no bony defect after the operation (see
Puncture of the Lateral Ventricle as a Decompressive Measure, pages 95
and 96).
The results of operations for tumors of the brain are very variable. In
this field surgery is recording some of its most brilliant triumphs. These
operations should be undertaken only by an experienced surgeon. Sudden
cessation of breathing from compression of the medullary centers is not
uncommon, and must be guarded against. H. Gushing has succeeded in
restoring breathing by evacuating a cerebellar cyst in a patient who had had
paralysis of respiration for forty-five minutes. The mortality of operations
is quite as variable as the results. In skilled hands, there should be no
mortality in sub temporal decompression; osteoplastic craniotomy with
partial or total removal of tumor shows a mortality of 8 per cent.; trans-
sphenoidal operations for hypophyseal tumor show a mortality of about
6 per cent. ; and suboccipital partial or total removal of tumor show a mor-
tality of about 1 2 per cent. Operations on cerebellopontine tumors, occurring
in the acoustic or lateral recess, have a high mortality. Gushing lowered the
mortality of operation by a bilateral exposure. He thought the operation
best done in one stage.
Operations on the Hypophysis of the Brain. — The hypophysis of the
brain, or piiuiiary body, plays so important a role in the glandular functions
of the body, and its diseases produce such serious consequences, that surgery
has attempted and has succeeded in dealing with some of the most serious of
its lesions. Tumors and hypertrophies of the hypophysis, which are
causing serious symptoms, are amenable to surgical treatment, and operation
may give good results. Thus far operations have been aimed at the removal
of the tumor. The hypophysis lies in the sella turcica of the sphenoid
bone. It is surrounded by such structures as the cavernous sinus, the optic
tracts and the termination of the internal carotid arteries.
There are several routes by which the hypophysis may be approached.
It may be reached by the frontal operation through the anterior fossa of the
skull, or by the basilar transsphenoidal operation through the body of the
sphenoid bone. The basilar operation is done through the nose or through
the mouth and nose. Exposure laterally through the middle fossa of the
skull, by lifting up the temporosphenoida} lobe of the brain, has been used.
The former two methods of approach are the best. The objections to the
trans-sphenoidal operations which are performed through the nose or mouth,
are that infection may occur and the operation must be carried out through
a long and deep channel.
The differences in size and shape of the sella turcica and of the sphenoid
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 83
cells are very variable. There is not only a wide normal range of difference
but great pathologic variations also are encountered. The surgeon should
always have in mind these possibilities, and should have checked up the
situation with #-ray pictures (Fig. 743). The sphenoidal cells may be
continuous with the ethmoidal cells and intimately connected with them.
The posterior wall of the sphenoidal sinuses in a third of the cases is very
thin. Injury to the pons must be guarded against, as in these cases there
may be but the merest shell of bone. In a few cases there will be found a
transverse sphenoidal septum, which must not be mistaken for the floor or
roof of the sinus. In the cases of shallow sella, the surgeon must be on his
guard lest he make a path beneath the sella and enter the cranium behind it.
In some cases, the tumor will have caused erosion of the sella, and entered
the sinuses of the sphenoid; and when the anterior wall of the sphenoid body
has been removed, the tumor comes into view.
The choice of operation must depend upon the conditions present. In
cases in which the #-ray shows that a growth of the hypophysis deepens the
sella turcica and encroaches upon the sphenoidal cells and the orifice of the
cells is narrowed, the growth is best reached by one of the basilar operations,
carried out through the nose or mouth. In cases in which the x-ray, the
nasal examination, and the clinical signs indicate that the sphenoidal cells
are notfencroached upon but that the growth is pressing upon the brain and
developing|upward and laterally, the best approach is by the frontal route.
Operations on the hypophysis should preferably be done only by surgeons
experienced in brain surgery. No surgeon should attempt these operations
without having, in addition to an understanding of the anatomy, a knowledge
of the functions of the hypophysis. The surgeon in his attacks upon this
organ should bear in mind that it is a composite gland. It has a small pos-
terior lobe, the posterior part of which is of neural origin and the anterior
part of which originates from the pharyngeal epithelium. The posterior
part is called the pars nervosa; the anterior part of the posterior lobe is called
the pars intermedia. The larger anterior lobe, which originates entirely
from the same structures as the pharyngeal epithelium, is the pars anterior
and originates from the same structures as the pars intermedia. The total
removal of the hypophysis leads to death with the peculiar symptoms known
as apituitarism, or cachexia hypophyseopriva. Even partial removal of the
gland interferes with the balance of internal secretions and indirectly affects
the thyroid, testicles and other glands. The most profound disturbances
arise from removal of the anterior lobe, and it is probable that overactivity of
this lobe causes giantism and acromegaly. The tumors for which operation
is done, which spring from the hypophysis or neighboring structures, may
be removed without removing so much of the gland structure as to cause
appreciable disturbance. A tumor of the hypophysis it should be remember-
ed, is not a hypertrophy of secreting tissue. By its pressure it may cause
diminution of secretion; and its removal restores the action of the gland.
The tumor cannot be dissected out with the nicety of the ordinary dis-
section on account of its depth and inaccessibility. Usually a soft growth
is found^ which can partially be scooped out, or a cyst which can be evacuated.
Hard tumors are to be removed piecemeal. Complete extirpation is not to
be expected in the majority of cases.
Profound anesthesia is not necessary in most cases. The nasal operations
may be done with local anesthesia. Twenty per cent, cocain solution with
adrenalin, or the pure flakes of cocain are preferred by the rhinologists for
anesthetizing the mucous membrane in the line of incision. Scopolamin and
morphin, combined with local anesthesia, suffice for the nasal operations.
84
SURGICAL TREATMENT
FIG. 743. — SHOWING VARIOUS RELATIONS AND SIZES OF PITUITARY BODY (P}, SELLA
TURCICA (ST), AND SPHENOIDAL SINUS (5).
T, Tumor of hypophysis; A, large sized sinus; B, small thick- walled sinus; C, large sinus,
small sella turcica; D, large multiple sinuses; E, small sinus, small pituitary tumor; F,
small sinus, large pituitary tumor; G, low sinus; H , high sinus. The possibility of (meeting
any one of these conditions must be had in mind in operating on the pituitary body. The
x-ray can be of valuable service in predetermination.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
85
The patient should be placed on a table which will permit tilting in any
direction, as it may become necessary to elevate the head to stop bloody
oozing, or depress the head to cause the brain to move upward to make more
room.
Approach to the hypophysis by the frontal route is accomplished by turning
back an osteoplastic flap on the forehead. The two horizontal incisions
may be hidden by placing them on the hairy scalp, the lower limb involving
the eyebrow. The vertical incision may fall in the median line (Fig. 744).
The plate of frontal bone turned back with this flap should be about 5 cm.
(2 inches) in diameter, or more, and should include the supra-orbital ridge
FIG. 744. — APPROACH TO HYPOPHYSIS BY THE FRONTAL ROUTE, SHOWING LINE OF
INCISION.
The patient's head has been shaved. The incision is in hair-bearing areas except in the
median line.
(Fig. 745). The object of this opening is not only to give access but also
to provide for some extruding displacement of the frontal lobe (see Osteo-
plastic Resections of Skull, page 30).
The orbital plate of the frontal bone should be removed with rongeur
forceps. The removal of the roof of the orbit should be carried back through
the lesser wing of the sphenoid to the optic foramen. The head of the
table should be elevated about 30 degrees. The patient's head is then ex-
tended dorsally and allowed to hang over the end of the table so that the
brain shall be displaced upward. By retracting the frontal lobe of the brain
upward and depressing the contents of the orbit, the contents of the sella
turcica are freely exposed. The optic nerve is gently retracted outward, and
the dura, covering the hypophysis, is incised from one anterior clinoid proc-
ess to the other. This brings the hypophysis into full view (Fig. 746).
The incision in the dura should be about 0.5 cm. (-}{ Q inch) above the base
86
SURGICAL TREATMENT
FIG. 745. — FRONTAL APPROACH TO HYPOPHYSIS.
Osteoplastic flap has been turned back. Supra-orbital bone is to be removed with roof of
orbit.
FIG. 746. — FRONTAL APPROACH TO HYPOPHYSIS.
The roof of the orbit has been removed. The frontal lobe is elevated with a thin flat
retractor. The optic nerve (NO) is exposed. To the left of the optic nerve is seen the
hypophysis (#).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
87
of the skull. By passing a retractor into this slit the hypophysis is seen as
a reddish-gray body. The optic chiasm is above the opening.
C. A. Elsberg made the scalp incision almost wholly upon the hair-
bearing scalp. (Annals of Surgery, 1914, vol. 59, page 455.) This is done by
placing the base of the flap at the median line (Fig. 747). The only advan-
tage of this is the cosmetic elimination of the incision in the middle of the
forehead. The flap with the base outward has better nourishment.
C. H. Frazier (Annals of Surgery, 1913, vol. 57, page 145) preferred the flap
with the base outward. He did not include the superciliary ridge in the
osteoplastic flap, but removed it with part of the orbital plate, and replaced
it afterward. The operation is done preferably on the right side.
FIG. 747. — FRONTAL APPROACH TO HYPOPHYSIS.
Incision for turning back osteoplastic flap with base inward.
If the condition of the patient requires it, the scalp-bone flap may be
cut but not turned back until the patient has fully recuperated after one or
more weeks, thus doing the operation in two stages. It is possible, by cutting
an H-shaped opening in the dura, greater displacement of the brain takes
place and more room is secured. This should rarely be resorted to. If
adequate room is provided without cutting the dura, it is much better to
preserve the dura, carefully separating it from the bone, and leaving it
unopened until the hypophysis is reached. Under no circumstances should
the basilar dura be injured before reaching the chiasm. A broad flat re-
tractor should lift up the dura with the brain, while another retractor should
press downward the orbital contents. This retraction must be intrusted
only to a skilled assistant; it is one of the most important functions in the
operation.
In making the transverse incision in the dura, 0.5 cm. above the level
of the floor of the anterior fossa, great care must be used. Krause has de-
88 SURGICAL TREATMENT
vised a hook-shaped knife for this purpose. If the incision in the dura is
made too low the venous sinus, which lies in the groove between the two
optic foramina, will be opened. The hooked knife prevents cutting the ves-
sels immediately under the dura. The incision is placed between the sinus
and the optic chiasm. The chiasm does not occupy the optic groove but
lies above the sinus which does. This frontal operation, if carefully carried
out, does not endanger or involve any important structures until the incision
is made in the dura.
After exposing the hypophysis, and dealing with the tumor, a thin cigar-
ette drain is carried back to the dural opening, brought out through the
eyebrow region, and the wound closed.
The osteoplastic flap method may give place to resection of a bony seg-
ment, and its replacement at the close of the operation. This frontal opera-
tion, although planned by Krause. was first applied by N. F. Bogojawlensky
(Zentralb. f. Chir., Feb. 17, 1912, vol. xxxix, no. 7), and in America by
L. L. McArthur (Jour. Am. Med. Assoc., June 29, 1912, vol. Iviii, no. 26).
H. Gushing (Jour. Am. Med. Assoc., Oct. 31, 1914) worked out an opera-
tion whereby approach is made through the mouth. The operation is a low
nasal approach. An incision is made along the line of mucous membrane
reflection between the alveolar margin and the upper lip. The soft parts are
dissected up and the nose entered.
Approach to the hypophysis by the nasal route has been made safer by the
newer methods of rendering the operative field aseptic. The use of iodin
plays an important role in this. The nasal route is to be chosen in cases in
which the growth is downward and encroaching on the sphenoidal sinus.
The simple transnasal operation may be done under cocain anesthesia in
several stages. Cocain and adrenalin solution are used. The operation may
be done most easily on the left side. At the first sitting the middle turbinated
bone is removed. After several days the ethmoid cells are removed. After
another interval of several days the anterior wall of the sphenoidal sinus is
removed. This is done with trephine, rongeur, chisel, or burr (see Operations
on the Nose, page 179). These operations are performed by the methods
commonly used in rhinologic work. The hypophyseal prominence is now
seen projecting into the sinus. At a later sitting a transverse opening is
made through the bony wall of the sella turcica by means of a burr or chisel.
The wall of bone may be removed with a steel hook, or, if very thick, it may
be cut away with a trephine or burr. This brings the hypophysis into view.
The dura, covering it, may then be incised, and the operation completed, or
the incision of the dura may be done at a later sitting. A small antiseptic
gauze packing completes the operation. Some surgeons leave the cavity
without any dressing, but simply plug the naris with a gauze tampon. A
head mirror or a nasal lamp is necessary for this operation. It can be done
only in large nasal cavities. Sacrifice of the turbinates and ethmoid sinuses
is often followed by chronic ozena.
Nasal operation with removal of the septum gives a wider path of approach
(Fig. 748). The turbinates are removed from both nasal cavities at a pre-
liminary operation. Usually it will be found best to remove the middle
and part of the inferior turbinates. At a later sitting the anterior wall
of the sphenoidal sinus is removed on either side of the septum. At the same
operation or later a quadrilateral piece is removed from the nasal septum.
This is done by making an incision, about 2.5 cm. (i inch) long, parallel with
and anterior to the anterior border of the perpendicular septal plate of the
ethmoid. From each end of this incision the septum is divided with a chisel
in an upward and backward direction in two parallel lines as far as the sphe-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
89
noid (Fig. 349). This quadrilateral piece of septum is removed as for
submucous resection. The remains of the septum attached to the sphenoid
are removed together with the median portion of the anterior wall of the
sphenoidal sinus. At the same or at a later operation the sella is opened.
pk e noida.1
jSinuse-s
SelL
Turcica.
•Nasal
bone
FIG. 748. — SHOWING ANATOMY OF NASAL SEPTUM.
This opening has the disadvantage that it gives an oblique path of access
to the sella and it is more difficult to orient such a path. Direct median
straight access may be secured by carrying a skin incision around the base of
each ala of the nose, and prolonging the upper end of the anterior septal
incision upward to the tip of the nasal bones and completing the division of
the septum at its lower anterior part (Fig. 749, FA and EB). This permits
lifting up the anterior part of the nose and turning it back as a flap.
FIG. 749. — NASAL APPROACH TO HYPOPHYSIS.
Showing quadrilateral piece (ABDC) removed from septum to give access to sphenoid
sinus (55) and hypophysis (H). The anterior wall of sinus and the floor of sella turcica
remain yet to be removed. The middle turbinate (MT) and the inferior turbinate (IT)
have been partly removed. By making incisions FA and EB through the septal cartilage,
the tip of the nose may be reflected upward and wider access secured.
A more satisfactory method is to turn up the anterior part of the nose as
a flap as the first step in the operation. The operation is done with the
patient in a semisitting position. A tampon is inserted to close the posterior
nares. The nose is packed with adrenalin gauze. An incision on the face
follows the curve of the alae and passes just below the nostrils. The cartilage
90 SURGICAL TREATMENT
of the septum is cut from its attachment to the vomer below and from the
perpendicular plate of the ethmoid above. This leaves the end of thejiose
and.'septum free as a flap. The cartilaginous septum is retracted to one side,
the middle turbinates are removed, and the bony septum is cut away with
rongeur forceps back to the sphenoid. The sphenoidal foramina are identi-
fied and the cells opened with chisel and forceps. This is the operation
worked out by A. B. Kanavel. Instead of removing the turbinates, they
may be pressed aside and flattened by long straight retractors.
''The high nasal operation is the most destructive, but provides the shortest
path to the hypophysis. An incision is begun at the inner end of the eye-
brow, passing down the side of the nose, curving about the ala, and ending at
FIG. 750. — HIGH NASAL APPROACH TO HYPOPHYSIS.
Skin incision.
the opposite side of the septum (Fig. 750). The nose is reflected to one side,
the vomer being cut as far back as possible and reflected with the flap.
Preservation of much of the vomer is necessary to prevent subsequent
saddle-nose. The operation then proceeds directly backward, removing the
turbinates and the rest of the vomer, and reaching the sphenoidal sinus
(Fig. 751).
O. Chiari (Wiener Klin. Woch., Jan. 4, 1912, vol. 25) obtained access
to the hypophysis by an incision along the outer edge of the nasal bone.
The soft parts are retracted, the eyeball carefully pressed outward, and the
inner wall of the orbit, the ethmoidal and sphenoidal cells, resected and the
rear part of the nasal septum removed.
It is possible to substitute for this operation a submucous resection of
the septum. The resection is carried as far as the rostrum of the sphenoid.
The middle turbinate is removed, and a long nasal speculum used to hold
aside the flap of mucous membrane, cartilage and periosteum. The mucous
membrane, with the periosteum, is elevated from the point of the sphenoid.
By retracting the parts the denuded sphenoid is well exposed and the an-
terior wall is broken into and removed. The septum of the sphenoid may be
removed with forceps.
The combined frontal and nasal operation may be performed in cases in
which the frontal operation has been attempted and the tumor found to have
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
91
FIG. 751. — HIGH NASAL APPROACH TO HYPOPHYSIS, NOSE REFLECTED ASIDE.
The upper nasal cavity is exposed and entrance through the frontal sinus provided.
FIG. 752. — NASOBUCCAL APPROACH TO HYPOPHYSIS.
Mouth held open by gag. Incision made at labio-alveolar junction. Mucous mem-
brane stripped up from cartilaginous septum. Retractors in opening showing septum of
nose. Note mouth-gag provided with ether vapor tubes.
92
SURGICAL TREATMENT
grown downward into the sphenoid so far as to be inaccessible from above.
Under such circumstances the surgeon may proceed to make an incision
along the inner margin of the orbit, remove the inner wall of the orbit, gain
access to the posterior nares, and complete the operation by the intranasal
route.
The bucconasal route is practically the same as the low nasal approach.
It gives more room than the unilateral operations, and does not require the
rhinologist's skill. Intratracheal etherization is most effective in these opera-
tions. A transverse incision is made in the mucous membrane at the angle
where the posterior lining of the upper lip is reflected upon the alveolar process
- 753- — NASOBUCCAL APPROACH TO HYPOPHYSIS.
Transverse horizontal section, looking down upon the parts in a reversed position
The mucous membrane has been stripped from the septum nasi. The bony part of the
septum has been removed. The turbinates and mucous membrane are pressed against
the lateral walls by long retractors. The anterior wall of the sphenoidal sinus is exposed
for removal.
of the upper jaw. The mucous membrane is separated upward, and the
septum of the nose exposed without opening through the mucous membrane of
the nasal cavities (Fig. 752). The mucous membrane is separated from
the septum and retracted laterally. The cartilaginous septum is cut
through obliquely at the level of the anterior limit of the upper jaw. The
upper lip, and the anterior part of the nose and septum are retracted upward.
Lateral retractors are inserted, and the posterior part of the cartilaginous
septum and the bony septum are removed directly back to the sphenoid.
(Figs. 748 and 749). The turbinates are flattened against the lateral nasal
walls by lateral retractors. By saving the turbinates, the patient is spared
the disagreeable ozena which commonly follows their removal (Fig. 753).
After the removal of the septum back to the sphenoid, a special bivalve
speculum is inserted. This shows a straight path to the sphenoid. The
sphenoid antrum is opened with cutting forceps and the hypophyseal bulge
exposed (Fig. 754). This is the operation worked out by H. Gushing.
Encephalocele. — This is a developmental defect, occurring usually in
the median line of the skull. It is observed in the occiput, below or above
the tentorium cerebelli, and in the region of the frontonasal angle, having
passed through a defect in the ethmoid bone. Meningocele, hydrencephalocele,
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
93
encephalocystocele, and cenencephalocele are all variations of this form of
encephalomeningeal hernia. The important fact in the treatment is that
they are congenital defects which are apt to be associated with other defects
such as spina bifida, hydrocephalus, and other brain abnormalities, which
often render a complete cure difficult, if not impossible. The treatment
by compression, tapping, reduction and retention, or by the injection of
irritating substances has in rare cases been successful. It is not to be
recommended.
The skin over these tumors should be kept healthy and clean, lest ulcera-
tion and sloughing lead to infection. The rational surgical treatment con-
sists in exposure of the hernia, reduction or removal, and closure of the
opening. As much of the scalp should be removed as is necessary to avoid
FIG. 754. — NASOBUCCAL APPROACH TO HYPOPHYSIS; SPECULUM IN PLACE.
Nasal cutting forceps are removing wall of sphenoidal sinus. The gauze sponge in the
naso-pharynx is controlled by a thread passing forward through the nostril.
redundancy. The incision should be carried down to the meninges. In a
comparatively large tumor the meninges will be found much thinned.
There may be an absence of dura, and the pia-arachnoid will be found
lying against the connective tissue of the scalp. The treatment of the her-
niated tissue must depend upon its structure. If the thinned-out meninges
and nerve tissue enclose a chamber of cerebrospinal fluid which communi-
cates with a ventricle, as is usually the case, the fluid may be drawn off and
the hernia reduced; or the herniated structures may require to be excised and
the meningeal wound sutured with fine catgut. If enough dura is present
it should be sutured across the opening. The closure of the cranial defect
is most important. A good covering of dura mater may suffice, but usually
this is not to be had. The most effective closure is secured by means of an
osteoplastic flap, which may be added to the dural covering or used in its
stead. Absence of dura may in some cases be compensated for by trans-
planting a piece of fascia lata.
94
SURGICAL TREATMENT
In the absence of dura a flap of bone or periosteum is necessary for success.
The pericranium in children has the power of generating bone, and it may be
used as a flap without taking the underlying skull. Such a flap may be
turned in from the adjacent parts of the skull (see Operations on Bones, Vol. I,
page 688) . The skull in infants is thin and pliable and may be cut and turned
in as desired. The edges of the cranial opening may be freshened and a piece
of skull of similar size and shape may be cut out from the adjacent bone and
transplanted into the opening (see Bone Grafting). Or partly detached
flaps may be used (Fig. 755).
The success of such an operation can be assured only by asepsis. If the
operation is not well done it had better not be done at all. Before under-
taking it, the surgeon can know the size and site of the bony opening, and
-w-
FIG. 755. — SLIDING FLAPS OF BONE
(AA) FOR CLOSING DEFECT IN INFANT'S
SKULL.
These flaps may be left attached to
the scalp; rotated across the opening,
and sewed.
FIG. 7550. — FLAPS OF BONE USED TO
CLOSE DEFECT IN SKULL.
Diagram showing flaps slid over defect
and sewed.
he should have worked out tentatively the osteoplastic operation which he
purposes to do. After closing the wound a firm dressing should be applied
so that the crying of the child shall make the last possible strain upon the
sutures. There is often obstruction in the ventricular communications in
these cases, often associated with hydrocephalus, and recurrence is prone
to take place. The withdrawal of cerebrospinal fluid from the lumbar region
is often called for to relieve tension. Or drainage of the ventricles may be
indicated (see Hydrocephalus).
Hydrocephalus. — Hydrocephalus is a symptom of local disease which
results in an excessive collection of cerebrospinal fluid in some of the intra-
cranial chambers. There may be an excessive secretion of fluid or a deficient
absorption of fluid. The latter is most commonly due to some obstruction
in the channels, as a result of which the fluid is prevented from escaping from
the ventricle where it is secreted to the parts where it is absorbed. This is
the common cause of hydrocephalus, and treatment to be curative must
remove the barrier, (i) External hydrocephalus, in which the excess of fluid
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 95
is between the brain and the skull, is rare. (2) Acquired internal hydro-
cephalus results from postnatal obstructions, caused by meningitis, ependy-
mitis, venous obstruction in the velum interpositum, or tumors. (3) Con-
genital ventricular hydrocephalus is the common form, and is apparently due
to some disease which produces both obstruction and increase of the ven-
tricular fluid.
External hydrocephalus must be treated by the withdrawal of the fluid,
the location of which may be determined by the #-ray. A small trocar
and canula or aspirating needle may be passed through the skull at any
convenient point away from the venous sinuses and meningeal arteries.
Acquired internal hydrocephalus is caused by certain known conditions,
and the treatment is first that of the causative factor. Because of the fact
that consolidation of the skull is well advanced when this disease occurs,
death usually takes place with symptoms of compression; although a spon-
taneous bulging apart of the cranial sutures may produce natural decom-
pression. Compression of the brain is the cause of death in most cases of
basilar meningitis. Sometimes the exudate may act as an intermittent
obstruction to the ventricular passages, and there may be remissions and
exacerbations. Obstruction in a single ventricle at the foramen of Monro
causes unilateral internal hydrocephalus.
The removal of the obstruction is sometimes possible if it is a tumor.
If the tumor cannot be removed, a decompression operation will sometimes
so relieve the pressure that the cerebrospinal fluid again circulates and the
symptoms are mitigated. Before obstruction to the ventricular outlet has
become complete, relief may be secured by lumbar puncture. Warning is
necessary against the danger of this operation if the intracranial pressure is
considerable, and especially if the ventricular outlets are not free, because the
withdrawal of spinal fluid may cause the medulla to be jammed down into
the foramen magnum with fatal force. Lumbar puncture may be done safely
after a decompression operation or after withdrawal of the ventricular fluid by
puncture.
Puncture of the cerebral ventricles^ is done when curative treatment cannot
be carried out. Direct drainage of the fluid from the distended ventricles
should be done in connection with all operations for decompression, unless
it is known that there is no obstruction to the ventricular passages. This op-
eration is also done for diagnostic purposes. Ventricular puncture proves
to be curative in cases in which the obstruction is due to inflammation or
congestive swelling which may be helped to subside by the removal of the
compressing or infected fluid. Natural drainage of the ventricles may be
reestablished when the pressure is removed.
The technic of ventricular puncture is simple. The puncture should be
made with an aspirating needle with openings on the side and a closed point,
a trocar and canula may be used, but if there is doubt as to the diagnosis,
a blunt-pointed needle, having lateral openings should be used in order that
any other fluid, such as abscess, short of the ventricle may be discovered.
The operation requires that the needle shall not wound sinuses, meningeal
arteries, sulci, or the island of Reil, in order to avoid hemorrhage. Impor-
tant cortical regions should be avoided. The operation is proceeded with
as any brain operation (see Operations on the Skull, page 26). The skull
is exposed by a linear incision or by turning down a small U-shaped flap.
A trephine opening is made, and the dura incised in order to discover the
summit of a convolution. The needle is passed to the ventricle, the fluid
drawn, the button of bone replaced (if no infection is present), and the wound
closed. A bilateral operation may be required; or subsequent punctures
96 SURGICAL TREATMENT
may have to be made. If meningitis is present, care must be taken to
sterilize the site of puncture.
The site of puncture, commonly selected is the posterior part of the middle
frontal lobe, 2.5 cm. from the median line and 3 cm. anterior to the fissure
of Rolando. On the skull this is perpendicularly above the midzygomatic
point, somewhat in front of the bregma (page 49). The needle should pass
downward and slightly backward. The ventricle is 4 or 5 cm. from the
surface, and extends at least 2 cm. from the median plane.
Keen advocated puncturing at a point about 3 cm. behind and 3 cm.
above the external auditory meatus, in the posterior part of the first temporal
convolution. The needle should be directed toward the top of the opposite
pinna. The ventricle will be reached at about 5 cm. from the surface.
This temporal puncture has the advantage that it may be used in those
cases in which the mastoid cells have been opened and the temporal lobe
exposed in search of abscess. When no abscess is found to account for
pressure, it may be determined by puncture of the ventricle that the symp-
toms are due to ventricular obstruction due to basilar meningitis.
Puncture of the lateral ventricle as a decompressive measure was advocated
by F. von Bramann (Deut. Med. Woch., Sept. 23, 1909, vol. 35, no. 38) and
now widely applied in brain tumors and hydrocephalus. It has given very
satisfactory results. A short longitudinal incision is made in the scalp i or
2 cm. to the right of the median line and a small button of bone removed from
the skull with a trephine i or 2 cm. posterior to the coronary suture. The
dura is incised and a small curved trocar and canula is passed downward
and inward. It should reach the tough falx cerebri, which serves as a guide,
and glide downward along the side of the falx to the corpus callosum.
The trocar should not be too sharp, lest it puncture the falx. It should then
be pressed gently through the corpus, and when it has penetrated that body,
its tip lies in the cavity of the ventricle, and fluid should flow. The opening
through the corpus callosum should be enlarged to i cm. by moving the
canula forward and backward. The canula should then be removed, and
the incisions in the dura and skin closed. The pressure of the ventricular
fluid causes it to continue to escape through the wound tract, which is thus
kept patent, and find its way to the subdural space.
In some cases of internal hydrocephalus the opening seems to become
permanent.
In children the trephine need not be used; the canula may be introduced
through the coronary suture.
In cases of intracranial tumor, whether the increased tension is due to the
tumor alone or to edema, there is interference with the flow of fluid from the
lateral ventricles to the fourth ventricle and the cord. This causes in-
creased intraventricular pressure, which this operation relieves. In tumors
causing blindness and coma, this simple operation has produced most bril-
liant improvement.
Not only are symptoms relieved, but, the pressure complications being
removed, focal signs are more easily discovered, and the location of a tumor
determined. Many surgeons believe that this method should be used in
preference to decompression operations. In skilled hands it is practically
without mortality or harm.
In cases of congenital hydrocephalus, subtemporal drainage has some
advantages. A curved incision, 6 cm. (2% inches) long, is made above
the right ear with its convexity directed backward. A scalp-flap is turned
forward. The fibers of the temporal muscle are separated in the front part
of the wound. The skull is opened at the point for ventricular puncture
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 97
(see page 36). The opening is made with a burr or small trephine. The
dura is incised and the lips of the wound held apart. A ventricular punctur-
ing tube or a large hollow needle with a dull point is passed into the ven-
tricle. The cerebrospinal fluid flows forth. A silver drainage tube is then
inserted into the ventricle. Its end should just emerge through the bony
opening. A flange should prevent its inward displacement. The wound is
closed, and the patient kept quiet. The fluid from the ventricle passes into
the connective-tissue spaces of the temporal region.
Congenital ventricular hydrocephalus is peculiar because it develops while
the skull is still capable of distention, and produces a characteristic enlarge-
ment of the head. Prophylaxis demands the elimination of syphilis in the
parents. The etiologic factors in rachitis must also be eliminated. Healthy
parentage is the essential preventative. In the treatment, it does not seem
to be sufficient to draw off the fluid because there seems to be an abnormal
and excessive secretion of cerebrospinal fluid. Even when the foramen of
Magendie is patent, which it usually is, and the ventricles can be tapped by
puncture of the lumbar subarachnoid space, the disease persists.
Encephalocele and spina bifida are so often associated with this disease
that it would seem that some congenital defect in the circulatory system
of the cerebrospinal fluid must lie at the base of the trouble. Attempts
to find and remedy the defect have had poor success. Some cases of con-
genital hydrocephalus undergo spontaneous cure. This has been observed
usually in the mild cases. The pronounced cases and the rapidly progressing
cases have perhaps never been cured by surgery.
Inasmuch as no means has yet been found to check the abnormal pro-
duction of cerebrospinal fluid, three alternatives remain: to remove it as it
accumulates, to restore communication between the occluded cavities, or to
conduct it to some tissue which can accomplish its absorption.
The ventricles in these cases may be tapped without much consideration
of the rules for tapping in acquired hydrocephalus. The brain is flattened
out against the dura in some cases to the thinness of paper, and puncture
may be made most anywhere except through the venous sinuses. The
fontanel, at one or the other side of the longitudinal sinus, is commonly used.
All that is required is that the scalp shall be cleansed and the puncture made
with a hollow needle. All of the excess of fluid may be drawn off at one time
if no bad symptoms develop. It may be expected to reaccumulate rapidly
— sometimes within a few hours. The operation may be repeated indefinitely.
It has no curative value. Its only uses are for diagnosis; as a temporizing
expedient to keep the child alive in the hope that the natural circulation and
absorption of the cerebrospinal fluid may become established; and as a pre-
liminary or part of an operative attempt to cure the disease.
Attempts to reestablish communication between the ventricles and the
subarachnoid space around an occluded foramen of Magendie have failed
to cure the disease. Even if the occluded foramen becomes patent, as it is in
most cases, the disease persists.
Many operations have been devised to establish permanent drainage
between the subarachnoid space and the connective-tissue spaces of some
external tissue. The operations which have given the best results originated
in attempts to establish communication with the peritoneal cavity. This
communication has failed to remain patent, perhaps, in all cases because of a
sealing over of the peritoneal opening, but communication with the sub-
peritoneal connective-tissue spaces has persisted and continued to drain off
the cerebrospinal fluid.
Before attempting the operation for subperitoneal drainage it is important
VOL. II— 7
98 SURGICAL TREATMENT
to know if there is any obstruction in the passage from the ventricles to the
subarachnoid space of the cord. This may be determined by lumbar punc-
ture. If a sufficient amount of fluid flows to show evidences of emptying
of the head accumulation, as manifested by the amount of fluid and by the
depression of the fontanel, it may be known that there is a patent communica-
tion. The fluid flows slowly. The amount that escapes depends upon the
internal pressure. Some temporary occlusion may be deceptive. Some
surgeons make the test more accurately by simultaneous lumbar and ven-
tricular puncture, connect a small glass tube with each needle and observe
the fluid rise to the same height in each if the communications are patent;
and if one tube is lowered to permit the fluid to flow away the pressure in
the other tube is at once observed to be reduced if the two fluids connect.
Several days after the above test has shown that the ventricles empty
into the subarachnoid space, the operation may be done. The bifurcation
of the aorta is exposed by a median laparotomy. The peritoneum is divided
just below the bifurcation, and the anterior surface of the body of the fifth
lumbar vertebra is exposed. The bone is penetrated by a small trephine,
and the spinal canal opened. The dura is cut away, and the arachnoid
membrane perforated by blunt dissection. This is followed by a steady flow
of cerebrospinal fluid. A bit of peritoneum may be removed from either
side of the wound so as to leave it open, and the abdomen is closed. There is
a tendency after this operation for the peritoneal wound to become sealed
over; but still the drainage goes on into the retroperitoneal space. After
a time the bone wound tends to close and shut off entirely the escape of the
fluid.
To keep the wounds open a silver tube may be inserted into the trephine
opening, giving the bony canal a silver lining. Gushing then turned the
patient over, did a laminectomy, and opened the subarachnoid space. The
strands of the cauda equina are separated, and another tube is inserted which
fits and locks into the anterior tube. The wounds are then closed. The fluid
drains at first into the peritoneal cavity, but the peritoneal opening soon
becomes closed and drainage goes on into the retroperitoneal connective
tissue, whence the fluid is taken up into the receptaculum chyli, and thrown
back into the blood. The reports of enough of these operations have not
been published to justify a conclusion as to their merits. It is doubtful if the
introduction of a silver tube adds much to the permanent value of the opera-
tion; the presence of a foreign body certainly has decided disadvantages.
If, in the preliminary tests, it is found that the subarachnoid space of
the cord cannot be made to drain the ventricles, then a communication
must be made. This is accomplished by exposing the brain in the temporal
or parietal region, incising the ventricle, and removing a bit of brain tissue
so that the ventricular fluid shall flow into the arachnoid. It is best that
the brain wound should not lie in contact with the wound of the dura, skull
and scalp, lest adhesions defeat the object of the operation. Hernia cerebri
is also to be feared. These objections may be obviated by turning down a
skull flap.
Drainage of the cisterna magna into the cranial sinuses was worked out
and first practised by I. S. Haynes (Annals of Surg., vol. 57, 1913). The
operation aims to expose the occipital bone from the foramen magnum to the
occipital protuberance by a median incision. The periosteum and muscle
are reflected laterally. The bone is trephined midway between the foramen
and the protuberance, and the bone removed upward to expose the posterior
end of the longitudinal sinus. The feature of the operation is to connect
the cisterna magna with the longitudinal sinus by a tube which shall permit
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 99
the flow of fluid. Haynes used rubber and silver tubes having an internal
diameter of 1.5 mm. The tube is let into the cistern and the sinus by minute
openings into which it fits tightly, and sewed with silk. The length of the
tube should be from 2 to 2.5 cm. (^ to i inch). The lower puncture is made
through the dura and arachnoid into the cisterna, the upper puncture is made
through all of the structures directly into the longitudinal sinus. As the
pressure in the basilar subarachnoid space (the cisterna magna) is greater
than in the venous sinus, the flow of fluid should be toward the sinus.
The operation with tubes of rubber or metal is naturally bound to fail.
Payr used a piece of the child's long saphenous vein. If that is not big
enough, an enlarged scalp vein, external jugular, internal jugular or femoral
vein may be used.
So far as is known none of these operations have succeeded in restoring
hydrocephalic children to health. Payr attempted diverting the fluid through
a vein into the superior longitudinal sinus. A rubber tube is not to be con-
sidered for such a purpose.
W. Sharpe (Am. Jour. Med. Sci., 1917), employed strands of linen thread,
inserted into the ventricles in the internal type of hydrocephalus and into
the subarachnoid and subdural spaces in the external type. Six strands
are used and their ends brought out through the temporal muscle and
temporal fascia beneath the scalp in a stellate manner. This method has
given better results than any of the operations yet devised.
Epilepsy. — Many cases of epilepsy are of surgical significance from an
etiologic, pathologic, or therapeutic standpoint. The prophylaxis of epilepsy
is one of the important functions of eugenics. It is of greater social than
surgical consequence. Most epilepsy is preventable through the regulation
of human propagation. The alcoholic, the syphilitic, the neurotic, and the
degenerate are the progenitors of the epileptic; and the prevention of epilepsy
demands the prevention and treatment of these conditions, and the regula-
tion and inhibition of their breeding.
From the more strictly surgical standpoint, the prevention of epilepsy
is to be furthered by proper surgical treatment of causative lesions. Frac-
tures of the skull should not be left with fragments of bone pressing against
the cortex of the brain. No depressed fracture should be left unelevated;
it may give no immediate disturbance, but ultimately it is prone to be a
factor in epilepsy. Subdural hemorrhage may not give sufficient pressure
to cause alarm; the clot may be absorbed in due time; but the small residuum
of fibrous tissue which marks the site from which the clot was absorbed often
becomes the etiologic factor. The same of foreign bodies, relics of menin-
gitis, abscess, etc. Therefore, in the treatment of these conditions, especially
involving the cortex of the cerebrum, something more than saving the life
of the patient should be had in mind; the future possibilities of epilepsy
should be thought of, and such treatment applied as shall leave the least
irritation. This is a reason for the removal of clots and foreign bodies. Many
of the cases of epilepsy of supposed congenital origin are due to injuries
sustained by the brain during difficult labor. The child recovers from the
hemorrhage, later to become an epileptic. The blood in these cases should
be liberated even though the compression is not sufficient to threaten life
(see Intracranial Hemorrhage of the Newborn, Vol. II). It is important
that these etiologic factors should be removed early because if their removal
is deferred until the "epileptic habit" has become established, the seizures
will continue even after the original local cause is apparently removed.
Many pathological conditions, which may be remedied by surgery, are
capable of producing the irritation necessary to precipitate epileptic attacks;
100 SUmiCAL TREATMENT
and when these conditions are cured the attacks cease. Such conditions are
found in every part of the body. Elongated prepuce, deep urethral disease
intestinal adhesions and obstructions, appendicitis, orificial fissures and ulcers,
eye-strain, nasal disease, and other conditions producing nerve irritation are
among the lesions amenable to surgery.
In all cases, the general hygienic treatment is important. Causes of
irritation to the nervous system should be eliminated. This means not only
immediate and gross causes but distant and indirect causes. Sources of
peripheral irritation should be sought for especially in the sexual organs and
abdomen. Errors of refraction in the eyes should be corrected. The
gastrointestinal tract in many patients is a source of absorption of nerve-
irritating toxins (see Nourishment, Vol. I). Regulation of the diet, which
usually means simply diminution of food intake, is imperative. The dis-
continuance of vicious habits, such as the use of alcohol, tobacco and other
narcotics, is to be demanded. In general, a hygienic mode of life should be
adopted.
Diseases of the nose and its accessory sinuses should be corrected. Nasal
obstructions which prevent a proper cooling of the basilar sinuses should be
removed.
In a certain number of cases a definite local cause may be known to exist
or its presence may be pointed to by focal symptoms. It is rarely too late
for the removal of an old traumatic cattse, even though this should have been
done before the attacks began. An old depressed fracture should be treated
by removal of the depressed bone. Exceptionally, it is so extensive that it
should be elevated instead of removed. At the same time any scar tissue
which is present should be cut away. It is often worth while in these cases
to turn back the dura, and with a fine probe or knife separate any adhesions
between it and the arachnoid. None of the dura should be removed. Such
operations while not often curative, in old cases may be expected to ameliorate
the disease. Foreign bodies and scar tissue due to old clots may be exposed
either by turning down an osteoplastic flap or by removal of bone. In these
cases also it is well to divide adhesions existing between dura and arachnoid.
Some of the measures for preventing adhesions may be used with advantage.
A piece of hernia sac or fat, introduced under the dura, to prevent the dura
adhering to the pia and brain, is often effective.
Epilepsy, occurring in cases in which there is a bone defect in the skull,
calls for a search for cortical irritation. The trouble in these cases will often
be found in the form of subdural adhesions, due to the original lesion which
made necessary the opening. These should be separated. If any gross
scar tissue is present, it should be removed. The old practice of closing
such openings with a silver plate, thinking that the opening was the cause
of the epilepsy, never gave results. It would, indeed, be better surgery to
enlarge the whole defect by removing bone from its circumference, for it is
often the case that irritation has developed in connection with the edge of the
bone.
It is doubtful if operation has much value in patients over forty-five years
of age. If there is history or evidence of a traumatic cause, operation is
to be considered. If no absolute localizing guide is present, a craniotomy
may be done on the right side, anterior to the motor area.
It should be laid down as a rule that upon the first appearance of epilepsy
of traumatic origin the region of the traumatism or focus of the symptoms
should be exposed; and that, although the correction of the local conditions
may not effect a cure, it may be expected to ameliorate the symptoms in
the reduction of the frequency and severity of the attacks.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 101
There are local causes of spontaneous origin which can often be removed.
Tumor as a cause of epilepsy is well known (see Tumors of the Brain and
Meninges, page 75). The adhesions following meningitis or spontaneous
hemorrhage should be treated by separating them. Sometimes these adhe-
sions are very delicate, requiring only that the dura shall be turned back as
a flap and the fine adhesions to its under surface broken with a probe. Such
operations often give surprisingly good results.
The cases which are most amenable to surgical treatment are those of
distinctly focal epilepsy. Here the peripheral symptoms call attention to the
cortical focus of disturbance, which may be exposed with anatomic exactness.
Whatever lesion is found should be dealt with accordingly; depression,
scar mass, foreign body or tumor removed, and subdural adhesions divided.
A scar involving the cortical substance should be regarded as a tumor and
removed. The appearance of focal symptoms should call for immediate
exploration of the focus indicated. In spontaneous cases a tumor may be
found. These are the cases in which tumor of the brain is most successfully
treated.
In a certain proportion of these focal cases, when the cortical area indi-
cated is exposed, no visible lesion can be found. If such a patient has had the
benefit of general hygienic treatment without avail, if there are no evidences
of deeper disease, and if the epileptic seizures are distinctly referable to the
functions controlled by the exposed area, the surgeon may excise that portion
of the cortex indicated by the aura of the disease. This operation requires
exact anatomic knowledge, which should be corroborated, if possible, by
electric tests (see Cerebral Localization, page 43).
Some cases of epilepsy, due to a local cortical lesion, do not give focal
symptoms; some cases with focal aura have no discoverable focal lesion;
and many cases present neither focal aura or lesion. Much can often be
done by way of general surgical treatment of non-focal cases.
Epilepsy associated with persistent or enlarged thymus calls for excision
of the gland (see Thymus Gland).
Jonnesco conceived the idea of inducing a cerebral hyperemia by a bilat-
eral removal of the sympathetic ganglia in the neck. The operation causes a
dilatation of the cerebral vessels and was presumed to produce a better
nourishment, oxidation, and elimination in the brain. The two upper
ganglia require to be removed to accomplish this. Theoretically, it was
believed that reflex impulses to the brain from the viscera would be cut off.
The operation has received a fair trial. In less than half of the cases, no
improvement has been secured. In the others the results have not been
sufficiently encouraging to warrant an acceptance of the operation as a thera-
peutic measure (see Cervical Sympathectomy, Vol. I, page 898).
Kocher has advocated decompression for the treatment of epilepsy of
unknown origin and pathology. By giving the brain more room, or by its
relief of pressure when abnormal hyperemia occurs, or for some other reason,
this operation has seemed to benefit a small percentage of patients. The
operation may be bilateral or unilateral. It should preferably be a temporal
decompression, preserving the muscle (see Temporal Craniotomy, page 36).
The curative effects of operations per se, through psychic effect or other
agencies, are undoubtedly factors in the results secured in operations for
epilepsy. Thus the decompression itself or the operation per se, may be
a factor in the cure in the cases in which good results are secured where no
lesion is found. Operations remote from the nervous centers are often fol-
lowed by cure or marked improvement if the psychic influence is sufficient.
Operations on the genital organs, or any other operation which is done un-
102 SURGICAL TREATMENT
der general anesthesia and with the impressions of gravity, may cure epilepsy
as effectively as a trephining which discovers nothing, or, indeed, as effect-
ively sometimes as trephining which actually discovers a lesion. The turning
down of a large osteoplastic skull flap has often cured epilepsy when no
definite lesion was found. It may also be said that amputations of the arm
and operations on the leg have been followed by equally good results in
some cases.
The internal treatment of epilepsy has for many years rested upon the use
of bromids. The bromids of sodium, potassium, ammonium, and stron-
tium are given to the point of toleration. They have decided value in lessen-
ing the susceptibility of the nervous mechanism to reflex excitability; and
their administration tends to diminish the frequency of attacks. When, by
disturbing the digestion or other functions, they interfere with the general
health, then their use becomes detrimental. The benefit of operations some-
times rests upon the fact that medication is stopped and a better general
hygiene is secured. It is well recognized that constipation, excessive pro-
teid diet, and intestinal infections must be remedied before a cure can be
hoped for.
Traumatic Psychoses and Insanity. — Early disturbances of the mental
state, due to concussion, contusion, laceration, or compression of the brain,
should be treated by the measures recommended for these several conditions.
Primary traumatic insanity, due to one or more of these conditions, may con-
tinue for several weeks and subside, without developing any indications for
operation. Restraint by force may at times be necessary. Operation for
compression sometimes reveals only edema or serum to account for it.
Residual disturbances are the later manifestations which develop out of
the early disturbances or appear de novo as postlraumatic neuroses. Pro-
phylaxis is the main thing in these cases. Their prevention is based upon
the same grounds as that of epilepsy, just as their causation is similar (see
Epilepsy, page 99). It cannot be too strongly impressed upon the
surgeon that the immediate recovery in brain injuries is not all. With rest
and time, nature may put the patient on his feet and send him back to work,
but later disturbances may develop from some condition which might have
been corrected primarily, but which defies later treatment. It is imperative
that the brain and meninges should be left in as nearly a normal condition
as possible. If traumatism has caused any change of anatomic relations
which nature will not correct, it should be corrected by art. A patient may
recover apparently from the effects of compression from fracture, clot, or
serum, but he stands less chance of developing later traumatic psychoses if
the compression is relieved at once, as soon after the injury as its symptoms
can be discovered. Wounds of the dura should be nicely closed so as to give
the least amount of subdural scar. The whole treatment of intracranial
injuries should be conducted with the view of minimizing connective tissue
and scar formation.
There is less liability to later disease if cases with pressure symptoms
are trephined than there is if they are allowed to recover without operation.
This is not only true when the compression is due to hemorrhage or bone
depression which can be localized, but it also applies to fracture and contusion
cases in which there are but vague general symptoms of compression.
Many fractures of the base develop compression symptoms. They will
usually subside, but in the interest of the patient's later welfare, it is best to
make a trephine opening to drain the bloody serum from the base. Such an
opening should be placed to drain the fossa through which the fracture passes.
This means a low operation in the temporal fossa for the middle fossa of the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 103
skull; a subtentorial operation through the occipital bone for the posterior
fossa; or, more rarely, an opening through the frontal bone in the temporal
fossa just above the level of the roof of the orbit for drainage of the anterior
fossa of the skull. The operation may be unilateral or bilateral, depending
upon the needs of the case.
If the location of the fracture is not known and there are no localizing
signs, a low temporal opening on the right side should be made. No cause
of compression being found, a subtentorial operation on the left side may fol-
low. In these operations, a button of bone should be removed, the dura
picked up, and a small opening made, through which the serous fluid may
drain. If free subdural fluid is not found, the opening in the dura may be
enlarged, sufficiently to give a view of the arachnoid, which should be punc-
tured in several places if edema is present. And, whether there is fracture
or not, compression symptoms due to edema or amicrobic serous meningitis
are best treated by trephining and drainage. A low temporal opening can
do no harm, and it may do much good.
Patients who have fully developed neuroses or insanity as a result of these
unrelieved traumatic conditions, are objects for pity more than for surgery.
If there is any discoverable clue to a lesion, exploration should be made,
and any operable lesion that is found dealt with the same as in epilepsy
(page 99). The hope of relief in these later cases is even poorer than it is
in epilepsy.
It should be borne in mind that insanity often follows some slight trau-
matism to the brain, not because of any gross injury but because the patient
had inherited an unstable mental organism already predisposed to insanity.
Such cases are not surgical.
What cases of insanity shall be operated upon? J. C. Da Costa said that
operation should be undertaken in cases in which insanity has soon followed
an injury to the head, if the location of the injury is indicated by a scar,
local tenderness, localized headache, depression of bone, or other localizing
symptoms. Operation should be done in cases in which the insanity has
come on later, but in which the period between the injury and the insanity
has been characterized by the development of a change in the patient's
disposition, by headache, irritability, insomnia, outbreaks of passion,
moodishness, loss of memory, immoral excesses, alcoholism, carelessness of
person, neglect of business or family obligations, or epilepsy. "One should
not operate upon a case simply because there is a dubious record of an ante-
cedent fall or blow, which merely suggests the possibility of a traumatic
origin for the insanity. In any case in which there are positive signs of in-
creased pressure, it may be considered proper to trephine as a palliative
measure."
Congenital Imbecility, Idiocy, and Insanity. — These conditions, due to
developmental defects, are not amenable to surgical treatment. It was once
thought that microcephalic idiocy was due to premature ossification of the
skull, and that linear craniotomy, to permit the brain to expand, would be of
service. The operation is of no value. The rational treatment of these
conditions rests upon the application of the principles of eugenics. The
unborn should be given the benefits of prophylaxis, and the born idiots the
benefit of educational training.
Traumatic Neurasthenia and Traumatic Hysteria. — The treatment of
these conditions should begin with prophylaxis. Persons who have sustained
injuries which are associated with psychic or physical shock should be as-
sured of recovery, and reassured. They should be given a hopeful outlook.
After the psychosis has developed, treatment is a matter of hygiene. Any
104 SURGICAL TREATMENT
functional derangements which can be discovered should be corrected. A
good state of mind and body should be secured. The patient should be
made to live under the most hygienic conditions possible. Work, to occupy
the mind and body, is most important.
Surgery of the Insane. — These are certain peculiarities in the treatment
of surgical diseases of the insane. Treatment is often difficult because of
the failure of cooperation on the part of the patient. The character of the
diseases to be treated is often unusual. Peculiar injuries made in an unusual
manner, extraordinary cases of foreign body in unusual places, self mutila-
tions, accidental wounds, and suicidal attempts are often such as the surgeon
is not accustomed to treat among the sane.
Because of the restlessness of most lunatics, the fastening of dressings
upon wounds and fractures must be made with extraordinary security.
Physical restraint is often necessary to keep the patient quiet or to prevent
him from removing the dressings. The temperature in insanity is often
subnormal, and a normal temperature or a slight rise of temperature may
signify infection. Infection should be suspected and wounds examined for
it upon the evidence of a much lower temperature than would indicate in-
fection in the sane.
The insane are especially liable to fractures, particularly of the ribs,
because the bones are unusually fragile and accidents more common.
The prevention of these injuries is important. Patients who are apt to
injure themselves should be watched and protected. Beds with sides, to
prevent their falling out, or a mattress on the floor, should be provided.
Ulcers and abscesses are common, and should be prevented by cleanliness.
Hematoma of the ear is best treated by cold applications, if seen early, to
check the bleeding; then, by painting the skin with collodion, protection and
slight pressure are secured. If the hematoma becomes infected it should
be incised. If the clot becomes fluid, it may be aspirated. Whatever treat-
ment is applied, the ear should be separated from the scalp by layers of gauze,
and well enveloped in cotton to prevent further traumatism.
Gall-stones, cholecystitis, appendicitis, and hernia should receive the
same treatment which they do among the sane, excepting that operation is
more urgently called for because of the lesser certainty in the recognition of
grave symptoms. Hernia is always a menace, and should be operated upon
whenever practicable. In many cases extraordinary precautions are
necessary to prevent infection. For this purpose, a plaster-of-Paris spica
may be put on over the dressing, and, if necessary sealed against soiling by
the use of rubber tissue and collodion.
Operations for delusions have been done to remove the locus of an
imaginary ill; but these operations are not curative because the mind is
diseased and the operation only results in shifting the delusion to some
other part. When hallucinations originate in some part of the cortex, the
function of which is known, and the seat of origin can be identified, it is
possible that surgery may be of service in excising this particular area. The
matter has not yet passed beyond the realm of theory.
Pelvic disease, especially affecting the ovaries, is common among insane
women. These diseases are often contributory causes of the insanity.
Operation should positively be done for those conditions which are amenable
to operation. The cure of pelvic diseases or the removal of the diseased
organ is followed by an amelioration or cure of the insanity in a gratifying
proportion of cases.
Catatonic dementia precox seems to have some connection with the
internal glandular secretions. A curative or ameliorative effect is sometimes
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 105
secured by partial thyroidectomy if the operation is done in the early stages
of the disease. In the later stages, operation is of no benefit.
Surgery of the Neurotic and Neurasthenic. — The principles of surgery
which are applicable to the insane apply also to the neurotic. In gyneco-
logical cases especially, prolonged and repeated treatments are most objec-
tionable. Minor treatments, applied for a prolonged period, may be ex-
pected to aggravate and fix the neurotic condition. Radical operations which
are destined to be followed by depression are to be deprecated, and should
be done only when the indications are well defined. When the question of
operative treatment of a neurasthenic person is under consideration, surgery
should be avoided if possible. Operation should not be attempted, as in
epilepsy, with the hope that the operation per se may have a helpful effect,
for want of something better to do. No operation should be done on a
neurasthenic unless the indications for operation are so clearly defined that,
operation would be indicated were the patient perfectly free of neuras-
thenia. If operation is undertaken, the hope that it will cure the neuras-
thenia should not be entertained.
INTRACRANIAL OPERATIONS UPON THE FIFTH NERVE (TRIGEMINAL)
The roots of the trigeminal nerve and the Gasserian ganglion require
operation for neuralgia and tumor. Intracranial operation for trigeminal
neuralgia is called for in the major form of trifacial tic involving more than
one of the divisions (see Trifacial Neuralgia, Vol. I, page 865). These pa-
tients come to operation after having suffered much pain and treatment.
They have usually had divisions of the peripheral branches, alcohol injec-
tions, internal medication, and local treatments. Often their general health
is much impaired by pain, loss of rest, and morphine addiction. It is clear
in these cases that the disease is a central one, and partial division of the
sensory root is the least that will be of service. The Gasserian ganglion is
the anatomic key to the situation (see Neuralgia of Trifacial Nerve).
Anatomy. — A perfect familiarity with the anatomy of the parts is essential. The
fifth nerve is made up of a sensory and motor root which come forward from the basilar
ganglia, and pierce the dura mater. The larger root (sensory) arises chiefly from the
medulla, and has upon it the Gasserian ganglion. This ganglion lies in a hollow on the
apex of the petrous portion of the temporal bone. On its inner side is the cavernous sinus
embracing in its wall the oculomotor, trochlearis, and abducens nerves. The latter lies
close to the ganglion. The ganglion is a reddish-gray enlargement situated at the trifur-
cation of the sensory root, and is enclosed in a sheath of dura mater, which must be incised
to expose the ganglion. It measures about 2 cm. by i cm. and is crescentic in shape.
Two vessels supply it; a branch of the middle meningeal and a branch of the internal
carotid, both entering the under surface. These vessels are encountered in the effort to dis-
lodge the ganglion from its bed. The middle meningeal artery enters the skull through the
foramen spinosum which is external to the ganglion. Usually the spinosum is behind and
external to the ovale, although it may lie anterior to it. The important point is that, to
approach the ganglion, the artery must be ligated and divided. The motor root passes
beneath the ganglion without having any connection with it. From the front of the
ganglion the three divisions proceed; the ophthalmic, through the sphenoidal fissure; the
superior maxillary, through the foramen rotundum; and the inferior maxillary, through
the foramen ovale. The first two have only sensory fibers, the third division receives
also the fibers from the motor root.
The disease usually involves the second and'third divisions. When the first division is
not involved, there is no advantage in dividing the filaments which constitute it; and there
is a decided disadvantage, because paralysis of sensation of the conjunctiva usually means
keratitis and possibly loss of vision.
No surgeon should attempt intracranial operations upon this nerve without having
practised the operation on the cadaver. Even then the difficulties arising from hemorrhage
cannot be appreciated. A study of the base of the skull and of the relations of the basilar
foramina to the external landmarks is essential.
106 SURGICAL TREATMENT
Craniotomy for Exposure of the Gasserian Ganglion. — Many methods
of approach to the Gasserian ganglion have been devised. No single one
has been adopted to the exclusion of others. The approach should give
adequate room, should not expose the brain to undue traumatism, should
not injure important structures, and should be capable of restoration of the
parts to a nearly natural condition. It is a decided disadvantage to divide
the temporal branch of the temporofacial division of the facial nerve, which
supplies the orbicularis palpebrarum muscle. In all operations the brain is
exposed by a temporal craniotomy (see page 26).
High temporal craniotomy is carried out through a horseshoe-shaped
incision through the scalp and pericranium. It begins just behind the exter-
nal angular process of the frontal bone and ends above the tragus of the ear.
The base of this flap corresponds to the upper border of the zygoma; and the
upper margin reaches the height of the temporal ridge which marks the upper
border of the temporal fossa. The bone is divided along the line of the scalp
incision and the bone-scalp flap turned down. As the bone breaks across
the base of the flap, the middle meningeal artery may be torn, and require
ligation at once. The zygoma need not be divided. This is the approach
of the now little used Hartley-Krause operation.
Low temporal craniotomy is done as follows: The incision is the shape of
a horseshoe. It begins just behind the frontal process of the malar bone and
terminates at the zygoma a finger's breadth in front of the ear. The summit
should be about i cm. below the temporal ridge. The scalp, muscle, and
periosteum are divided in the line of the incision, and the zygoma is divided
at the two termini. The flap of soft parts is dissected free from the great
wing of the sphenoid as far down as the pterygoid ridge and from the temporal
bone. The periosteum should be included in this flap. The flap is retracted
downward and the zygoma depressed. Gushing removed the zygoma.
A trephine opening is then made in the skull midway between the external
auditory meatus and the external angular process of the temporal bone. This
is then enlarged in all directions. The upper margin of the opening need
not pass the grove of the middle meningeal artery at the anterior-inferior
angle of the parietal bone. Below, the opening should be carried nearly to
the foramen ovale. The middle meningeal artery may be ligated or not, as
seems best. By cutting away the base of the skull toward the foramina
ovale and rotundum, the opening through the temporal fossa need not be more
than 4 cm. high (see Craniotomy).
Auriculotemporal craniotomy approaches the ganglion posteriorly. It
is adapted for access to the sensory root. A horseshoe-shaped incision is
made, beginning at the middle of the zygoma, passing up to within i cm. of
the temporal ridge, and ending posteriorly behind and a little below the
summit of the auricle. The flap of scalp, muscle and periosteum is turned
down over the ear. The skull is opened with a trephine, and the opening
enlarged to within 0.5 or i cm. of the scalp wound. The enlargement of the
opening is extended downward as far as the infratemporal crest. This is
the route of Frazier.
Subtemporal craniotomy may be done through a right-angle incision with
the apex downward. It avoids the temporofacial branch of the facial
nerve. It is begun about i cm. behind the frontal process of the malar bone,
passes downward and backward to the condyle of the inferior maxilla,
and thence at a right angle upward and backward a short distance in front
of the ear. This is the incision used by T. Kocher. The terminal branches
of the temporal artery should be ligated. The temporal fascia is cut at its
attachment to the upper border of the zygoma, and the zygoma is divided
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
107
at either end and retracted downward. The skin flap is dissected up, and the
temporal fossa exposed by splitting the muscle and strongly separating its
fibers. The skull is trephined low down, and the opening enlarged almost to
the foramina ovale and rotundum. The opening is carried upward for 3 or
4 cm. In performing this operation the preliminary flap of soft tissues may
be made rounded instead of angular.
The intracranial operation varies with the craniotomy of approach and the
methods of the surgeon. The operation has passed through many stages.
Many procedures have been followed: (i) Division of the
affected branches distal to the ganglion; (2) division of the
branches and avulsionl of the ganglion; (3) division of the
branches and root and removal of the ganglion; (4) division
of the sensory root and avulsion of the ganglion and branches;
(5) avulsion of the ganglion, root and branches; (6) division
of the sensory root; and (7) splitting the ganglion and remov-
ing only the portion connected with the second and third
branches — these are some of the operations which have been
done. The operations now in use are: (a) division of the
sensory root; (&) total extraction of the ganglion if the
ophthalmic is involved; (c) extraction of the part of the
ganglion connected with the second and third divisions if the
ophthalmic is not involved; and (d) simple division of the
second and third divisions, if the ophthalmic is not involved,
and the interposition of some foreign substance to prevent
their union. An important discovery is that, when the sen-
sory root is divided, it does not reunite.
The skull opening having been made and the dura mater
exposed, the latter should be separated from the base of the
skull by the handle of a scalpel and lifted up on a thin flat
retractor. This should gently lift up the dura and brain as
far inward as the foramen spinosum, and bring into view
the middle meningeal artery as it enters the skull. A liga-
ture upon a small carrier should be passed around the vessel,
tied close to the foramen, and the artery divided. Most sur- Fl G 756 _
geons do this. The dura is then incised just internal to this, BLUNT HOOK
directly above the foramen ovale. The inferior maxillary USED IN OPERA-
division is the guide to the ganglion. ™ONS ON NERVE
To divide the sensory root, the dura is carefully dissected '
from the superior surface of the ganglion backward and in- serves lsto °J^SS
ward. The sensory root may now be caught on a blunt hook ligature around
(Fig. 756), and divided, or avulsed as suggested by Spiller the middle
and first practised by Frazier. If any of its fibres are not menmseal artery
. • , • rm • i T • • r .,1 and to catch the
cut, pain may continue. I his simple division ot the sensory nerve aruj draw
root is a less bloody operation than removal of the ganglion; it out.
there is the least danger of injury to important structures;
and rarely the motor root may be preserved, and the subsequent disturbances
of the muscles of mastication prevented. Sensory paralysis of all three
divisions follows complete division of the sensory root. If it can be identi-
fied, the motor root should be avoided. Exposure of the sensory root is
best accomplished by auriculotemporal craniotomy (Fig. 757). This is the
Spiller-Frazier method.
To remove the ganglion, after raising the dura and brain, the third and
second divisions as they enter their foramina are exposed and followed
backward to the ganglion; the dura is split to expose the ganglion; the latter is
108 SURGICAL TREATMENT
isolated, grasped with forceps, the divisions cut with scissors, and the gan-
glion rotated and avulsed, bringing with it the sensory and motor roots. This
is the Hartley-Krause method, which approaches by the high temporal route.
To remove part of the ganglion, the third and second divisions should be
well exposed, and the dura detached until the ganglion is freed from its bed;
the two exposed divisions are then cut across just above the foramina; the
ganglion is grasped with forceps, and the part connected with the two cut
divisions is removed, while the part connected with the ophthalmic division
is left.
Special modifications of these procedures have been made by many
surgeons. It is conceded that the best approach is secured by ligation of
the middle meningeal artery. In the low temporal and subtemporal opera-
tions, temporary resection of the zygoma is called for, and gives decidedly
more room. Both Gushing and Lexer advised total extirpation of the ganglion.
Horsley approached by the low temporal method, exposed the ganglion,
divided the third and second divisions, detached the first division, and
FIG. 757. — OPERATION ON SENSORY ROOT OF TRIFACIAL NERVE.
The third division and the posterior aspect of the ganglion have been exposed. The hook
has been passed around the sensory root.
avulsed the ganglion with its roots. Abbe cut the affected divisions, pre-
vented their regeneration by interposing rubber tissue, and left the ganglion
intact. He has been able to secure sufficient exposure for this operation
through a vertical incision. Kocher slowly avulsed the sensory root and
left the ganglion.
Operation in two stages sometimes becomes necessary when bleeding is
persistent and controlled with difficulty, or when the patient becomes in-
tolerant to further operation. Under such circumstances the immediate
conditions are met and the wound temporarily closed. Tampons should
not press so firmly as to give, compression symptoms. After a few days,
when hemorrhage is controlled and the patient's condition permits, the wound
may be reopened and the operation concluded.
The position of the patient is worthy of consideration. A table should be
used which will permit longitudinal tilting so that the head may be elevated
at any time. Von Bergmann advocated operation in a nearly vertical
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 109
position, and many surgeons now operate with the patient in that position.
A special operating chair with a head rest has been made for the purpose.
The advantage of the elevated head position is that hemorrhage is less.
At the same time, any posture which minimizes venous engorgement
renders anemia of the cardiac and respiratory centers more liable. The
surgeon is between two dangers. Greater skill on the part of the anesthetist
is required in the upright position. Upon the appearance of the signs of
anemia of the vital centers the head must be lowered.
The control of hemorrhage is first facilitated by ligation of the middle
meningeal artery. Bleeding from the scalp and skull have been discussed
elsewhere. The annoying hemorrhage which interferes with a view of the
nerve is from the small veins passing between the dura and the skull. Bleed-
ing from these is best controlled by pressure applied at the bleeding point
with a small piece of gauze. This may often be held in place with a spatula-
retractor. Adrenalin gauze has been used for that purpose. Pressure for a
few minutes will usually suffice. It is much better to give attention to each
bleeding place and attempt to control it by pressure than to attempt gross
sponging out of the blood while the operation proceeds between times.
By making pressure with minute sponges in one place, the operation may
proceed in another. Wounds of the venous sinuses are still more trouble-
some; but a properly applied piece of gauze, held in place by a flat retractor,
will be found best. In closing the wound these pieces of gauze should not
be neglected. The patient's blood-pressure should be recorded before the
operation, and accurately kept track of during the operation.
The operation of choice must vary with the conditions to be met and the
surgeon's individual preferences. At present surgeons are not performing
typical or routine operations. The procedure must be modified to suit the
peculiar conditions present. In general, there are certain things of advantage :
(i) The surgeon's first operation should not be upon a living patient; or,
if it is, he should have assisted in the operation many times. (2) Hemostasis
by means of the scalp tourniquet will save blood. (3) A skillful anesthetist
is necessary. (4) The low temporal, subtemporal and temporoauricular
routes of approach are the best. (5) In the first two, it is of advantage to
continue the bone opening nearly to the foramen ovale. (6) Division or
avulsion of the sensory root is the operation of choice — it is a less bloody
operation, and in all respects more easy and less hazardous than removal of
the Gasserian ganglion. Removal of the ganglion is a difficult and dangerous
procedure. Kocher, following Spiller's suggestion, avulses the sensory
root, and has not had a case of recurrence of neuralgia in his experience.
(7) The dangers of the operation inhere in hemorrhage and traumatism to
the brain. With care both of these may be confined within the limits of
safety. This is an operation in which haste can not be made. The brain
need not be elevated more than i or 1.5 cm. from the base of the skull.
Artificial illumination may be used, if necessary, to throw light into the
wound. (8) Some oozing will usually make it advisable to close the wound
with drainage, leaving sufficient tampon for hemostasis. After division of
the sensory root the field of operation is anesthetic, and no further anesthesia
is required (see Operations on the Scalp, page 19). Operations on the
Skull, page 26; Brain Topography, page 43; Injuries of the Venous Sinuses,
page 54; and Intracranial Operations, page 30).
Mortality from the operation varies with the skill of the surgeon. The
mortality from the old operation for removal of the Gasserian ganglion was
high. Perfection of the technic has removed much of the hazard. The
modern operation upon the sensory root gives a lo\v mortality. Frazier
110
SURGICAL TREATMENT
collected the statistics from his own clinic, and from those of Lexer, Horsley,
Dollinger, and Gushing, and found the mortality to be 3.7 per cent. Among
his own cases there was a mortality of 3 per cent. Loss of blood, traumatism
to the brain, and depression from the anesthetic are the chief causes of
immediate death; and infection is the chief cause of later death. All of
these dangers are preventable, and scarcely play a role in the work of the
well-equipped surgeon.
Results in these operations are improving as the technic improves. Fol-
lowing attempts at extirpation of the ganglion there has been not a small
percentage of recurrences; but division or avulsion of the sensory root gives
an assurance of permanent sensory paralysis and cure of the neuralgia. Fol-
lowing the older operations for removal of the ganglion, complications such
as restlessness, headache, dizziness, and motor paralyses occurred; but these
now rarely follow operations on the sensory root.
Keratitis is very apt to occur if to the sensory paralysis of the cornea there
is added an inability to close the eye on account of division of the temporal
branch of the facial nerve. Trophic disturbances also, perhaps, play a role.
To prevent disease of the cornea, the eye should be protected from the en-
trance of dust by being covered with a shield having a glass window. In
extirpation of the whole ganglion, besides paralysis of the ophthalmic branch,
there is always danger of injury to the third, fourth, and sixth nerves in the
wall of the cavernous sinus adjacent to the ganglion. This is another strong
reason in favor of splitting the ganglion and leaving the part attached to the
first division when it is not neuralgic.
INTRACRANIAL OPERATIONS ON THE AUDITORY NERVE
Operations upon this nerve are done for tinnitus, otalgia, acoustic vertigo
and tumor. It is distributed exclusively to the inner ear. It passes from the
Hid. ffeninyeal Art;
Tri facial N-
Ex.Petrosa.1
Sm.Pefrosal
LrPetroJal
Geniculat
Ganglion.
A Facial N
Auditory N. in
Internal Auditory
Meatua facial N:
Chorda Tympani
External Ear-
FIG. 758. — SHOWING RELATIONS OF SEVENTH NERVE IN TEMPORAL BONE.
The nerves have been uncovered by removing the roof of the petrous portion within the
skull.
lower border of the pons forward in company with the facial nerve, with
which it enters the internal auditory meatus. It is soft in texture, des-
titute of neurolemma and distinguished from the facial which is firm. It lies
external to the facial. It is larger than the facial, somewhat flattened and
grooved to envelop it (Fig. 758). Within the meatus it receives one or two
filaments from the facial. The nerve is recognized in the wound by its
glistening white appearance. Directly posterior and below the internal
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
111
auditory meatus is the posterior lacerated foramen, transmitting the inferior
petrosal sinus, the lateral sinus, and the glossopharyngeal, pneumogastric
and spinal accessory nerves. These come into view in the operation. The
root of the trifacial passes just internal to the auditory. The positions of the
lateral sinus and the jugular foramen should be fixed in the mind (see Cranio-
cerebral Topography).
The skull is opened by the suboccipital route (see Suboccipital Craniotomy,
page 36). The unilateral operation suffices in most cases. The bilateral
operation is called for in operating for tumor. Frazier performed the
operation under intratracheal insufflation anesthesia with the patient in
the prone position, the forehead resting on a special support.
COMMON TRUNK OF FACIAL
FIG. 759. — EXPOSURE OF SEVENTH NERVE BY SUBOCCIPITAL CRANIOTOMY.
The cerebellum is retracted. The facial and auditory nerves are exposed at the internal
auditory meatus. The facial is the upper of the two in this picture. IX, Glossopharyn-
geal; X, pneumogastric; XI, spinal accessory. These three latter nerves are about to
enter the jugular foramen.
After cutting away the bone sufficiently, the dura is incised a short dis-
tance from the bone edge and turned down as a flap. The cerebellum is then
lifted with a flat retractor and the auditory nerve brought into view. Much
care must be exercised in this operation lest serious pressure be made upon
the medulla or the cerebellum lacerated. The cerebellum should be dis-
placed backward, making use of the skull opening to give room for its dis-
placement. By no means should attempts be made to press the brain in-
112
SURGICAL TREATMENT
ward. Some venous bleeding will occur as the brain is separated from the
region of the petrous portion. This is controlled by gauze pressure. The
surgeon should think of approaching the nerve laterally rather than from
behind. Good artificial illumination is necessary. Retraction, giving an
opening i cm. in height, should suffice to expose the nerve (Figs. 759 and
760).
In operating for tinnitus or acoustic vertigo, the nerve must be divided.
The facial should be protected and preserved. Retracting the cerebellum
should expose the two nerves as they are put on the stretch. The facial
FIG. 760. — EXPOSURE OF SEVENTH NERVE BY SUBOCCIPITAL CRANIOTOMY.
The auditory nerve (8th) has been caught on the blunt hook and is separated from the
facial nerve (7th).
and auditory nerves may be separated by blunt dissection. The blunt hook
is useful for this purpose. This should be done patiently and deliberately.
No strands of the auditory should be left clinging to the facial. The nerve
having been isolated, it is grasped with forceps and avulsed. Any remaining
fibers may cause a continuation of the symptoms for which the operation was
done. The facial nerve should be identified by applying an electrode to it.
The operation is done upon patients who already have serious impairment
or loss of hearing. Labyrinthine disease calls for the operation; in tinnitus
or vertigo of central origin, the operation would be of no avail. Lesions of
the cochlear ganglion or vestibular ganglion create the indications. Vertigo
is relieved by removal of the semicircular canals, but this operation does
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 113
not affect the tinnitus. In cases in which the vertigo is not associated with
tinnitus, removal of the semicircular canals is the operation of choice. This is
a much less formidable operation.
This nerve has been approached by the temporal route and by the masto-
occipital route. None of the operations have succeeded wholly in relieving
the symptoms. Patients should be warned of the possibility of facial paraly-
sis. The mortality has been high. Complete deafness results. Only the
extreme cases should be operated upon by this method.
A certain number of cases of aural vertigo, even with tinnitus, are cured
by destroying the vestibule and semicircular canals. Therefore, upon the
basis of present information, the operation on the ear should be tried first.
The removal of tumors of the auditory nerve is accomplished through the
same route. The bilateral operation is necessary to give the requisite
displacement of the cerebellum. If the tumor has reached a size to cause
internal hydrocephalus, the increased intracranial pressure may be largely
due to the hydrocephalus, which may require to be relieved by tapping before
the occipital operation is done. Neurofibroma of the nerve should be rec-
ognized early and removed. In the case of large tumors an operation in
two stages may be done.
Usually after these operations there will be considerable bloody oozing.
Gauze or wick drainage should be provided for one or two days. The drain-
age should be dispensed with as soon as the bleeding has ceased. The sooner
it can be removed the less is the danger of a continuous discharge of cere-
brospinal fluid.
Operation by the mastoid route in two stages is as follows: The incision
begins just below the tip of the mastoid process on the affected side. It
passes upward and slightly backward to the level of the upper border of the
external auditory meatus, thence curves backward above the external oc-
cipital protuberance and downward, just to the sound side of the median line
to end at the spine of the second cervical vertebra. The bleeding is checked
and the skin-flap thus outlined is dissected free and turned downward. The
incision is then deepened and the flap of fascia, muscle, and periosteum is
turned down. All bleeding should be checked. Bleeding from foramina in
the bone should be checked by plugging them with wax or a wooden pin.
The occipital bone is opened where it is thin just below the superior
curved line. A burr or gouge quickly makes an opening here and exposes the
dura. About this opening the dura is separated and the bone is removed with
bone-cutting forceps. As the separation of the dura proceeds, the bone is cut
away until much of the exposed area of the occipital and temporal bones is
removed. The bone is removed to a point just beyond the occipital sinus
in the median line, above until the lateral sinus is exposed, anteriorly along the
sigmoid sinus, and downward nearly to the margin of the foramen magnum.
It is not necessary to open into the foramen. The lateral and sigmoid sinuses
are so intimately connected to the bone that some force and much care are
necessary in separating them from their beds. The dura having been freely
exposed and all bleeding checked, the soft parts are replaced, sutured back
into position, and the wound dressed.
At the end of a week, the sutures are removed, and the flap of soft tissue
is again turned down. A large flap of dura is turned down, the margins of
which lie just within the area bounded by the occipital, lateral and sigmoid
sinuses. The base of the flap is downward. This step should be carried out
with care to prevent hemorrhage, and unnecessary wounding of vessels.
When all vessels have been tied, adrenalin may be applied to check oozing.
A thin flat retractor is carefully passed beneath the cerebellum, and the
VOL. II— 8
114
SURGICAL TREATMENT
brain lifted upward and inward away from the base of the skull. An electric
head lamp should furnish illumination. The retraction should proceed
slowly and carefully. As the cerebellum is lifted up cerebrospinal fluid rushes
forth from the basilar cistern. The fluid should be sponged away, and the
retraction slowly continued until the auditory nerve is seen passing forward
with the facial nerve to enter the meatus auditorius internus in the petrous
portion of the temporal bone. By means of faradic stimulation applied to
FIG. 761. — SHOWING OPERATIVE FIELD IN EXPOSURE OF SEVENTH NERVE.
The skull has been opened by removing the bone with rongeur. The flap of dura has
been turned down. The cerebellum is gently retracted. The auditory nerve is caught
by the hook, separating it from the facial nerve.
the facial nerve with a long electrode that nerve may be identified and its
division avoided. The auditory nerve lies external and below the facial.
The auditory artery usually lies between the two. For tinnitus, the auditory
alone is drawn away with a blunt hook, grasped with forceps and pulled
away from its central attachment. For otalgia, both the facial and auditory
are divided (Fig. 761).
The flap of dura mater should be sewed back in place. The muscle
should be sewed with catgut, and the scalp with silk or silkworm-gut.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 115
INTRACRANIAL OPERATIONS ON THE FACIAL NERVE FOR FACIAL NERVE NEURALGIA
As the facial is a mixed nerve with a sensory ganglion (the geniculate
ganglion), receiving sensory fibres from the root of the auditory nerve
through the pars intermedia, neuralgia of the circumscribed area of its sensory
distribution sometimes requires operation. The area of sensory distribution
is the anterior wall of the external auditory canal and the skin just in front
of the ear. The natural treatment for this neuralgia, when operation is
necessary, is division of the pars intermedia.
INJURIES AND DISEASES OF THE FACE
Contusions of the face, for cosmetic reasons require to have their traces
quickly removed. Cold followed by heat and massage gives the best results
(see Contusions, Vol. I, page 218).
Wounds of the face heal most quickly because of the vigorous blood supply.
Nice apposition is essential for the minimization of scar (see The Closure of
Wounds, Vol. I, page 187).
Fractures of the jaws, malar bone, and zygoma have been discussed (see
Fractures).
Inflammations usually heal more promptly than in other parts. When
necessary to apply irritating solutions to the face, the eyes may be protected
by compresses wet with boracic acid solution and covered with impervious
protective. Erysipelas, lupus, and tuberculosis has been discussed under
Inflammations.
Tumors come early to the surgeon because of their cosmetic importance.
Sebaceous cysts, nevi, moles, and epitheliomata may be removed by the knife
in their early stages, the wounds nicely closed, and good results expected
(see Tumors, Vol. I, page 323).
Facial Neuralgia. — (See Trifacial Neuralgia, Vol. I, page 865; Facial
Neuralgia, Vol. I, page 877.)
Facial Paralysis. — (See Facial Nerve, Vol. I, page 881; Facial Spasm,
Vol. I, page 888.)
THE EYE
Anatomy. — The eyeball or globe of the eye (bulbus oculi) is situated in'the anterior part
of the orbital cavity (Fig. 762). It is embedded in the fatty connective tissue of the orbit,
being surrounded immediately by the capsule of Tenon, a thin membrane, which allows
of free movement. It has about it also the muscles of the orbit which give it motion (Fig.
763). The conjunctiva lines the back of the eyelids and is reflected upon the front of the'eye.
When the lids are closed the conjunctiva forms a sac (Fig. 764). The lacrimal apparatus
consists of the lacrimal gland, situated at the upper and outer part of the orbit, its ducts,
and the tear ducts at the inner aspect of the eyelids which carry the tears into the nose
(Fig. 765).
The anterior part of the eyeball is most commonly the field of surgical operations.
The most sensitive and important regions are the cornea, the iris, the ciliary body, and the
crystalline lens (Fig. 766).
Treatment of Diseases of the Eye. — In the treatment of surgical diseases
of the eye every care should be given to the protection of the cornea from
irritation. When a dressing is required for the eyelids, compresses wet with
boric acid or other non-irritating solution should be used. If discharges
behind the lids are present, the lids should be separated at least once or twice
a day, and the discharges, which have not escaped, should be washed away
with non-irritating solution. It is a great mistake to cover with a dressing
eyes from which there is much discharge, unless the dressing can be removed
frequently and the eye cleansed. If there is profuse discharge, no dressing
should be used unless the eye can be uncovered and cleansed hourly.
116
SURGICAL TREATMENT
In order to expose the eyeball or conjunctiva for treatment, the upper
lid must often be everted. To accomplish eversion of the lid, the patient
should be directed to look continuously downward; the surgeon then takes
between the index-finger and thumb of the left hand the central lashes of the
upper lid, draws the lid downward and forward, places the tip of the thumb
of the right hand on top of the lid, steadies the other fingers against the head,
POST. CHArtBf-B
OCULAR
COHJUNCTIV*
C/LIAHf
nusct-l.
PAB&CILIAPH
OPTIC PAPILLA
OPTIC
EXCAVATION
OPTIC NCKVt
FIG. 762. — THE EYEBALL OR GLOBE OF THE EYE (BULBUS OCULI).
Horizontal section of right eyeball.
and turns the lid back over the tip of the thumb. If there are no lashes
on the upper lid, the lower lid may be pushed beneath it and used to turn it
back. A match or toothpick may be used instead of the thumb.
In order to inspect the cornea to observe the progress of treatment or to
discover foreign bodies, oblique illumination is used. The patient is placed
2 feet from a light which is located to the side and somewhat anteriorly;
.SUPERIOR OBLIQUE
LESSER WING Of SPHENOID
UPPER HEAD
LOWER HMD
INTERNAL RECTl
OPTIC
INFERIOR RECTU5
LEVATOR FSLP. SUP.
SUPERIOR RECTU5
TERNAL RECTUS
INFERIOR 06LIQUE
PIG. 763. — MUSCLES OF THE EYE, RIGHT ORBIT.
the surgeon sits facing the patient; with a simple 5- or locm. lens, a beam of
light is thrown upon the eyeball, while with the other hand a similar lens
is used for magnifying the field to be inspected. Oblique illumination enables
not only an inspection of the cornea but also of the anterior chamber and
the crystalline lens. Strong magnifying lenses are also used for this purpose.
For observing the interior of the eye, the ophthalmoscope is used.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
117
The use of mydriatics (drugs which dilate the pupil) is often called for.
Atropin has the widest range of application. It is usually employed in a
strength of 0.25 Gm. (4 grains) of atropin sulphate to 30 c.c. (i ounce) of
FIG. 764. — CONJUNCTIVA. FIG. 765. — LACRIMAL APPARATUS OF
Vertical section of eye showing RIGHT EYE. (After Gray.)
upper and lower fornices of conjunc-
tival sac.
Circular ciliary 1musc!e
Ciliary process
Insertion of tendon of sup. rectu
Subconjunctival fa
Anticiliary vessels
Circulus major
Superior angle of anterior
chamber
Canal of Schlemm
Conjunctiva
Connective tissue
Ligamentum
Pectinatum
Edge of cornea
Iris
Cornea
Pars optics retina
:rrata
is retinae
er of retina.
Posterior chamber
Epithelium of lens capsule
Cortical substance of lens
Nucleus of lens
Epithelium of
cornea
Ant. elastic lamina
Posterior elastic lamina x x
\ Stroma of iris
Sphincter of pupil Pigmentary layers of iris
FIG. 766. — FRONT OF EYEBALL, UPPER HALF OF VERTICAL ANTEROPOSTERIOR SECTION.
sterile water. A drop of this solution on the conjunctiva dilates the pupil
in about fifteen minutes; and by causing paralysis of the ciliary muscle
paralyzes accommodation, which lasts for a week. The retraction outward
118 SURGICAL TREATMENT
of the iris renders it less liable to become adherent when inflammation reaches
the anterior chamber. The mydriatic places the eye in a state of physiologic
rest, and diminishes the possibility of iritis. To keep the pupil dilated, it
may be necessary to use the drug daily for several days. From i to 5 drops
are used at a time. Homatropin produces an effect lasting about two days.
A solution of 0.5 to i Gm. (8 to 16 grains) to 30 c.c. (i ounce) is used — i
drop every fifteen minutes is instilled for an hour and a half, beginning two
hours before the full effect is required. Cocain hydrochlorid (2 to 4 per cent,
solution), besides its anesthetic effect upon the conjunctiva and cornea, is
an excellent mydriatic. If a mydriatic produces signs of glaucoma, it should
be neutralized at once by a myotic and discontinued.
Should atropin not be tolerated, solution of hyoscin (1:400), scopo-
lamin hydrobromid (i : 500), or duboisin sulphate (i : 500 or i : 200) may
be used.
Drugs which contract the pupil are called miotics. The salicylate
of physostigmin (eserin) is used for this purpose and as an antidote to
counteract the effect of atropin. It is used as eye drops in solution — 0.03 to
0.25 Gm. (]/2 to 4 grains) to 30 c.c. (i ounce) — several drops 3 times daily.
The hydrochlorid of pilocarpin has a similar miotic action, and is used in
a strength of 0.13 to 0.6 Gm. (2 to 10 grains) to 30 c.c. (i ounce) of water. In
chronic glaucoma the strength of the miotic solution should at first not
exceed 0.03 Gm. (% grain) to the 30 c.c. (i ounce).
For using cocain as an anesthetic in eye operations, such as iridectomy and
cataract extraction, a sterile 4 per cent, solution is employed. Three
instillations are made at intervals of four or five minutes. After each in-
stillation, the eye should be closed, and covered with a pad. Holocain
in a 2 per cent, solution is used by some surgeons.
Solutions of dionin (peronin, ethyl-morphin hydrochloride) in strength of
from 5 per cent, to saturation are used. The pure powder is also used. Ap-
plied to the conjunctiva, it possibly has some effect in dispersing lenticular
opacities. It is most effective when used by subconjunctival injection. It is
a valuable analgesic in the treatment of corneal ulcers, acute glaucoma,
iritis, scleritis, and other inflammations of the uveal tract. It is applied to
the conjunctiva in these diseases. It seems to be harmless.
The antiseptics are useful. Boric acid solution is most commonly em-
ployed in connection with eye work. Mercuric and silver solutions are used
in'more pronounced infections. After wounds of the eyeball in which some
discharge is to be expected, a mercurial ointment may be placed in the con-
junctival sac with advantage. It prevents adhesion of the lids and crust
formation.
Grams
Hydrarg. iod. rub o . 06 gr. i
Pot. iodid 0.30 gr. v
Aquae, q. s
Adipis lanae 30.00 5 i
Petrolati albi, q. ?. ad 300.00 5x
This ointment, Dichloramin-T (0.5 to i per cent.), may be dropped in
the eye every hour. The smarting is temporary. A 25 per cent, solution
of argyrol is useful.
The preparation of the patient is important. Except in emergency opera-
tions, for several days before operation the eyes should be protected from
anything that might cause irritation. The patient should rest his eyes.
The face and lids should be washed frequently with warm water and soap.
If there is any abnormal discharge, it should be treated with a 25 per cent.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 119
solution of argyrol or other mild antiseptic. Operation should not be done
in^the presence of an infective discharge. This should be determined by
bacteriologic examination. Disorders of the nasopharynx should be corrected ;
and for a few days before the operation the nose should be cleansed with a
nonirritating nasal wash. The preparation of the skin of the face has been
described. Before operating, the margins of the lids should again be washed
with soap and water, the conjunctival sac freely irrigated with normal salt
solution, and the lacrimal sac pressed to remove any infective material.
The canthi are then wiped with wet cotton. After the anesthetization and
the introduction of the speculum, before inserting the knife, the cornea should
again be irrigated.
The position of the patient should be such that a good light is had and an
easy attitude for the operator secured. The patient should lie in a com-
fortable position with the head resting upon a fairly hard cushion or sand
bag.
For most operations involving the interior of the eye, besides the instru-
ments, the following materials should be at hand; cocain (4 per cent.),
atropin, 0.25 Gm. (4 grains) to water, 30 c.c. (i ounce); eserin, 0.03 Gm.
(/^ Sram) to water, 30 c.c. (i ounce); saturated boric acid solution; normal
salt solution ; bichloride of mercury (i : 5000) ; sterilized gauze ; gauze bandages ;
and absorbent cotton.
The position of the surgeon, if he is right-handed, for operations on the right
eye, should Abe above the patient; for operations on the left eye, he should
stand at the side of the patient.
DISEASES OF THE EYELIDS
Congenital anomalies, such as absence of the lids, cleft eyelid, and
cryptophthalmos are to be treated by plastic operation (see Plastic Surgery,
Vol. III). Ankyloblepharon (union between the margins of the lids),
symblepharon (cohesion between the eyelid and ball), blepharophimosis
(cohesion at the outer angle), ptosis, ectropion, and entropion are all
treated the same as the acquired lesions (which see). Epicanthus (a fold of
skin passing in front of the inner canthus from the inner end of the brow to
the side of the nose), when aggravated and bilateral, is remedied by excision of
an area of skin at the middle of the root of the nose and closing the wound,
thus smoothing out the two folds.
Cellulitis of the lid should be treated by hot, antiseptic compresses until
an abscess forms. This should be opened by an incision through the skin,
parallel to the lid margin.
Sty (hordeolum), in its early stages, should be treated by hot fomenta-
tions. Ointment of yellow oxid of mercury, i part; petrolatum, 30 parts;
and lanolin, 30 parts, are of service. As soon as pus collects, a free incision
should be made into the bottom of the swelling parallel to the edge of the
lid.
Herpes zoster of the lids, associated with derangement of the cutaneous
nerve supply, tends to run an acute course and to subside in two or three
weeks. It may be treated locally by weak phenol solution. The treatment
of the diseased nerve is of greatest importance.
Blepharitis (inflammation of the margin of the eyelids) should call atten-
tion to the refraction of the eye, and any anomaly should be corrected by
glasses. The general health should be improved. If the disease persists,
a daily washing of the eyes with warm water, containing i per cent, of alcohol
is useful. For seborrhea of the lid-border or squamous blepharitis the
120 SURGICAL TREATMENT
scales should be removed with bicarbonate of soda solution (2 per cent.)
or chloral hydrate solution (5 per cent.) ; and an ointment of yellow oxid of
mercury (i part), petrolatum (30 parts), and adeps lanae hydrosus (30 parts)
applied once or twice daily. In chronic cases with ulceration, the loose
hairs should be extracted, the ulcers touched with nitrate of silver, and the
above ointment used. Boric acid ointment (10 per cent.) is also employed.
Another useful ointment is salicylic acid, i ; ointment of red oxid of mercury,
3; and ointment of rosewater, 30.
Blastomycosis of the lids is commonly associated with the same lesion
in the adjacent skin of the face (see Vol. I, page 838). The local appli-
cation of antiseptics, such as 4 per cent, silver nitrate, to destroy the fungus
is most effective. Curetting is useful in obstinate cases. Large doses of
potassium or sodium iodid internally are effective. Copper sulphate in-
ternally in doses of from 0.05 Gm. (^ grain) to o.i Gm. (i^ grains) dai'ly,
and externally a i per cent, copper sulphate wash are useful.
Tumors of the eyelid should receive the same treatment as tumors else-
where. Benign tumors should be removed if they cause irritation. Cysts
may first be punctured, and, if they return, dissected out (see Cystomata,
Vol. I, page 325).
Xanthelasma, yellowish patches of connective-tissue growth with fatty
tissue, are most successfully treated by excision as a tumor. They often
return. The high-frequency electric current is also of value. Removal by
escharotics is effective.
Chalazion (meibomian cyst) is best treated by operation (see page 138).
Blepharospasm, spasm of the orbicularis muscle, is due to irritation in
the facial nerve either direct or reflex, and, in general, demands the same
treatment as facial spasm (Vol. I, page 881). The correction of defects of
refraction should receive attention. In children it is often a form of chorea.
When the spasm is tonic, it will usually be found that some local lesion
requires attention — fissure, foreign body, or conjunctivitis. Reflex irritation
in the trifacial nerve may require relief.
Ptosis of the upper eyelid, if due to hypertrophy, requires excision of
tissue, if due to'paralysis of the oculomotor nerve or injury to the levator
muscle, it requires treatment of the causative lesion. Aggravated and in-
tractable cases are cured by operation on the lid. In congenital ptosis only
operative treatment is of service; in acquired ptosis operation should be
resorted to only after all other measures have failed (see Operations for Ptosis,
page 138).
Lagophthalmos (an inability to close the eyelids) should be treated by
remedying the cause; if this cannot be done operation is called for (see
Tarsorrhaphy, page 144).
Symblepharon, ankyloblepharon, and blepharophimosis, may be pre-
vented by treatment of the causative inflammations. For operative treat-
ment see page 142.
Entropion (turning of the lid border toward the ball), when temporary
or spasmodic may be corrected by everting the lid and painting the skin with
collodion to hold it. Adhesive plaster is used for the same purpose. When
organic, it requires operation (see page 143).
Ectropion (turning forward of the lid margin away from the ball) when
temporary or spasmodic requires treatment of 'the cause. Organic ectropion
requires plastic operation (see page 144).
Injuries of the lids are to be treated as injuries in other parts. Nice
approximation of wounds with fine sutures leaves little scar. Wounds if
possible should be made parallel to the lid margin. Edema easily develops
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 121
and subsides. The treatment of ecchymosis should be first by cold to check
bleeding, and then by hot applications and massage to hasten absorption.
For temporary cosmetic purposes, the discolored skin may be painted flesh
color.
WOUNDS OF THE EYEBALL
Foreign bodies should be removed as promptly as possible under aseptic
precautions. Mild antiseptic washing is advisable in all wounds of the eye-
ball. Boracic acid solution, iodid of mercury (1:5000), cyanid of mer-
cury (i :2ooo), or bichlorid of mercury (i :sooo) maybe used. Particles
of iron should be removed with the magnet. No eye should be con-
demned to enucleation until it has been cleansed and a careful investigation of
the extent of the injury made. The surgeon should know precisely with what
injuries he has to deal. Atropin and dionin should be used when indicated.
Wounds and operations upon the several parts of the eye are dealt with
under each separate head (see Operations on the Eye, page 138). Wounds
of the lids and conjunctiva should be sutured. Wounds of the cornea which
penetrate should be closed with the finest silk sutures. Extrusion of the
iris should be treated by replacing it and suturing the wound. If it cannot
be replaced it should be cut off. Penetrating wounds of the globe should be
treated by cleansing, removing foreign matter, and suturing. The utmost
patience and persistence should be practised in removing foreign bodies.
Many sittings may be required. Too much should not be attempted at one
time. The eye should always be given time to recover from traumatic
reaction after each operation. The patient should be kept quietly in bed.
Hot dressings are to be preferred. Enucleation is called for if a foreign body,
which would destroy sight, cannot be removed.
Enucleation of the eyeball should be done when the eye is irreparably
destroyed. An eyeball which has lost its vitreous may be saved by filling it
with salt solution and closing the wound. Even in bad wounds, if there is
a possibility of saving the eye, the surgeon may defer enucleation till the
third or fourth day. In the meantime it should be kept cleansed, and gotten
into the best possible condition. Enucleation should be done at once upon
the slightest symptom of sympathetic irritation in the other eye. Even
though the vision of the injured eye is capable of light perception, sympa-
thetic ophthalmia calls for its enucleation. If the injured eye remains painful
and subject to recurring attacks of acute inflammation, without restoration
of vision, it should be removed. It is, perhaps, unwise to enucleate when
sympathetic inflammation is in progress, if sight has not been destroyed in the
injured eye.
DISEASES OF THE CONJUNCTIVA
Hyperemia of the conjunctiva requires correction of any refractive errors
and removal of local exciting causes. Boric acid, 0.6 Gm. (10 grains), in
camphor water, 30 c.c. (i ounce) is useful. More astringent solutions may
be called for — such as alum, tannic acid, or zinc sulphate. Constitutional
disorders should be corrected.
Purulent nonspecific inflammation, requires the same treatment as
hyperemia. If a cure is not effected, the disease should be treated as
ophthalmia.
Conjunctivitis (ophthalmia) varies much in character, depending on the
cause. Causative and irritative factors should be removed. Simple con-
junctimtis, due to organisms of low virulence, should be treated by frequently
washing out the discharges with boric acid in normal salt solution and keeping
122 SURGICAL TREATMENT
the margins of the lids clean. Other preparations which are of value are:
alum, 0.25 to 0.5 Gm. (4 to 8 grains) in 30 c.c. (i ounce) of water; or sulphate
of zinc 0.06 to o.i 2 Gm. (i to 2 grains) in 30 c.c. (i ounce) of water. Either
of these may be combined in the boric acid solution, and used as eye drops.
If the infection does not subside, the everted lids should be touched with a
solution of silver nitrate (0.4 to i per cent, in strength), or protargol (5 to 20
per cent.), or argyrol (10 to 25 per cent.). Once or twice daily the lids should
be separated and one of these solutions dropped into the conjunctival sac.
If the disease does not yield to silver, irrigation with bichlorid of mercury
(i : 1 0,000) should be used.
The eyes should not be bandaged or covered with compresses of any kind.
No pressure should be made upon the lids, but the discharges should be
allowed free exit. Colored glasses may be worn for the photophobia. Small
squares of gauze, cooled by ice, laid on the lids give relief from pain during
the acute state. A useful eye-wash for simple cases is boric acid, 2 ; chlorid
of sodium. 0.3; and camphor water, 100.
In acute contagious conjunctivitis and catarrhal epidemic conjunctivitis,
silver solution should be used at once, and followed by mercury if necessary.
The other eye should be protected from infection. Strict cleanliness for
the protection of others should be observed.
Diplobacillus conjunctivitis (nongonorrheal) is best treated with zinc
solution; silver seems to be of little value.
Conjunctivitis neonatorum (ophthalmia neonatorum) should be prevented.
Women should not have gonorrhea. A child's head which has passed
through an infected birth canal, as soon as born, should be treated as follows:
the lids should be cleansed and separated and 2 drops of a i per cent,
solution of silver nitrate dropped into each conjunctival sac at the outer
canthus. In the present stage of civilization all birth canals should be re-
garded as infected unless they can be proved to be not infected.
When the disease has developed vigorous treatment must be pursued.
There is perhaps some value in hot applications made by means of small
squares of gauze wrung out in weak phenol solution at a temperature of 4Q°C.
(i2o°F.). The discharges from the eye must have free escape. The eye
should be cleansed often enough to keep it free from pus. This may be every
half hour, or it may be every three hours; but it must be kept clean. The
cornea should be spared from traumatism; and the utmost gentleness should
be used. Every hour, day and night, if necessary, the lids should be gently
separated and the discharges washed out with boric acid and salt solution.
Thick or hardened discharges should be wiped from the lids. The edges of the
lids should be anointed with vaselin, olive oil, liquid petrolatum, or boracic
ointment, to prevent their sticking together. Once a day the conjunctiva of
the lids should be exposed, cleansed and touched with a strong solution of
silver nitrate 0.6 or 1.2 Gm. (10 or 20 grains) to the 30 c.c. (i ounce). This
should be followed by irrigation with normal salt solution until the excess
of silver is washed away. In making the applications, it is well to wrap the
child in a sheet to confine its arms and legs. It should be held by the nurse,
sitting in a chair opposite the surgeon. The latter may hold the child's
head between his knees, covered with a rubber cloth. The lids should be
lifted away from the eyeball. The cornea should not be touched. A smooth
wire retractor may be used.
In milder cases argyrol (25 per cent.) or protargol (10 per cent.) may be
used. These substances should be instilled at intervals of from every
hour to every four hours. Some surgeons use argyrol solution (10 per cent.)
every half hour until suppuration ceases, and then silver nitrate (i per cent.)
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 123
once daily. Whatever method is used, once daily the palpebral conjunctiva
should be exposed, cleansed, dried, and touched directly with the stronger
solution.
In the presence of corneal ulcers the utmost gentleness should be used
in handling the eye. No pressure should be made on the ball. The appear-
ance of a corneal haze should call for i drop of a 0.5 per cent, silver nitrate
solution dropped into the eye 2 or 3 times daily.
The uninfected eye should be protected from infection by antiseptic
gauze held on with a bandage or shield.
Gonorrheal conjunctivitis, whether in young or adults, should be treated
essentially the same as conjunctivitis neonatorum. If the swelling of the
lids becomes so great that discharges do not freely escape, the outer canthus
should be divided as far outward as the bony wall of the orbit. The inci-
sion should not involve the conjunctiva. In desperate cases it may become
necessary to split the lid vertically, and repair it later. Permanganate of
potash (i : 5000 to i : 2000), used 3 or 4 times daily as a continuous stream of
irrigation has found much favor. Silver should be used as in conjunctivitis
neonatorum. Atropin should be employed upon the first appearance of cor-
neal ulceration (see Keratitis and Corneal Ulcer, page 125). To protect
the uninfected eye it should be kept covered. For this purpose a watch-
glass may be fastened in front of the eye and its edges sealed with adhe-
sive plaster reinforced with collodion.
Pseudomembranous conjunctivitis, is best treated by cleansing irrigations
and instillation of silver solution. Diphtheric conjunctivitis should receive
frequent local treatment with mild cleansing solutions; and diphtheria anti-
toxin should be used as soon as the diagnosis is made.
Phlyctenular conjunctivitis (eczema of the conjunctiva) requires mild
antiseptic collyria such as are used for simple conjunctivitis. After the acute
symptoms, yellow oxid of mercury ointment (2 per cent.) may be introduced
into the conjunctival sac. The constitutional treatment is that of eczema.
Vernal conjunctivitis should be treated by change of climate, correcting
nasal disease, and locally applying the measures used in simple conjunctivitis.
Colored glasses protect from light, and the instillation of adrenalin chlorid
solution (i : 10,000) relieves congestion. Yellow oxid of mercury ointment
(i : 60) is of service after the acute stage.
Follicular conjunctivitis, if not amenable to the treatment described for the
simple form should be treated by incision and expression of each follicle.
Granular conjunctivitis (trachoma, granular lids) is an infectious contagious
disease which unless cured results in trichiasis, entropion, contractures of the
conjunctiva, cloudiness and ulceration of the cornea, and pannus. The
treatment consists in cleansing the conjunctiva and destroying the infective
material. Care must be taken that neither the disease nor the treatment
shall produce much cicatricial tissue.
If there is much discharge, the antiseptic astringent solutions used in sim-
ple conjunctivitis should be employed. Permanganate of potash solution
i : 3000 and i : 5000 also are used. When softening and swelling of the granu-
lations are present, nitrate of silver (2 per cent, solution) should be used as in
conjunctivitis neonatorum.
In the stage of eruption of new granulations and cicatrization of the old,
a smooth crystal of sulphate of copper may be applied to all of the affected
area, especially the retrotarsal folds. The treatment is painful unless pre-
ceded by cocain. It should be followed by irrigation to wash away the
copper. This treatment should be confined to the mild cases of passive
papillary trachoma with little or no secretion.
124 SURGICAL TREATMENT
In some cases, carbon dioxid snow is efficacious. Five to twenty applica-
tions are required. A 5 per cent, ointment of copper citrate, followed by
gentle and thorough massage, is useful in papillary cases.
When the disease has been brought under control, the absorption of the
remaining granulations may be hastened by the application with a cotton
swab of boroglycerid (50 per cent.) or tannic acid in glycerin (10 per cent.).
Most of the known antiseptics and astringents have been used in this disease,
including phenol, ointment of yellow oxid of mercury, and ichthyol. Dionin
is useful if pannus or corneal disease is present — one or two drops of a 5 or
10 per cent, solution twice daily. If exacerbations appear, irritating treat-
ment must be discontinued, and simple cleansing washes used.
True trachoma tends to become chronic. The two remedies for the early
stage are silver nitrate, when there is much secretion or corneal ulcers, and
copper sulphate, when there is much hypertrophy. Silver nitrate must not
be used continuously as it stains the fornices and conjunctiva. Argyrol (25
per cent, solution) stains less.
The operative treatment has more to offer than any other measure. Of
the operations used, expression of the follicles, is the most effective (see
operations for Trachoma, page 150).
The treatment of pannus associated with trachoma depends upon its
degree. If limited, it will disappear with the trachoma; but if it is extensive
or complicated by ulceration, it should receive the treatment described for
vascular keratitis. Jequirity and jequiritol serum are recommended by many
ophthalmologists for trachoma.
Pinguecula and pterygium are treated by operation (see page 149).
Tumors of the conjunctiva should be excised. Malignant tumors, car-
cinoma and sarcoma, can rarely be removed without removal of the eyeball.
Tuberculosis of the conjunctiva should be treated the same as tuberculosis
elsewhere. Hygiene, tuberculin injections, excision, and curettage are most
effective.
Skin diseases may involve the conjunctiva, and require the same treat-
ment as when in other parts of the body.
Foreign bodies in the conjunctiva are usually easily removed with a bit
of cotton wound about the end of a splinter. If lodged far back under the
upper lid, they may not come into view when the lid is everted unless the fold
is pushed forward and the eyeball rolled downward. Cocain or other
anesthetic is of help.
Wounds of the conjunctiva should be sutured the same as wounds in other
parts. A buried suture with fine chromicized catgut is good.
Burns of the conjunctiva with lime, hot fluids, acids, etc., should be
treated by first washing out the foreign material. This may be done by
injecting water or oil with a syringe into the conjunctival sac. To prevent
adhesions the sac should be injected full of vaselin or oil.
DISEASES OF THE CORNEA
The treatment of diseases of the cornea must often be looked to to save the
eye from blindness or serious defect due to infiltration of the cornea, causing
loss of transparency, the development of vessels in the cornea, and ulceration.
Antiseptics and mild astringents are usually called for. Protection from
light by means of goggles or bandage is essential. Atropin is necessary
in many cases. Dionin, an antispasmodic analgesic drug, seems to have the
power also of promoting the local lymph flow. It is used in a i to 5 per cent,
solution, of which i or 2 drops are instilled into the eye from i to 4
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 125
times daily. At first it produces smarting and edema. These subside and
an immunity develops, after which it may be increased in strength up to 10
per cent.
Phlyctenular keratitis (eczema of the cornea), occurring usually in'chil-
dren, should be treated with irrigations with saturated boric acid solution, fol-
lowed by i or 2 drops of i per cent, solution of silver nitrate. Ointment
of the yellow oxid of mercury (i : 60) is of value. In order to make these
applications, the child's head should be held firmly and the eyelids separated.
Local anesthesia may be used for the first few applications, or a little chloro-
form given. For the photophobia, the eyes should be protected with goggles ;
and the dread of light may still further be overcome by douching the eyes
with cold water. For the blepharospasm, the ulcerated external commissure
may be touched with pure sulphate of copper. Extreme cases may require
incision of the external commissure. The constitutional treatment of this
disease is the same as that of eczema. Ulcers resulting from the disease
require their own special treatment.
Lymphatic nodular keratoconjunctivitis is a local expression of constitu-
tional disease, as it is most commonly found in persons suffering with tubercu-
losis. The nodules (phlyctenules) present a microscopic appearance very
like tuberculosis. Accordingly the treatment should be addressed to the
hygiene of the patient. The local treatment should be similar to that of
conjunctivitis. If corneal ulceration is present i per cent, atropin and colored
glasses should be used. Prolonged treatment with tuberculin is useful.
Thirty to fifty treatments are necessary. The average dose should be
about o.oooi mg.
Ulcers of the cornea must be prevented and cured because of the dangers
of opacity or perforation.
Simple ulcers may be treated by the methods given for phlyctenular
keratitis: boric acid solution and dark glasses for the photophobia; cocain
will give temporary relief from photophobia, but its continuous use does harm.
Holocain is not harmful. An application to the ulcer of nitrate of silver
solution (i per cent.) will often be sufficient to effect a cure. This is less apt to
cause a permanent stain than are the proprietary silver preparations.
Dionin (2 to 5 per cent, solution) is recommended as of value. The conjunc-
tiva should be kept cleanly irrigated. If the ulcer does not heal promptly
stimulation is secured by the use of yellow oxid of mercury ointment (i : 60).
In deep ulcers threatening involvement of the anterior chamber atropin
should be used. When perforation seems imminent the eye should be kept
clean and after each treatment covered with a dry sterile compress. Upon
the appearance of bulging of the floor of the ulcer intra-ocular tension should
be reduced by paracentesis of the cornea (see page 152). This operation
will often relieve pain, prevent perforation, and hasten the healing of the
ulcer.
In ulcers which spread in spite of treatment, more active measures must
be adopted. The ulcer may be touched with phenol followed by alcohol.
These applications should be made quickly and neatly. A fine probe with a
small amount of cotton wound about the end is used. The eyelids should be
separated so that they cannot close during the operation. The ulcer should
be touched in every part with the phenol, which should not run over on the
rest of the cornea. Following the phenol, alcohol should be applied
in the same manner; and then the eye irrigated with normal salt or boric
solution.
Other substances, such as tincture of iodin, nitrate of silver, and tri-
chloracetic acid, also are used. When sloughing tissue is present it should be
126 SURGICAL TREATMENT
curetted away and a dry antiseptic powder, such as iodoform, applied.
Some indolent ulcers are best sterilized and stimulated by the actual cautery
applied lightly just to the edges of the ulcer and to the sloughing tissue.
This is the most effective treatment for serpiginous ulcer, annular ulcer,
fascicular keratitis, furrow keratitis, and rodent ulcer. The method was
first used and described by Martinache of San Francisco, Cal. (Pacific
Med. and Surg. Jour., Nov. 18, 1873; and Ann. d'ocul., 1878, 80, 21).
In order to bring out an ulcer so that it may be seen clearly, there may be
dropped into the eye a solution containing 2 per cent, of fluorescein and 3 per
cent, of bicarbonate of soda. This stains a bright green the area which [is
denuded of epithelium; healthy epithelium is not affected, but it should be
remembered that epithelium damaged by inflammation takes the stain.
For the same purpose may be used toluidin blue (i :iooo solution).
The general health of the patient should be improved. Disorders of the
nose and mouth should be corrected. The patency and health of the
lacrimal canal should be insured.
Corneal opacity, resulting from ulceration or inflammation, is treated by
massage of the cornea. This is made with the finger tips against the closed
lids. Absorption is hastened by introducing a bit of ointment of yellow
oxide of mercury (i :6o) into the conjunctival sac. A small amount of
cocain will allay the pain. Fine vibratory massage also is used. Galvanism
and phototherapy have been used. The transplantation of cornea from
another person or animal has met with some encouragement. Iridotomy,
to form a new lateral pupil, may be done in cases of central opacity.
Corneal opacity, due to the action of lime or other caustics, may be
removed by dissolving the opaque tissue. The eye should be anesthetized,
and treated with a 4 per cent, solution of ammonium chloride, to which 0.02
to o.i per cent, of tartaric acid has been added. Applications of the chlorid
may be increased in strength up to 10 per cent., but the amount of tartaric
acid should not be increased.
Special forms of keratitis require special treatment. N euro paralytic
keratitis, from trigeminal paralysis, such as follows operations on the Gasse-
rian ganglion or its root, requires that the cornea shall be protected from the
dust of the air and that it shall be kept moist. The lids should be kept closed
and covered with a dry gauze dressing, or a protecting shield should be worn
as in gonorrheal conjunctivitis. Such eyes are more comfortable in a moist
atmosphere. Some surgeons practise stitching the lids together.
Hypopyon keratitis (keratitis with pus in the anterior chamber of the
eye) is treated by incision. A Beer's knife is held so that its back is toward
the cornea, and the point is caused to enter obliquely at the margin of the
ulcer. The knife is then passed across the middle of the ulcer to the opposite
margin. The incision should be as deep as possible without opening the
anterior chamber. The slanting position of the knife, as it is pushed
along, prevents wounding Descemet's membrane. The point of the knife is
then entered at the center of the incision and an incision made at right angles
to the first. A similar incision is made on the other side. These incisions
are carried to the margin of the ulcer thus a crucial incision is produced.
If the ulcer is large several incisions may be made to radiate from the center.
The border of the ulcer is then scraped with the edge of the knife, and the
ulcer dried with small swabs.
The ulcer should then be touched with an antiseptic solution. For this
purpose iodin, 25; potassium iodid, 50; and water, 100, are applied for five
minutes. This solution should touch, only to the ulcer, as it is capable of
seriously injuring the epithelium of the cornea. Salt solution should be
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 127
ready to wash off the eyeball at once should any of the solution flow beyond
the ulcer.
If the ulcer is very small the incisions may be omitted. If the hypopyon
is large a small puncture should be made through the center of the ulcer, and
the infected aqueous fluid evacuated. The puncture should not be large
enough to evacuate the hypopyon which serves to hold the iris and lens
away from the opening.
The patient should be kept quietly in bed. Bland mercuric ointment
should be applied as a lubricant, and atropin should be instilled to keep the
pupil open. This is the method of treatment employed by F. H. Verhoeff
(Jour. Am. Med. Assoc., June 30, 1917).
Xerotic keratitis, in which the lids do not cover the eyeball, requires
a dressing to hold the lids, or stitching together of the lids. Herpetic keratitis,
is treated the same as herpes zoster. Dionin, i or 2 drops of a 5 or 10
per cent, solution, is much in favor. A pressure bandage is of service.
Tincture of iodin is also used. In keratitis bullosa, the blebs should be punc-
tured and the constitutional disorder corrected. Vascular keratitis may
require iridectomy to form a new pupil. One of the measures which have
proved helpful is periotomy, which consists in removing a strip of conjunctiva
around the circumference of the ball just posterior to the cornea. Inter-
stitial keratitis, involving the whole thickness of the cornea and usually syphi-
litic, requires atropin and dionin, and, if indicated, antisyphilitic treatment.
Foreign bodies in the cornea and conjunctiva are usually particles of
cinder, ash, metal, or sand. In most cases the body will be found on the
cornea or the tarsal portion of the conjunctiva of the upper lid. The upper
lid should be lifted up or everted. Good light must be thrown upon the eye.
Often a magnifying lens will help to discover a small body. First the
cornea should be examined, then the upper lid, and lastly the lower lid.
When the body is discovered, its removal will be facilitated by local
anesthesia.
The cornea is anesthetized by a drop of a 4 per cent, solution of cocain,
a 4 per cent, solution of alypin, a 2 per cent, solution of holocain, or a 4
per cent, solution of novocain. But i drop of cocain solution is required.
The other solutions require a drop every two minutes, repeated 2 or' 3
times. The two lids are held apart with the thumb and forefinger of the
left hand, in the case of a body on the center of the cornea. A splinter, hair-
pin or a needle is tightly wound about one end with a small bit of cotton,
taken in the right hand, and used to lift out the foreign body. A naked
needle may in some cases be required.
The patient should be requested to keep both eyes open. The foreign
body should be dealt with very gently. The first effort to remove it should
be with the cotton swab which should be used to brush it off.
If the foreign body, such as a splinter of steel, has penetrated the cornea,
it should be removed with a magnet (page 160). Complete penetration of
foreign bodies may sometimes be prevented by passing a needle into the
chamber of the eye behind the body and thus preventing further backward
progress while its removal is attempted.
A foreign body, lodged behind the retrotarsal fold of the upper lid, is
exposed by turning up the lid as the patient looks downward; then the edge
of the everted lid is pressed against the supraorbital margin writh the left
thumb; and the lower lid is pressed upward over the cornea with the fingers
of the right hand.
If there is strong reason to believe that a foreign body is present, and
nothing can be found after systematic search with a good light and a magni-
128 SURGICAL TREATMENT
fying glass, a drop of fluorescein solution may be placed in the eye. This is
a solution of 2 per cent, fluorescein and 3 per cent, bicarbonate of soda in
water. The lids are closed and the solution allowed to remain for two
minutes. The excess of solution is then washed away with boric acid
solution. This pigment stains abrasions of the cornea. If there is an
abrasion caused by a foreign body, a small green ring will appear around it,
and make its discovery easy.
The foreign material should all be removed. Care must be taken not
to push it into the anterior chamber. If it has perforated the cornea and
lies just behind it, the foreign body should be removed by enlarging the
wound. In partial penetration it may be necessary to pass a needle behind
the body to lift it out.
No matter how small the foreign body, the eye should be washed out
every hour with a few drops of boric solution until soreness has subsided.
Following an operation with much wounding, atropin should be instilled,
and the eye protected by a bandage for a few days. If much wounding of
the cornea has occurred or the danger of infection seems considerable, the
conjunctival sac should be irrigated with bichlorid of mercury solution
(i : 1 0,000).
Wounds of the cornea are nonpenetrating or penetrating. The former
should be treated as a simple ulcer. In penetrating wounds, the eye should
be cleansed with boric acid solution, and the iris, if prolapsed, replaced by
means of a small probe. If there is much protrusion of the iris, it is usually
impossible to replace it, and it should be excised as in iridectomy. Gaping
wounds should be sutured with fine silk. Atropin should be used if the wound
is central. If the wound is toward the periphery beyond which atropin
cannot draw the iris, physostigmin or pilocarpin should be employed.
Plastic operations are done in some cases. One operation consists in suturing
a flap of conjunctiva across the cornea, and then replacing it after healing
has been secured. In severe wounds, involving the iris, ciliary body and
lens, the advisability of enucleation must be considered.
Burns of the cornea are treated the same as burns of the conjunctiva
(page 124), keratitis and ulcer.
Tumors of the cornea are treated by excision.
Hypopyon (abscess of the anterior chamber) should be treated by
paracentesis or incision (see page 152).
Staphyloma should be prevented, if possible, by preventing perforation of
the cornea. After perforati n has occurred, a compressing bandage and the
use of eserin, is of service. If the bulging continues, paracentesis of the an-
terior chamber or an iridectomy opposite the clearest part of the cornea may
be done. A staphyloma which is unsightly and incurable, or which threatens
the other eye with sympathetic ophthalmia calls for enucleation.
DISEASES OF THE SCLERA
Episcleritis is often complicated by inflammation of the cornea and uveal
tract. Hot compresses promote healing. Atropin allays pain. Dionin is
of service. If no iritis is present, in chronic cases, myotics are indicated. A
localized inflamed area may have its hyperemia artificially increased by scari-
fication or cauterization. Massage with ointment of the yellow oxid of
mercury (i : 60) is of service in chronic cases.
Scleritis and sclerokerato-iritis is treated like episcleritis. The eye
should be protected by colored glass. When the acute symptoms have
subsided subconjunctival injections of saline solution are helpful. Consti-
tutional disorders should be corrected.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 129
Staphyloma of the sclera, if due to wound, should be treated as a hernia,
the scar excised and the wound sutured, if it is accessible. If intra-ocular
tension is greater than normal, it should be reduced by iridectomy.
Wounds of the sclera are perforating or non-perforating. The former are
dangerous because of the loss of vitreous and the possibilities of infection of
the interior of the globe. The first thing is to learn if a foreign body is left
in the globe (see below). The wound should be cleansed and sutured with
fine silk or catgut. The sutures should not touch the choroid. Some sur-
geons suture only the conjunctiva. The most careful asepsis is necessary
to save the eye. The eye should be covered with a gauze dressing and the
patient kept quietly in bed. If the wound is extensive, and the sight un-
doubtedly destroyed, enucleation should at once be done to minimize the
dangers of infection and disease of the other eye.
Foreign bodies which have passed through the sclera into the eye should
be removed, although if the body is small it may remain for a long time and
cause but little trouble. Ultimately it may be expected to damage the
vision. The determination of the location of the body is most important.
The #-ray is used for this purpose in the case of substances opaque to it. If
possible the body should be grasped by delicate forceps passed through the
wound, or through a new wound made near its predetermined position.
Foreign bodies lying free in the vitreous gravitate to the bottom of the cham-
ber. Bodies of iron are best removed by the magnet (see page 160).
Infection of the interior of the eye demands drainage of the infected
chamber. If necessary irraigtion should be added to this. If efforts to save
the eye fail and infection threatens destruction of sight, enucleation or evis-
ceration of the ball is called for.
Tumors of the sclera should be removed and the wound closed with
sutures.
DISEASES OF THE IRIS
Iritis requires treatment varying with the stage and character of the dis-
ease. The cause of the disease should be ascertained and remedied.
Syphilis especially should be had in mind. For the acute inflammation
hot fomentations to the eye should be used. To prevent adhesions and
secure rest for the iris atropin should be used. Further than this, operative
treatment may be called for to meet certain special indications.
Atropin solution should be dropped in the eye every three or four hours.
Dilatation of the pupil should be continued until ciliary irritation has abated.
If atropin is not well tolerated another mydriatic may be used. Dioninjs
used in 5 to 10 per cent, solution, and is believed to be of value.
The specific iritides, such as syphilitic, gonorrheal, rheumatic, gouty, and
diabetic, require in addition their specific constitutional treatment.
In some forms of iridocyclitis with continued high tension, paracentesis
of the cornea is advisable. Mydriatics cannot be continued indefinitely,
and chronic iritis which recurs or refuses to heal may be helped by iridotomy.
Iridectomy is indicated especially in posterior circular synechise to establish
communication between the anterior and posterior chambers. Glaucoma
may thus be prevented.
Tumors of the iris are removed through an incision in the cornea, which is
closed by suture after the removal of the tumor.
Wounds of the iris require the treatment described for the structure
through which the wound is received.
Iridodialysis, a rupture of the ciliary attachment of the iris, whereby a
second pupil is established external to the torn-off iris, may be cured by the
VOL. n— 9
130 SURGICAL TREATMENT
vigorous use of atropin which may cause the iris to readhere. If the opening
is small it does little harm.
DISEASES OF THE CILIARY BODY,
Cyclitis, inflammation of the ciliary body, requires the same treatment
as iritis.
Uveitis, causing a deposit of whitish clots on the back of the cornea, is
treated in a manner similar to iritis.
Wounds of the ciliary body are best treated by suture the same as wounds
of the sclera and cornea. The asepticity of such wounds is of extreme im-
portance. The ciliary body is the source of infection from which sympathetic
ophthalmia in the other eye originates. It is a dangerous zone. Asepsis is
more important than a good mechanical result, and if it cannot be secured
enucleation should be done at once to save the other eye.
The following are rules for enucleation which have been compiled by de-
Schweinitz for application in these cases in order to prevent sympathetic
ophthalmia extending to the other eye and destroying its sight.
1. An eye with a wound so situated as to involve the ciliary region, and so extensive
as to destroy sight immediately, or to make its destruction by inflammation of the iris or
ciliary body reasonably certain.
2. An eye with a wound in this region already complicated by severe inflammation of
the iris or ciliary body, even if sight is not destroyed ; or an eye containing a foreign body
which judicious efforts have failed to extract, and in which severe iritis is present, even if
sight is not destroyed.
3. An eye, the vision of which has been destroyed by plastic iridocyclitis, or one which
has atrophied or shrunken, provided there are tenderness on pressure in the ciliary region
and attacks of recurring irritation; or without waiting for signs of irritation.
4. An eye, the sight of which has been destroyed, even though sympathetic inflammation
has begun in the other eye, in the hope of removing the source of irritation.
5. An eye in which a wound has involved the cornea, iris, or ciliary region, either with
or without injury to the lens, and in which persistent sympathetic irritation in the other eye
has occurred, or in which there have been repeated relapses of sympathetic irritation.
6. An eye, either primarily lost by injury or in a state of atrophy, associated with signs
of sympathetic irritation in the other eye.
The enucleation of an injured eye, the vision of which cannot be restored, is one of the
surest ways of preventing sympathetic ophthalmia; but if sympathetic ophthalmia is
well established, enucleation of the exciting eye must not be done if there is any vision
remaining in the latter, because it may ultimately be the more useful of the two.
DISEASES OF THE CHOROID
Choroiditis requires treatment of any specific constitutional disorder
which may be present, rest of the eye, relief of tension by atropin, and the
correction of refractive errors by proper glasses. Suppurative choroiditis
with infiltration external to the choroid should be treated by the above means
and by hot wet compresses; free incision of the sclera should be made where
pus seems confined. Panophthalmitis in these cases calls for enucleation of
the eyeball. Some surgeons believe that there is less danger of meningitis
if evisceration instead of enucleation is done.
Tumors of the choroid are usually sarcomata. They are usually primary,
and call for enucleation as soon as the diagnosis is made. Other rarer tumors
require treatment, varying with their malignancy and theirf location.
Tuberculosis of the choroid should be treated by general measures.
If the eyesight is destroyed enucleation should be done.
Injuries of the choroid require treatment similar to injuries of the sclera.
Wounds and foreign bodies should be treated the same as of the sclera.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 131
For rupture of the choroid, atropin should be used, and a pressure bandage
applied.
Glaucoma. — This disease, if not checked, goes on to blindness in acute
cases. Early operation offers the most hope. Iridectomy may be looked
to to check the disease. But before an operation can be done myotics should
be quickly instilled to give relief. As soon as the severity of the attack is
over the operation should be performed. In both acute and chronic cases,
the most valuable myotics are physostigmin (eserin) salicylate, and pilocar-
pin nitrate. Pilocarpin is best used every four hours during the day, and
physostigmin in twice the strength at night. In beginning cases 0.015 Gm.
(/4 grain) to 30 c.c. (i ounce) of water is used, and the strength gradually
increased during the first two years. Physostigmin, 0.06 to 0.25 Gm. (i to
4 grains) to 30 c.c. (i ounce) of water, or pilocarpin, 0.12 to 0.3 Gm. (2 to 5
grains) to 30 c.c. (i ounce) of water, usually relieve the acute symptoms. One
or 2 drops should be instilled in the eye every hour in acute cases, until
relief is secured. If relief is not secured within a few hours, iridectomy should
be done. Dionin is also of service. Full doses of salicylate of strontium
and a purge will help give relief.
In chronic or subacute glaucoma the myotics may be depended upon in
smaller doses (page 118) to hold the disease in check. The minimum
amount to keep the pupil contracted should be used. Pilocarpin is least
irritative, and it may be used at first in a strength of 0.015 Gm. (^ grain)
to 30 c.c. (i ounce) of water; and gradually increased until at the end of
three years it is used in a strength of 0.6 Gm. (10 grains) to the 30 c.c. (i
ounce) if necessary. The solutions should be sterile and the conjunctiva
should be irrigated frequently with boric acid solution.
Gentle massage of the eye may be practised several times daily with
advantage. But little near use of the eyes should be allowed. The general
health should be improved.
The above measures are tentative. Iridectomy is the best treatment for
acute glaucoma. It should be done early, before the periphery of the iris
has become adherent to the cornea. If done promptly the eye will be saved
in most cases. The indications for iridectomy in acute glaucoma are,
greatly increased intraocular tension; semidilated, immobile pupil; pro-
nounced deficiency of vision; much pain; shallow anterior chamber; and
edematous, anesthetic cornea. General anesthesia is best. The operation is
performed with a narrow cataract knife if the anterior chamber is shallow.
The knife should be withdrawn slowly to prevent a too rapid escape of
aqueous fluid. The excision of the iris should be carried to the periphery, and
represent about one-fifth of the circumference. It should be done cleanly,
and no bit of iris left in the angles of the wound. In chronic non-congestive
glaucoma the coloboma need not be so broad. If iridectomy fails, it may be
repeated, or a sclerotomy done. Sclerotomy is called for as preliminary to
iridectomy in great tension. The other eye should be kept under the in-
fluence of a myotic during the treatment. If it shows prodromal signs of
glaucoma, it should have the benefit of iridectomy.
The osmosis treatment of glaucoma gives temporary relief. It is based
on the principle of the transmission of fluids of different densities, or the
power of solutions of neutral salts to imbibe water from colloid fluids. From
0.3 to i c.c. (5 to 15 minims) of 4 to 5.4 per cent, solution of pure sodium
citrate is injected into the subconjunctival sac, adjacent to the eyeball.
The injection is preceded by cocain and adrenalin solution to prevent pain.
Following the injection, tension is reduced and the patient is much more
132 SURGICAL TREATMENT
comfortable. The relief lasts for a few days or several weeks (see Subcon-
junctival Injections, page 179).
The results obtained from sclerocorneal trephining are best in the non-
inflammatory type of the disease.
In chronic glaucoma, iridectomy should be done as early as possible;
but the strikingly good results are not to be expected as in the acute form.
If both eyes are affected with chronic glaucoma, the worst one should first
be operated upon even though it is blind. Malignant glaucoma calls for
myotics, posterior sclerotomy, and the administration of large doses of sali-
cylates. Excision of the superior cervical sympathetic ganglia has proved of
little use in this disease. (For other operations, see Operations for Glaucoma,
page 161.)
Reduction of intraocular tension by intravenous injections of glucose has
given remarkably good results. The normal tolerance limit of glucose intake
by the resting individual is between 0.8 and 0.9 Gm. per kilogram of body
weight per hour. When glucose considerably over this amount is injected
into a vein increased urine secretion takes place. If the amount of water
injected with the glucose is less than that excreted in the urine the tendency
is toward systemic dehydration. By using solutions of glucose which have
a strength of 35 to 55 per cent., and injecting at a rate corresponding to 3.6
to 5.4 Gm. of glucose per kilogram of body weight per hour, rapid dehydra-
tion takes place with the glycosuria. This is a refinement of the old methods
of treating glaucoma by catharsis, diuresis and sweating. The "soft eye-
ball" which is found in diabetics indicates that this treatment may be re-
versed and ocular hypotension increased by increasing the body fluids.
R. T. Woodyatt and W. D. Sansum (Jour. Biolog. Chem., 1917, 30,
155) prepared a solution of glucose with freshly distilled water, in strengths
of 36 to 54 per cent. The solution is filtered and sterilized in the autoclave.
The exact titer is determined by the polariscope. The solution is injected
into a vein. The rate of injection must depend upon the concentration of
the fluid, the nature of the case, and the amount of water which it is desired
to abstract from the body. By extending the injection over a period of two
hours, the dangers of more rapid injection are obviated. R. W. Wilder and
W. D. Sansum (Arch. Int. Med., Feb., 1917) found that a 54 per cent, solu-
tion given at a rate corresponding to 3.6 Gm. of glucose per kilogram of
body weight per hour (6.66 c.c. of a 54 per cent, solution per kilogram per
hour) has greater power of dehydration than the same amount of glucose
injected in the same time in the form of a 36 per cent, solution (10 c.c. of a
36 per cent, solution per kilogram per hour). During the administration
the ocular tension should be taken by a tonometer.
DISEASES OF THE CRYSTALLINE LENS
Cataract cannot be cured by any known drug. Operation is the only
effective treatment. Upon the first appearance of the disease refractive
errors should be corrected by glasses, the general health should be improved,
and the use of the eyes should be limited. In the early stages vision may be
improved by a weak solution of atropin, 0.015 Gm. (^ grain) to 30 c.c.
(i ounce) of water, instilled in the eye every three or four days. This
admits more light past the cataract by widening the pupil, but has no curative
effect. It is the stock in trade of the charlatan. All cataracts occurring in
persons over thirty years of age should be removed; all cataracts in persons
under fifteen should be treated by discission and allowed to dissolve. The
rule has been that cataract should be operated upon when ripe. This is
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 133
not accepted by surgeons now since the early operation in experienced
hands has proved so successful. Many oculists now declare that the most
favorable form of cataract for operation is the immature.
The results of operation are good, in old persons as well as young. About
4 per cent, of operations in the hands of skillful operators fail to give relief.
About 2 per cent, of the eyes operated upon are lost by infection. Con-
genital cataract should be operated upon about the tenth month; if de-
ferred longer permanent amblyopia may result. In all cases of binocular
disease it is best to operate upon but one eye at a time.
In partial cataract, a mydriatic will show how much improvement may
be expected from iridectomy; if worth while, it should be done opposite the
clear part of the lens. In posterior polar cataract iridectomy offers little
help; either no operation should be done, or if both eyes are involved, ripen-
ing should be hastened with a view of subsequent extraction. Zonular
cataract, if vision is greatly impaired, should be treated by iridectomy, or
by discission when mydriasis gives no improvement.
Inasmuch as extraction cannot be carried out as satisfactorily until the
degenerative process has separated the lens from its capsule, operation usually
is deferred until "ripening" is complete. Sometimes it is slow and the
patient is kept in a state of partial blindness. Artificial ripening is often
advisable. This is effected by division of the anterior capsule of the lens,
to allow the aqueous fluid to act upon it. Some surgeons combine the opera-
tion with iridectomy; others do a paracentesis of the cornea and massage the
anterior capsule to cause some irritation. Many ophthalmologists prefer
to extract an unripe cataract rather than do a ripening operation.
A monocular cataract, if extracted will not much improve the field of
vision. Extraction may be done for cosmetic reasons or to avoid overmatur-
ing. A subsequent operation for strabismus may be required (see Operations
for Cataract, page 165).
A ripe cataract usually is gray- white; it may be white or amber; rarely
it is black. A cataract is ripe when, after dilatation of the pupil, oblique
illumination of the papillary area causes no shadow of the iris to appear as
a dark semicircle on the opacity, and if illumination with the mirror of the
ophthalmoscope shows no red reflex, and if no shining sectors are visible.
Usually extraction should not be done until the cataract is ripe, but in patients
over sixty a cataract may be extracted even though not wholly matured if
the stage of swelling is not present. Operation should not be done if the
eye is otherwise not reasonably sound. This may be determined as follows:
The patient sits facing alighted candle about 2 meters away. The eye should
distinctly recognize the flame. As the vision is fixed upon this flame another
lighted candle should be moved through the field of vision. The patient
should recognize this flame as soon as the light falls upon the cornea. He
should recognize the direction in which the light moves.
Traumatic cataract is caused by injuries which by lacerating the capsule
permit the aqueous humor to reach the lens and cause complete or partial
opacity. If the cataract has become complete and the lens is swollen, it
may be removed at once. If not seen immediately after the injury, it may
be treated with hot compresses, atropin and dionin. When the acute dis-
turbance has subsided, extraction may be done. In some cases the aqueous
acting upon the lens causes cataract, and then, continuing to act, causes its
absorption and cure without operation.
Foreign bodies in the lens should be extracted if possible. Unless this is
done the condition should be treated as a cataract.
134 SURGICAL TREATMENT
Dislocation of the crystalline lens, if partial and producing little visual
defect, may require no operation. A lens dislocated into the anterior cham-
ber or under the conjunctiva should be removed. A lens dislocated into the
vitreous chamber, if causing no serious disturbance, may be left; but if it
requires removal, it may be caught with a needle or scoop, or it may be
manipulated into the anterior chamber, imprisoned by a strong miotic, and
extracted by incision of the cornea.
DISEASES OF THE VITREOUS
Pus in the vitreous is rarely sterilized by natural processes. Drainage
and sterilization by disinfectant solution may succeed. Enucleation is
usually necessary.
Opacities in the vitreous require correction of errors of refraction and
improvement of the general health. Muscae volitantes belong to this
category.
Hemorrhage into the vitreous is treated by removal of causative factors,
and rest of the eye.
Fluidity of the vitreous (synchysis) is not to be cured by any known
treatment.
Foreign Bodies in the Vitreous. — (See Foreign Bodies in the Sclera/page
129.)
DISEASES OF THE RETINA
Retinitis requires treatment depending upon its nature and cause. Pro-
tection from overuse and correction of errors of refraction are essential.
Diabetic, leukocythemic, hemorrhagic, nephritic, and syphilitic retinitis each
require attention to the constitutional disorder.
Detachment of the retina is highly amenable to treatment, provided the
surgeon applies patient and persistent methods. The most hopeful cases are
those produced by traumatism and spontaneous post-retinal hemorrhage, of
recent occurrence. Old cases rarely are cured. Spontaneous cure occurs
in many cases. When a patient first comes for treatment, non-operative
measures should be used for about a month.
Subconjunctival injections of salt solution should be given. Rest in bed
and avoidance of blood-pressure-raising conditions should be prescribed.
Coughing, sneezing, laughing, straining at stool, or anything which increases
intracranial pressure, should be avoided. The causative disease should be
treated vigorously. Tuberculin is valuable in tuberculous cases.
The simple surgical treatment consists in passing a broad needle or
narrow cataract knife, by the aid of a mirror, through the wall of the eye-
ball far enough posteriorly to tap the post-retinal sac. The retina should
not be injured. The flat instrument is rotated slightly, as it is withdrawn,
to allow some of the fluid to escape. The eye is quieted with atropin, band-
aged, and the patient kept at rest. The operation may be repeated as often
as necessary. This may be once or twice a week. The principle of osmosis
should be taken advantage of after such puncture. If i or 2 c.c. (15 to 30
minims) of salt solution are injected under the conjunctival sac, the intra-
ocular tension is lowered during its absorption. The strength of the salt
solution may be increased as high as 5 per cent.
Most satisfactory results have been secured by puncture of the sclera
beneath the detached retina to allow escape of the subretinal fluid. An
incision is made parallel with the fibers of the sclera as far back as possible,
by extreme rotation of the eyeball.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 135
If the detachment is in the lower part of the globe, the operation of bisec-
tion of the detached retina is the operation of choice. The eye is cocainized
and the field cleansed. A two-edged knife is passed through the wall of the
globe well back of the ciliary region. It passes downward and backward
through the vitreous chamber as directly as possible and punctures the
detached retina at a point opposite its entrance through the sclera. As the
knife is withdrawn it is rotated slightly to allow some of the fluid to escape.
The operation may be repeated as often as necessary, allowing sufficient
interval for recovering from the traumatic reaction. Atropin should be
used, and both eyes covered for the first twenty-four hours. After this atro-
pin should be continued and the diseased eye kept covered. The patient
should be kept in bed for at least a week and the condition examined, while
the patient is recumbent, with the ophthalmoscope. This is the method of
R. Deutschmann (Beitrage z. Augenheilk., No. 59, 1904). It may be re-
peated in a month if necessary. The operation has not found general favor.
Retinal hemorrhages require treatment of the cause of the disease.
Glioma of the retina requires enucleation with division of the optic nerve
as far back as possible.
DISEASES OF THE OPTIC NERVE
Intra-ocular edema of the optic nerve (choked disk, engorgement edema of
the papilla) is a sign of increased intracranial pressure or of obstruction to the
return of venous blood from the optic nerve. Relief of these conditions is
called for before the third stage of Gunn (decided increase of edema, increase
of elevation of the nerve head, vascular striation of the swollen tissue, striae
in the retina between the disk and the macula, and retinal hemorrhages).
If the obstruction or pressure is not relieved before these conditions have
appeared, atrophy of the nerve and blindness may be expected. Usually
within a week or ten days of the removal of the cause, the choked disk begins
to subside. The causes to be reckoned with are syphilis, secondary infection
from accessory sinus disease, sinus thrombosis, and intracranial tumors and
other pressure-producing conditions. Decompression is often the operation
called for (see Compression of the Brain, page 53).
Atrophy of the optic nerve, if not controlled by prophylactic measures,
may be treated by large doses of strychnia given hypodermatically.
Orbital optic neuritis, of irritative, toxic origin, should be treated by
removal of the cause. Any focus of infection in the body should be discov-
ered and removed. When the disease is due to tobacco, alcohol, lead, or
other poisons they must be withdrawn. Strychnin in large doses is of service.
Tumors of the optic nerve are removed by enucleation of the eyeball,
or by a resection of the temporal wall of the orbit (see Operations on the Eye,
page 164).
Wounds of the optic nerve may be approached by resection of the outer
wall of the orbit (see Operations on the Eye, page 164).
DISORDERS OF THE ORBITAL MUSCLES
Paralysis of the ocular muscles, giving rise to strabismus, is to be treated
the same as paralysis of other muscles. The correction of visual defects
due to such paralysis is accomplished in a large measure by proper glasses.
Exercises of the muscles are also practised. When all means to restore
vision have failed, tenotomy, or advancement of the paralyzed muscle, is
practised. In one-half to two-thirds of the cases of convergent squint,
136 SURGICAL TREATMENT
glasses, occlusion pads, cycloplegics, and stereoscopic exercises fail to correct
the squint, and operation is necessary (see Operations on the Eye, page 174).
DISEASES OF THE LACRIMAL APPARATUS
Inflammation of the lacrimal gland should be treated as other glandular
inflammations — hot applications to increase hyperemia, and incision through
the skin or conjunctiva when abscess is present. lodin is of value for chronic
inflammation. Fistula of the lacrimal gland opening through the skin,
should be converted into a fistula, opening through the conjunctiva.
Hypertrophy of the lacrimal gland which is chronic and uncontrolled,
and which is so great as to threaten the eyesight, should be removed by
dividing the external canthus and retracting the lid upward. The same
is the treatment of tumors of the lacrimal gland.
Prolapse of the lacrimal gland is best treated by suturing it back in
place.
Atresia of the puncta lacrimalia and canaliculi, which causes overflow
of the tears (epiphoria), may be congenital or acquired. Stricture, closing
the puncta or canaliculi, should be dilated with a silver wire made into a
probe or with a dilator. The canaliculus may require to be slit open; or if it
cannot be found, a new one should be made and kept open.
Malposition of the puncta may be forward or backward. If the puncta
are tilted slightly forward, epiphoria will be present. This may be corrected
by a plastic operation to tilt back the lid, or by enlarging the opening by
simply slitting it.
Before such operations are done the patency of the canals and nasal duct
should be ascertained by injecting some solution through the puncta to the
nose. Foreign bodies should be removed.
Dacryocystitis is usually associated with swelling and occlusion of the
canaliculi; and epiphora results. In most cases occlusion of the nasal duct
has preceded the inflammation of the lacrymal sac. The acute stage should
be treated by hot applications to the skin in the region of the sac. Any
disease of the nasal mucosa should be treated. But it is unwise to attempt
probing the duct in the presence of an acute inflammation. If the sac be-
comes distended with pus, it should be incised freely, usually below the inter-
nal palpebral ligament, cutting downward and outward. This should be
kept clean. When all inflammation has subsided, dilatation of the occluded
nasal duct should be done.
In some cases, especially in infants, in which the disease is not acute,
the canaliculi may be dilated and the contents of the sac massaged out. By
adding mild antiseptic collyria to this treatment, a cure may be effected with-
out incision of the sac.
A fistula persisting after rupture or incision of a lacrymal sac is cured
by dilatation of the nasal duct through the canaliculus.
Occlusion of the nasal duct is due usually to dense fibrous stricture,
having origin both from mucosa and periosteum. It should be treated by
dilatation or division of the canaliculus (usually of the lower suffices), and
the passage of sounds into the sac and thence into the duct. Under this
treatment with proper cleansing and irrigation, the skin opening into the
sac heals, and the duct becomes patent. The probes used should be from i
to 3 mm. in diameter.
When the dacryocystitis becomes chronic or a fistula refuses to heal,
injections of the duct with alcohol and water or silver nitrate solution (i or
2 per cent.) should be used. Removal of the lacrimal sac may be done if its
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 137
healing is not accomplished or if an operation on the eye must be done. If
epiphora persists, the next step is removal of the lacrimal gland or extirpation
of its palpebral portion. Usually this last operation is not required if the
conjunctiva is brought into a healthy condition (see Operations on the
Lacrimal Apparatus, page 177).
DISEASES OF THE ORBIT
Periostitis requires the same treatment as periostitis in other parts.
Abscess of the orbit commonly originates from disease of the ethmoid
sinuses. In such cases the orbital plate of the ethmoid should be perforated,
necrotic material removed, and a drainage tube passed into the nose. Phleg-
mon following erysipelas may require several openings. Wherever incision
is required it should be made parallel to the muscle fibers through which it
passes, and the muscles of the eyeball should be avoided. Abscess of the
orbit associated with panophthalmitis presents a difficult situation. Free
drainage should be secured by incision of the orbital abscess, and either
enucleation or free incision of the eyeball.
Tumors of the orbit should be removed if possible. Benign tumors, even
though causing no trouble, should be removed because of the danger to the
eyesight if operation is deferred until they do make trouble. Such growths
are removed by operations carried out by incision (i) through the lid, (2)
through the conjunctiva, (3) through the conjunctiva after division of the
canthus, (4) by osteoplastic exposure of the orbit, or (5) by enucleation of the
eyeball. The eyeball should be sacrificed, if necessary, to reach a malignant
tumor. The removal of some malignant growths may require enucleation
of the eyeball and removal of all the orbital contents as well. A cephalocele
should not be confounded with a cystoma.
Vascular tumors of the orbit, giving rise to pulsating exophthalmos,
vary much in character, aneurismal-varix, varicose aneurism, aneurism,
telangiectoma, angioma, etc., represent tumors which require either extir
pation or ligation of vessels. The reader is referred to the chapters which deal
with these several diseases. If sight has been destroyed, the course to be
followed is simplified; enucleation allows of free access to the orbit. If the
preservation of the eyeball is desired, approach to the disease is often dif-
ficult. It is possible to ligate all of the vessels of the orbit; and, therefore,
diagnosis of the disease and the determination of which vessels to ligate is
important. If the disease is located in the front part of the orbit, the neces-
sary ligations may usually be done without removing any more bone than
some of the orbital rim. I have successfully ligated the supraorbital
artery and vein behind and in front of a communication between them by
cutting out a section of the supraorbital ridge. The branches of the facial
communicating with the orbit are all easily approached.
Ligation of the common carotid or of the internal and external carotid
has long been a favorite method of treating these conditions. It is the
operation of choice if the lesion is inaccessible, such as rupture of the internal
carotid in the cavernous sinus. Such conditions have also been treated by
later ligation of the opposite carotid. But in diseases in which the vessels
or the tumor are accessible, the vessels near the disease should first be
attacked.
Resection of the outer wall of the orbit gives access to all the structures
in the orbit (see page 164). Ligation of the ophthalmic artery may be done
by this route. The artery enters the orbit at the outer side of the nerve,
curves still further outward, and then turns inward above the nerve. The
138 SURGICAL TREATMENT
vein accompanies it, but enters the cranium, through the sphenoidal fissure.
The terminal branches of these vessels may be ligated in the anterior part
of the orbit.
OPERATIONS ON THE EYE
Inasmuch as the eye cannot be sterilized, the best possible cleanliness
must be practised. All of the general rules for operating aseptically should
be observed. The normal conjunctiva is free from pathogenic organisms,
and if the surgeon does his part infection need not occur (see Operations,
Vol. I, page 166; Sterilization of Materials, Vol. I, page 33).
Preparation of the region of operation should consist in washing the skin
of the face, nose, forehead, and eyelids with soap and water, followed by
borosalicylic solution. This cleansing should include the ciliary margins
of the lids (see Preparation of Patient for Operation, Vol. I, page 176).
Materials should be sterilized according to rules already given. A
copious wet dressing, gauze wet with bichlorid solution, i : 5000, is the
best covering for the eye (for bandages, see Vol. III). Black silk sutures
are most easily seen for removal. Absorbable sutures should be used wher-
ever possible. Adrenalin is invaluable in operations upon the eye.
Instruments used in operations upon the eye are similar in principal to
those used in other parts of the body, but much smaller. Knives should be
delicate and sharp (Fig. 7660,).
Anesthesia is best secured by the local anesthetics, although in some
operations, such as in children, nervous persons, and for enucleation, glau-
coma, and plastic operations on the lids, general anesthesia is preferable.
Cocain is the anesthetic most used. It is employed in a 2 to 4 per cent,
solution. Still stronger solutions may be used. Dropped upon the con-
junctiva, and the eye quickly closed, it permeates to all parts of the conjunc-
tival sac, and causes anesthesia of the conjunctiva and cornea in a few min-
utes. Infiltration anesthesia is used in operations on the lids and skin. For
operations requiring full anesthesia, such as for cataract, the following
method should be used: 4 per cent, cocain solution should be instilled on the
eyeball, i or 2 drops every four minutes, for three or four instillations.
The operation may begin four minutes after the last instillation (see Local
Anesthesia, Vol. I, page 127).
Dressings for the eye should be nonirritating, and frequently changed.
To protect the eye from pressure, or to apply even pressure when desired,
an eye shield of woven wire is useful. Such a shield should be bent into a
concavoconvex form, and bound about the edge with gauze or tape. Tie-
tapes to retain it should be provided. It may be made in single form for
one eye, or double. A wire screen shield of this sort may be used (i) to retain
dressings or (2) without dressings to protect the eye from external harm
(Fig. 767) (see also Bandages of the Eye, Vol. III).
Operations upon the Eyelids. — Cysts of the eyelids are best removed
from the conjunctival side, although the operation may be done with equal
facility through the skin. The lid is grasped in a ring clamp which surrounds
the tumor (Fig. 768), or lid, a clamp may be used, and an incision made
parallel to the edge of the lid. The cyst is grasped with a fine clamp and
dissected out (see Cystoma, Vol. I, page 325).
Operations for ptosis should aim to shorten the levator muscle. It
does not suffice to remove an elliptic piece from the skin and connective
tissue. Care should be taken not to overcorrect too much the defect lest
lagophthalmos, by undue exposure of the cornea, especially during sleep, give
rise to serious keratitis. The most effective operation consists in shortening
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
139
FIG. 7660. — THE MORE COMMON INSTRUMENTS USED IN OPERATIONS ON THE EVE.
A, Spatula; B, wire loop; C, probe; D, knife-needle; E, curet; F, cataract knife; G,
cystotome; H, I, J, scissors; K, cross-bar lid forceps; L, paracentesis knife-needle; M, wire
speculum; N, fixation forceps; O, curved fixation forceps; P, keratotomy knife; (), cilia for-
ceps; R, blunt hook; 5, lid retractor; T, iris forceps; U, spoon; V, tenotomy scissors; W,
angular cystotome; X, lacrimal probes.
140
SURGICAL TREATMENT
the tarsal cartilage. An incision is made about 4 mm. from the margin of
the lid and parallel with it. The skin and orbicularis muscle are dissected
back and the whole tarsal cartilage is exposed. An elliptic piece is then
FIG. 767. — EYE SHIELD OF WIRE, BOUND WITH TAPE OR ADHESIVE PLASTER, AND PRO-
VIDED WITH TAPES FOR TYING.
cut out of the middle of the cartilage by making two transverse incisions;
the lower one is made parallel with the margin of the lid, the other is made
with its convexity upward. The center of the ellipse should be as broad as
FIG. 768. — LID CLAMP GRASPING UPPER EYELID FOR OPERATION ON CYST.
the distance which it is desired the lid should be elevated. It is customary
to carry these incisions through the conjunctiva. The tarsal cartilage is
then brought together with three or four interrupted sutures of fine chromi-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
141
cized catgut (Fig. 769), the skin wound closed, and covered with a piece of
silver foil. The tarsal "cartilage," fortunately is not cartilage and grows
together promptly. The levator muscle, being inserted in its upper border,
has its insertion thus advanced.
FIG. 769. — SIMPLE OPERATION FOR PTOSIS OF UPPER EYELID.
Showing interrupted sutures introduced in tarsal cartilage.
The occipitofrontalis muscle has some power to elevate the lid. This is
utilized in an operation devised by Panas. A curved incision, about 3 cm.
long, is made through the skin of the lid just below the upper margin of the
orbit. From this incision two vertical incisions i cm. apart are carried down-
FIG. 770. FIG. 771.
FIG. 770. — SKIN FLAP OPERATION FOR PTOSIS OF UPPER LID.
The angles ACD and BEF are dissected out and denuded of skin. The skin between
GH and AB is undermined. The flap ABED is drawn up beneath the skin and sewed to
the incision GH, and the skin margin CD sewed to CA , and EF to BF.
FIG. 771. — OPERATION FOR PTOSIS COMPLETED.
The flap ABED is drawn up beneath the skin and sewed to the incision GH, the skin margin
CD is sewed to CA, and EF to BF.
ward to a point about 3 mm. above the margin of the lid. Each of these
incisions is continued horizontally in the directions of the angles of the eye to
meet the first curved incision. Another incision, 2 cm. long, is made directly
above through the skin and muscle in the site of the eyebrow. The tissue
intervening between the first and last incisions is dissected free to make a
142
SURGICAL TREATMENT
bridge. The two outer angles of skin enclosed by the incisions on the lid are
dissected away to leave a raw surface. The flap of skin and muscle interven-
ing between these angles is dissected away from the underlying fascia and
cartilage, carried up under the bridge to the upper wound, and sutured.
The skin wounds are then closed (Figs. 770 and 771).
This operation has the disadvantage of having an epithelial surface buried
in the wound, which must either become destroyed by inflammation or cause
FIG. 772. FIG. 773.
FIG. 772. — BLEPHAROPLASTY.
Plastic operation for restoring upper eyelid or for ectropion. Flap marked out.
FIG. 773. — BLEPHAROPLASTY COMPLETED.
Flap swung down into defect on lid and wounds closed This operation may be used to
[lengthen the lid in ectropion or to restore a skin defect.
a permanent sinus. It is not a surgically correct procedure, though similar
to an operation much used by the ophthalmologists. After union has been
secured the bridge of overlying skin should be removed.
The frontalis may be brought to operate upon the lid. A skin incision,
3 cm. long, is made along the site of the brow. Through this the skin is
dissected from the orbicularis and frontalis muscles for a short distance
upward and downward on the lid. Sutures are
passed through the skin of the lid into the
wound and brought out through the skin of the
brow. When these are tied they slide upward
the skin of the upper part of the lid so that it
lies on the frontalis muscle. This is called the
operation of Hess.
Another procedure consists in making a
curved incision under the upper orbital ridge,
dissecting free the skin above and below, picking
up the levator muscle dividing it as far back as
possible, and attaching its distal stump to the
frontalis as it blends with the orbicularis muscle.
Fergus brings down a slip of the frontalis and
attaches it to the tarsal cartilage. Motais' operation takes a narrow strip
from the center of the superior rectus muscle, passes it through an opening
in the conjunctiva, and attaches it to the skin at the upper border of the
tarsal cartilage.
For restoring upper eyelid after the removal of tumors or scar tissue, a skin
FIG. 774. — CANTHOPLASTY
FOR ENLARGING PALPERAL
FISSURE.
Sutures about to be tied.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
143
flap may be turned into the denuded area from the outer side of the orbit.
This flap should be cut about twice the size of the area to be covered (Figs.
772 and 773).
Canthoplasty (blepharotomy) is done to enlarge an abnormally small
palpebral fissure. The external commissure is divided outward, preferably
with blunt-pointed scissors. The skin wound is carried slightly farther than
that of the conjunctiva. The conjunctiva and skin are then sewed together
with interrupted sutures (Fig. 774).
In extreme cases of shortening of the fissure, such as follows scar contrac-
tion, a flap of skin may be swung down from the temple and split (Fig. 775).
Tarsorrhaphy may be lateral or median. Lateral tarsorrhaphy is done to
reduce the size of an abnormally wide palpebral fissure, in congenital anoma-
lies, lagophthalmos, ectropion, and in exophthalmos. The operation is as
follows: The lids are closed, and a mark made with a scalpel or pencil at the
desired end of the fissure. With a spatula between the lids and the ball to
protect the latter the margins of the lids are denuded of epithelium. The
hair-bearing epithelium should not be removed. If it is desired to carry the
union within the outer limits of the cilia, the denudation should be made on
the conjunctival side of the cilia (Fig. 777). The denuded surfaces are then
sewed together with fine silk or horsehair.
FIG. 775. — PLASTIC OPERATION
TO ENLARGE AND RESTORE THE
PALPEBRAL FISSURE.
Wound and flap marked out.
FIG. 776. — FLAP SWUNG DOWN
AND SUTURED IN DEFECT AT ANGLE
OF EYELIDS.
Wound closed.
Median tarsorrhaphy is done to cover the cornea temporarily in exposure
keratitis, to protect the cornea in paralysis of the orbicularis muscle and after
operations on the root of the trifacial nerve. The middle of the margins of
the lids are denuded of conjunctiva, for a distance of 5 mm., just posterior
to the ciliary margins, and sewed together with silk. The edges unite and
the cornea may be inspected by turning the eye inward or outward and exam-
ining through the narrow chink on either side. When it is desired to release
the lids, they are cut apart and the wounds treated with ointment of yellow
oxid of mercury (i :6o) until they heal.
Operations for enlropion (inversion of the lid) are much to be preferred
to the removal of the offending lashes. In mild cases an incision is carried
along close to the margin of the lid, and a second incision having a greater
curve is made to connect the two ends of the first. The breadth of the in-
cluded crescent must vary with the degree of deformity. It should be at
least twice as wide as the eversion desired. This crescent of skin is removed
and the wound closed. In a still greater degree of inversion, not only the
skin but a section of orbicularis muscle also should be removed.
In the ordinary and more pronounced entropion of the upper lid, such as
144
SURGICAL TREATMENT
follows trachoma, a more effective operation must be done. An incision is
made the breadth of the lid parallel to the margin and about 3 mm. from it.
A more curved incision, corresponding with the upper margin of the tarsal
cartilage, then connects the two ends of this. The intervening crescent of
skin, measuring 3 or 4 mm. vertically, is excised. A narrow strip of the muscle
above the tarsal cartilage is excised for an extent equal to the extent of the
entropion. Sutures are passed through the skin at the lower border of the
wound, thence through the upper border of the tarsal cartilage, thence
FIG. 777. — EXTERNAL TARSORRHAPHY
FOR SHORTENING PALPEBRAL FISSURE.
Note oblique incisions.
FIG. 778. — OPERATION
FOR ENTROPION.
Suture about to be tied.
through the edge of the musculofascial wound, and out through the upper
border of the skin wound. Three or four fine silk sutures suffice (Fig. 778).
This operation shortens the skin and draws the ciliary border forward around
the lower edge of the tarsal cartilage.
In still more aggravated cases there must be added to this operation an
incision along the border of the lid on the conjunctival side of the cilia.
Through this incision the skin should be dissected free from the lower margin
FIG. 779-
FIG. 781.
FIG. 780.
FIG. 779. — OPERATION FOR ECTROPION.
FIG. 780. — THE WOUND is ENLARGED BY UNDERCUTTING THE SKIN.
FIG. 781. — THE ENLARGED WOUND is CLOSED IN THE FORM OF A Y, THUS INCREASING
THE VERTICAL MEASURE OF THE ANTERIOR SURFACE OF THE LID.
of the tarsal cartilage in order to facilitate its sliding forward. A skin graft
from some absolutely non-hairy part should be placed in this gap.
Operations for ectropion (eversion of the lid) vary with the degree of
the disease. Ectropion due to relaxation of the tissues, as in the senile form,
is cured by a V-incision or by the excision of a V-shaped piece of the
superficial tissues (Figs. 779, 780 and 781); but when due to cicatricial
contraction, or when the structures are more consolidated, a plastic operation
of greater extent is necessary. In less aggravated cases a smaller incision may
be used (Figs. 782 and 783). Shortening the lid, by cutting out a segment.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
145
rather than attempts at its inversion, is essential in cases of extreme eversion
(Figs. 784 and 785).
If there is relaxation of the tissues, eversion of the lower lid, and thicken-
ing of the everted conjunctiva, the Kuhnt-Szymanowski operation is valuable
(Fig. 786). The lid margin is incised posterior to the cilia, and the tarsus
separated from the tissues in front of it. This dissection should be made
throughout nearly the whole extent of the ectropion. A triangular piece is
then cut out of the conjunctiva and tarsal cartilage. To take up the slack
in the skin a second triangle, with the base upward, is removed at the outer
part of the lid. The wound from which the triangular piece of conjunctiva
FIG. 782. — OPERATION FOR
ECTROPION BY V-INCISION.
FIG. 783. — THE V-INCISION is
CLOSED AS A Y.
and tarsus was removed is closed by interrupted, buried sutures, of chromi-
cized catgut. The wound at the outer part and the wound on the margin of
the lid are closed with silk. It is doubtful if this operation has any advantage
over the more simple operation of Adams, which accomplishes the same things.
For ectropion of the upper lid, the same principles may be applied as are
used for the lower lid. In most cases it suffices to perform a simple V-
shaped plastic, closing the wound as an inverted Y. Or a transverse inci-
sion may be made across the lid, the skin dissected free sufficiently to allow
the correction of the ectropion, and the gap filled with skin either transplanted
from some hairless part or by means of a pedunculated flap. Such a flap may
FIG. 784. — OPERATION FOR ECTROPION
BY SHORTENING THE LID.
FIG. 785. — A SEGMENT OF THE LID is
CUT OUT AND THE WOUND CLOSED.
be taken from the skin at the nasal or temporal side of the eye (Figs. 772 and
773)-
For ectropion of the lower lid with apparent contraction of the facial
skin, a skin incision parallel with the margin of the lid may be made and the
wound permitted to gape widely. The two lids are sewed together temporarily
to correct the eversion, and into the gaping wound a piece of skin is transplanted
from some other part of the body (Figs. 787 and 788). Or the skin may be
obtained to fill the defect by swinging in a flap from the inner side of the
nose (Figs. 789 and 790).
Extreme cases due to contracture of facial skin may be treated by remov-
VOL. II— 10
146
SURGICAL TREATMENT
ing the skin below the lid in the form of a triangle and covering the defect
with a flap from the outer side according to the method of Dieffenbach (Figs.
791 and 792).
FIG. 786. — THE KUHNT-SZYMANOWSKI OPERATION FOR SENILE ECTROPION.
At the triangle A , conjunctiva and tarsal cartilage are removed. At B, skin is removed.
The flap of skin C is dissected free to allow the skin to be drawn outward to close the tri-
angle B. The wound A is closed by interrupted sutures.
FIG. 787. FIG. 788.
FIG. 787. — SKIN FLAP GRAFTING FOR ECTROPION.
Incision below margin of lid.
FIG. 788. — WOUND HAS BEEN SPREAD APART BY UNDERCUTTING THE SKIN, THE LOWER
MARGIN OF THE LID HAS BEEN ELEVATED, AND THE WOUND HAS BEEN FILLED WITH A
GRAFT OF TRANSPLANTED SKIN.
FIG. 789. FIG. 790.
FIG. 789. — PLASTIC SKIN FLAP OPERATION FOR ECTROPION.
FIG. 790. — OPERATION FOR ECTROPION COMPLETED.
The incision below the eye has been widened by undercutting the skin and the flap has
been sewed in the wound lengthening the anterior surface of the lid. The space from which
the flap was cut has been closed by sutures.
The tarsal cartilage may be shortened at its outer extremity instead of
removing a section from its middle. In this operation, as practised by A.
E. Davis, canthotomy is carried as far as the orbital margin. The periosteum
is exposed. The edge of the lid at its outer extremity is cut away. The outer
part of the tarsal cartilage is denuded and a piece somewhat smaller than
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
147
the wound in the lid is removed. If there is much redundance of skin a
triangular piece should be removed. The tarsal cartilage is then sewed to
the periosteum at the outer margin of the orbit by one or two chromic catgut
sutures, which should hold it slightly under the overlapping upper lid in the
FIG. 791. FIG. 792.
FIG. 791. — CLOSURE OF DEFECT, AFTER REMOVAL OF DISEASED SKIN, BY EXTERNAL
SLIDING FLAP.
FIG. 792. — THE FLAP HAS BEEN SWUNG ACROSS AND SEWED IN THE DENUDED AREA
BELOW THE EYELID. THE AREA FROM WHICH THE FLAP WAS TAKEN MAY BE COVERED
BY A SKIN GRAFT.
case of operation on the lower lid, and just behind the margin of the lower lid
in case of operation on the upper lid. Before applying the sutures the tarsus
should be placed in this position to see whether enough has been removed.
The wounds are then closed with fine silk sutures (Figs. 793 and 794).
FIG. 793. FIG. 794.
FIG. 793. — OPERATION FOR ECTROPION BY REMOVING OUTER PART OF TARSAL CARTILAGE.
The triangular piece of tarsal cartilage has been removed, and the fixation suture
inserted.
FIG. 794. — COMPLETED OPERATION FOR ECTROPION.
The wound has been closed by interrupted silk sutures.
Blepharoplasty for resection of the lid is best done after the method devised
by C. Gibson (Annals of Surg., 1914, vol. 59). Such operations are done for
epithelioma of the lid, and are best adapted to cases in which the outer part
of the lid is involved. The aim of this as of all operations is to secure a
148
SURGICAL TREATMENT
restoration of the lid with epithelium on both sides. A two-stage operation
is_done. The first operation may be done with local anesthesia. An incision
is made through the skin, from the outer canthus outward and slightly
upward as far as necessary. The length of this incision must depend upon
FIG. 795. — BLEPHAROPLASTY FOR
RESECTION OF LID. FIRST STEP.
A skin graft is placed in a pocket
made by undermining the skin ex-
ternal to the lower lid.
FIG. 796. — BLEPHAROPLASTY.
SECOND STEP.
The lid has been resected.
FIG. 797. — BLEPHAROPLASTY.
THIRD STEP.
The flap having skin on either side is
liberated and drawn into the defect.
FIG. 798. — BLEPHAROPLASTY.
FOURTH STEP.
Flap sewed in place and wound
closed.
b
FIG. 799. FIG. 800.
FIG. 799. — RESTORATION OF LOWER EYELID BY SLIDING FLAP.
A, The diseased tissue is removed with the triangle abc. The area cde is denuded; the
_ adjacent skin is undermined; the line cb is sutured to ab; and the line de is sutured to dc.
FIG. 800. — RESULT AFTER CLOSING WOUNDS OF SLIDING FLAP OPERATION.
the location and size of the segment of lid to be removed. The skin below
this incision is undermined, and into the pocket thus formed a skin-graft is
placed with the epithelial surface looking backward (Fig. 795). The graft
should be large enough to cover the raw edge of the flap. The graft and the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
149
prospective flap should be calculated for just the size desired, as no shrinking
will take place. The flap should not be made too large. The wound is
dressed, and after about ten days the second operation may be done (Fig. 796).
The diseased part of the lid is excised by a quadrilateral resection.
The outer edge of the wound should just touch the inner edge of the graft.
An incision is then made along the lower side of the graft, and the quadri-
lateral flap freed (Fig. 797). This flap with skin on either side is drawn
inward and sutured into the defect (Fig. 798).
When pathologic tissue is present in the eyelids, which requires to be
removed, whether it is new growth, scar tissue, or ulcer, the operation becomes
FIG. 801. FIG. 802.
FIG. 80 1. — OPERATION FOR PTERYGIUM
FIG. 802. — A DIAMOND-SHAPED PIECE HAS BEEN EXCISED AND THE WOUND CLOSED.
a plastic operation to close a defect. Such tissue may be removed by a
triangular incision, and the defect covered by a sliding flap. Any remaining
gap may be covered by skin grafts (Figs. 799 and 800). Defects at the angles
of the lids may be covered by pedunculated flaps (Fig. 775).
The skin about the eyes slides easily, lending itself to these operations.
Many of these procedures are known by the names of individual surgeons,
but they embrace only the simple general principles of plastic operations
(see Plastic Surgery, Vol. III).
Operations on the Conjunctiva.- — Operations for plerygium are called for
when the growth is advancing to the cornea or when it is unsightly. Errors
FIG. 803. FIG. 804.
FIG. 803. — OPERATION FOR PTERYGIUM, IN CASES IN WHICH THE GROWTH is TOO
LARGE TO BE REMOVED.
A diamond-shaped piece is removed.
FIG. 804. — THE SMALL WOUND is CLOSED WITH INTERRUPTED SUTURES.
of refraction should first be corrected. If the growth is not too broad, it is
seized with delicate forceps near its apex, and dissected from the cornea with
a slightly bent iridectomy knife. Its attachments to the sclera are then
divided for a distance of 3 or 4 mm. from the cornea. Then the growth is
divided with scissors at its base in such a way as to leave a V-shaped
notch. The surgeon should not be ambitious to follow the growth too far
internally. The edges of the wound in the sclera are then slightly undermined
with the point of the scissors, and the notch in the base of the pterygium and the
scleral wound sewed with fine silk (Figs. 801 and 802).
150 SURGICAL TREATMENT
When the growth is too broad for this operation, the pterygium may be
dissected up and reflected, the subepithelial tissue cut away from its posterior
surface with fine curved scissors, its end cut off by taking out a smaller dia-
mond-shaped piece, and the superficial layer sutured back to the sclera
(Figs. 803 and 804).
The operation of Knapp dissects up the growth, splits it from tip to base,
cuts off the two ends, and sutures the stumps each in its respective con-
junctival wound. The operation of Desmarres dissects up the pterygium,
makes an incision in the conjunctiva along its lower border, makes a pocket
in the subconjunctival tissue, and tucks the end of the growth in it.
Operations for symblepharon (adhesion of the eyelid to the eyeball) should
not be done until all inflammation has subsided. In some cases the adhesions
may be divided and each wound in the conjunctiva of the lid and on the eye-
ball sutured. In order to prevent the reformation of adhesions, the prin-
ciples laid down in the discission of serous surfaces may be applied (see Vol. I,
pages 756 and 816). Keeping the conjunctival sac weU flooded with vaseh'n
is, perhaps, as effective as any method.
If the raw surfaces are too large to be sutured, flaps of conjunctiva from
the adjacent parts must be used. Teale's operation removes the adhesions,
turns down two flaps of conjunctiva from the eyeball, sutures one in each
FIG. 805. FIG. 806. FIG. 807.
FIG. 805. — OPERATION FOR SYMBLEPHARON.
The adherent lid is detached at a.
FIG. 806. — THE DENUDED AREA (b) is COVERED BY Two CONJUNCTIVAL FLAPS CUT
FROM C AND d.
FIG. 807. — THE FLAPS ARE TURNED DOWN AND SUTURED IN PLACE, ONE (d) ON THE
EYEBALL AND THE OTHER (c) ON THE BACK SIDE OF THE LID.
The wounds are closed.
defect and closes the gaps from which the flaps were taken (Figs. 805, 806
and 807). Flaps may also be taken from the lid. Grafts of conjunctiva
from the human or from rabbits' conjunctiva may be transplanted or skin
grafts may be used. To immobilize the eyelid after the operation a lead
disk should be fixed to its skin surface.
Operations for trachoma are often the most effective treatment. Opera-
tion is done only in the chronic cases, follicular trachoma and trachoma with
hyaline infiltration. The cutting and traumatizing operations are not called
for in the acute stage. There are many operative procedures: scarification
of the conjunctiva; removal of the granulations with a curet or stiff brush,
and then rubbing the wound with antiseptic; abscission of the granulations;
excision of a strip of the diseased conjunctiva; extirpation of a strip of con-
junctiva from the fornix; squeezing out the trachoma follicles.
The operation of Knapp for expression of the follicles is the most effective.
The patient is given a general anesthetic, the lid everted, and as it is folded
back it is seized at its conjunctival surface and lifted away from the eye.
If there is much infiltration, the tissue should be scarified. The roller tra-
choma forceps then seize the lid, the blades being pushed well back, the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
151
forceps are strongly compressed, and drawn forward (Fig. 808). This is
repeated until all of the follicular contents have been expressed. No area
should be neglected. On the following day the lids should be everted, the
seronbrmous deposit removed, and the surface touched with a solution of
silver nitrate (2 or 4 per cent.). This cleansing of the surface should be done
daily, and the silver solution applied until the swelling has gone. This
method of treatment is quite invariably successful.
The operation of gratlage is carried out by making multiple scarifica-
tions parallel to the border of the lid, and rubbing the surface with a stiff
brush, such as a toothbrush, wet with antiseptic solution. Bichlorid of
mercury, i : 2000, is used. The after-treatment consists in the daily applica-
tion of the same solution until the traumatic reaction has subsided. This is
usually in a week or ten days, after which the milder treatments are employed.
The reaction following this operation is much greater than after expression.
Some surgeons prefer the operation of excision of a strip of the affected
conjunctiva or of the fornix, and closing the wound with sutures.
PIG. 808. — THE OPERATION OF EXPRESSION FOR TRACHOMA.
Expression of the follicles is indicated in cases of distended follicles of the
conjunctiva and retrotarsal folds. This operation alone does not cure the
disease; it makes the application of antiseptics more effective. The old cases
with scar tissue require something more. In the cicatricial stage in ad-
vanced cases, removal of the tarsal cartilage, its underlying conjunctiva,
and the retrotarsal fold is indicated. The upper lid should be everted and
an incision made transversely along the angle of junction of the palpebral
and ocular conjunctiva. The cut conjunctiva is slightly undermined. A
second incision connecting the two ends of the first, is carried along parallel
to the margin of the lid. This incision should be 2.5 mm. from the margin
and should pass through conjunctiva and cartilage. A thin strip of cartilage
is left. The diseased conjunctiva is dissected away. The two edges of con-
junctiva are united by three or four sutures. The same operation is done
in the lower lid when necessary
Subconjunctival injections are employed for many conditions, especially
in inflammations of the uveal tract, inflammations of the sclera, and in some
152 SURGICAL TREATMENT
forms of keratitis. Solutions of bichlorid of mercury (i 14000), physiologic
salt solution, sea water, serum, etc., are used.
Operations on the Cornea.- — Drainage of the anterior chamber is done
through the cornea. Paracentesis is employed for temporarily reducing
intraocular tension in iritis or uveitis, in corneal ulcers which threaten to
perforate, in glaucoma, if an iridectomy or sclerotomy cannot at once be
done, and for the purpose of drainage of the anterior chamber when it con-
tains pus or blood. The anterior chamber is tapped by means of a narrow
knife or a paracentesis needle. The eyeball should be steadied with a spring
speculum or with eye forceps. The instrument should be entered near the
lower border of the cornea and passed upward and backward at an angle of
45 degrees. The contents of the chamber should not be allowed to escape
rapidly lest the iris be damaged or a blood-vessel ruptured.
For hypopyon, or keratitis with infiltration of the cornea with pus, the
cornea may be incised across its whole diameter. Such a keratotomy drains
the cornea and anterior chamber and allows syringing it clean, and the re-
moval of the hypopyon. Its disadvantage is that the iris is apt to prolapse
through the wound.
Operations for staphyloma become necessary if preventive measures have
failed. A small staphyloma may be excised by an elliptic incision, and the
corneal wound sewed with fine silk. If the wound is too broad to be sewed,
the eyelid may be covered with a compress and a compressing bandage.
Compression should be continued until healing is complete. In some
staphylomas there remains enough clear cornea to make it worth while to
form a pupil behind it by means of iridectomy.
Complete staphylomas were formerly treated by excision, removal of the
lens, and sewing the sclera across the wound. The method of DeWecker
consists in detaching the conjunctiva from the margin of the cornea and
dissecting it free nearly to the equator of the eyeball. Four or five sutures are
then passed through the edges of the cornea and arranged ready for tying.
The staphyloma is then transfixed with a knife and divided outward, the
flap thus formed is seized and with curved scissors the amputation com-
pleted. The lens should be removed. The sutures are then tied, drawing
the conjunctiva over the wound. Knapp passes the sutures through the
episclera or sclera. No suture should involve the uvea. Panas amputated
the cornea, removed the lens and iris, and sutured the wound. These opera-
tions give a good stump upon which to rest a prosthesis. The closeness of
the uveal tract to the area of operation adds the danger of sympathetic
ophthalmia, upon the appearance of which enucleation is called for (see
Sympathetic Ophthalmia, page 130). If this condition already exists these
operations for staphyloma are contraindicated, and enucleation or one of its
substitutes should be done.
Tattooing the cornea is practised to conceal the white deposit of a dense
leukoma. A paste is made of India ink and water. The cornea is anesthe-
tized, the eyeball steadied with the fingers, a drop of the paste placed on the
leukoma, and pricked into the tissue with tattooing needles. For this pur-
pose a small bunch of fine needles may be mounted on a cork. Occasionally
the cornea should be irrigated clean in order to observe the progress of the
operation. The tattooing should be continued until the white area is all
blackened. It has been suggested to use various colored inks to match the
colors of the underlying iris.
F. H. Verhoeff (Jour. Am. Med. Assoc., Oct. 27, 1917) showed that the
same result can be secured with less traumatism by injecting the ink with a
hypodermic syringe.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 153
F. Allport (Jour. Am. Med. Assoc., Nov. 10, 1917) described a still more
simple method. He scraped off the epithelium of the cornea with a knife
where he desired the stain. A thick emulsion of India ink is then rubbed
into this area. The operation may have to be repeated.
The method of Froehlich consists in cutting a flap of outer layer of
cornea the size and shape of the pupil desired. This flap is turned back and
the underlying wound treated with an aseptic emulsion of India ink. The
flap is then replaced. This gives a covering for the dye.
Operations for conical cornea (keratoconus) are called for in aggravated
cases not controlled by glasses, eserin, artificial irides, or compression band-
ages. Two operations have value: (i) cauterizing the apex of the cone with
a cautery at a dull red heat, and depending upon the contracting scar to
remedy the defect; and (2) excising a portion of the cone and closing the
wound with fine sutures. After either of these operations paracentesis of the
anterior chamber is of service to reduce tension. A central opacity resulting
from the cauterization requires iridectomy to form a new pupil.
The most satisfactory operation is the following: An elliptic section of
the cornea is excised from near the periphery. This should include nearly
the entire thickness of the cornea. Descemet's membrane should not be
punctured. The edges of the elliptic wound should then be brought together
with sutures. This operation has the advantages that it produces a linear
scar and the lessened risk in avoiding prolapse of the iris.
The sutures are apt to cut. To prevent this M. Wiener used strips of
gold 0.005 mm- thick and i mm. wide with holes i mm. apart and just big
enough to permit the passage of a fine needle. Such a strip is placed on
either side of the wound and the sutures tied on the metal.
Transplantation of the cornea is successfully done for the treatment of
leukoma or other corneal opacity. The operation fails when cornea of one
animal is transplanted to a different species. The human cornea may be
transplanted in man with success. The cornea for transplantation may be
secured from the eyes of stillborn infants, from the eyes of persons in whom
enucleation has been done for some condition which has not affected the
cornea, or from the cornea of a person suddenly deceased. The excised globe
should be cleansed in several washings of the following solution: distilled
water, i liter; sodium chlorid, 9 or 10 Gm.; calcium chlorid, 0.20 Gm.;
potassium chlorid, o.io or 0.20 Gm.; sodium bicarbonate, o.io or 0.20 Gm.;
glucose, i Gm. (Locke). After washing ten times in this solution at body
temperature, the globe should be preserved in hemolyzed blood-serum, from
a person who is negative to the reaction for syphilis. The tube should be
sealed and placed in an ice box at a constant temperature of 5°C. An eye
may thus be preserved with the cornea useful for at least a week.
The center of the diseased cornea should be removed as far back as the
membrane of Descemet which lines the anterior chamber of the eye. All ooz-
ing should be controlled by adrenalin. The resection should be done evenly
and preferably in the form of a rectangle with rounded corners or a circle.
The same-shaped piece should be resected from the preserved eye. Slight
contraction of the latter should be allowed for. It should, therefore, be cut
slightly larger than the wound into which it is to be placed. It is only neces-
sary that the graft should be large enough to occupy the center of the cornea.
If it is 4 or 8 mm. in diameter it is adequate to admit light for vision. In so
small a graft the size of the graft should be about the size of the defect
made for its reception. The graft should not include the membrane of
Descemet but should have the same thickness as the segment removed.f rom the
diseased eye. It should be pressed gently into place, where it will remain
154
SURGICAL TREATMENT
without suture, if the incisions have been made at a right angle to the surface.
Both eyes should be bandaged shut. On the third day the dressing may
be removed and the eye inspected.
Grafting with thin grafts of cornea, shaved off with a razor as in skin-
grafting, have been successfully used. These grafts are sewed directly to the
cornea and covered by a conjunctival flap. Failures of autoplastic and
homoplastic grafting are due to defects of technic, sepsis, and opening of
the anterior chamber.
Operations on the Iris. — Iridectomy is done to admit more light, to relieve
intraocular tension especially in glaucoma, to relieve congestion of the uveal
tract, as a preliminary to extraction of the lens, and for foreign bodies and
tumors. The instruments required are a speculum, fixation forceps, bent
keratome, narrow knife, iris forceps, iris scissors, probe-pointed scissors,
probe, and spatula. (For the Preparation of the Patient, see page 138.)
The speculum is inserted, and the conjunctiva and subconjunctiva firmly
grasped with fixation forceps at a point opposite to that where the intended
incision is to be made. A narrow straight knife is entered at the corneo-
scleral junction from 2 to 4 mm. below the level of the summit of the cornea.
FIG. 809. — INCISION OF CORNEA WITH
KERATOME FOR IRIDECTOMY.
FIG. 810. — IRIDECTOMY.
Removal of segment of iris.
The point of the knife is passed through the cornea into the anterior chamber
in front of the iris, and thence out through the cornea on the opposite side
(Figs. 452 and 456). Then with a cutting motion, not dragging, the blade is
passed upward, keeping in the same plane, cutting a flap representing about
a "fifth to a third of the cornea (see Operations for Cataract, page 165).
Most ophthalmologists prefer to use the keratome for this incision. When
this instrument is used, the point is applied opposite the apparent corneo-
scleral margin. With the long axis of the knife at right angles to the cornea
the point is passed into the anterior chamber. As soon as the cornea is
penetrated, the handle of the knife is tilted backward and the point pressed
onward through the cornea. As the blade advances it should be kept in a
plane anterior and parallel to the iris. When an opening equal to about a
sixth to a fourth of the circumference of the cornea has been made, the instru-
ment should be slowly withdrawn (Fig. 809).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
155
Whether the knife or keratome is used the greatest care should be taken
not to wound the iris or the anterior capsule of the lens. If the anterior
chamber is shallow, the operation with the knife is the safer. After the
incision of the cornea has been made, the curved iris forceps are introduced,
and made to grasp the pupillary margin of the iris adjacent to the wound.
The iris is withdrawn through the wound and the part exposed snipped off
with fine scissors (Fig. 810). With a smooth probe and spatula, the stump of
the iris is pushed back and smoothed out so that none remains in the corneal
wound. No ragged iris tissue should be left. Blood collecting in the cham-
ber from the wounded iris may be gently expressed after separating the wound
edges, provided the pressure is not long-continued. Usually it is advisable
to instill a drop of atropin solution. The parts should be left smoothly
adjusted.
The best dressing consists of an oval piece of soft lint wet with i : 5000
bichlorid of mercury solution placed on each closed lid. Over this is placed
a mass of absorbent cotton large enough to come flush with the brow. This is
held in place by adhesive strips. Over all may be placed an ocular mask
to give additional protection from traumatism. It is best to keep both eyes
closed and covered for the first two days. After this, in the case of simple
iridectomy no further dressing is necessary, and the bandages may be removed
PIG. 811. FIG. 812. FIG. 813. FIG. 814.
FIGS. 811, 812, 813, AND 814. — FORMS OF IRIDECTOMY AND IRIDOTOMY.
Fig. 811. — Narrow iridectomy done for optical purposes. Fig. 812. — Small iridectomy
preserving ciliary body. Fig. 813. — Broad peripheral iridectomy for glaucoma. Fig. 814. —
V-shaped iridectomy.
and the patient caused to wear dark glasses. Usually these wounds heal
promptly.
If the iridectomy is done for optical purposes, the knife should be entered
at the apparent corneoscleral juncture; if the operation is for the relief of
intraocular tension, the knife should be entered about 2 mm. posterior
to this, thus beginning the incision in the sclera, in order to make an opening
which will permit reaching the periphery of the iris. An artificial pupil,
made because of a central opacity, should be in the inner or inner and lower
segment of the iris. Otherwise the iridectomy should be done away from
the opacity. If it is performed for adhesions of the iris, the artificial pupil
should be made through the non-adherent part. For glaucoma, a coloboma
with a broad peripheral base is made. For optic purposes, the opening
need not be so broad (Figs. 811, 812, 813 and 814).
The operation of iritoectomy is done through an incision about 5 mm. long,
made at the corneoscleral border. Through this, the knife divides the
periphery of the iris for about 2 mm. The fine iris scissors are inserted and
the other two sides of the triangle cut, having its apex at the center. This
piece is then picked out with forceps.
Iridotomy is preferred by some surgeons for optical purposes. The iris
is drawn out through a small incision and with the scissors cut in a radial
direction. It is then replaced and the natural retraction of its circular
muscles produces a gap. The operation is usually done in cases in which the
156
SURGICAL TREATMENT
lens is absent and the iris adherent. In some such cases, it suffices to insert a
needle-knife and make a radial rent in the iris.
The V-shaped iridotomy of Ziegler is done with a needle-knife, in cases in
which the iris is adherent as a diaphragm and the lens absent. The knife is
entered at the summit of the corneoscleral border. The point is pushed on
across the anterior chamber to within 3 mm. of the periphery of the iris, and
3 mm. to one side of a vertical line dropped from the point of entrance.
The blade is then caused to perforate the iris membrane and divide it up to
just beneath the corneal puncture. The blade is then withdrawn from the
gaping rent in the iris and swung to the other side of the anterior chamber
and a similar cut made about 4 mm. on the other side of the vertical plane.
FIG. 815. FIG. 816. FIG. 817.
FIGS. 815, 816, AND 817. — STEPS IN THE PERFORMANCE OF V-SHAPED IRIDOTOMY.
Fig. 815. — First incision. Fig. 816. — Second incision. Fig. 817. — Result after the two
incisions have been made.
This incision through the iris membrane should be carried upward to meet
the first incision just below its upper end. This makes a V-shaped flap
with the apex upward. If the flap does not drop back it may be pressed
back with the knife and the latter withdrawn (Figs. 815, 816 and 817).
Division of anterior synechia (adhesions of iris to cornea) is made by
inserting a needle-knife at the most convenient place in the periphery of the
cornea, and then by careful dissection dividing the adhesions. The point
of entrance should be far enough away from the site of operation to give a
sweeping motion as the blade lies across the anterior chamber. W. Lang
used a blunt-pointed knife to divide the synechia, after puncturing the cornea
with a sharp point.
Operations on the Sclera. — Anterior sclerotomy is employed to reduce
intraocular tension if iridectomy has failed. It is practised in congenital
glaucoma, and to relieve the pain-
ful tension in old, blind, glauco-
matous eyes. It may be repeated
as often as is desired. A narrow
sclerotomy knife is caused to make
a puncture through the sclera i
mm. from the cornea. The knife
passes into the anterior chamber
in front of the iris, and emerges
through the sclera on the opposite
side at a corresponding plane. The knife is then made to cut toward the
periphery, either upward or downward, as though it were intended to form
a flap 2 to 2.5 mm. in height. The cutting of the flap is not completed, but
the knife is withdrawn, leaving a bridge holding it to the sclera. The opera-
tion should be preceded and followed by the use of a myotic to prevent pro-
lapse of the iris. If the iris protrudes through the wound it should be re-
placed by means of a spatula; if it cannot be replaced the operation should
become an iridectomy (Fig. 818).
FIG. 818. — ANTERIOR SCLEROTOMY.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
157
Internal sclerotomy consists in incision into the anterior chamber, as in
anterior sclerotomy, and incision of the arches of the pectinate ligament.
Posterior sclerotomy is employed in glaucoma in which iridectomy is not
applicable and in detachment of the retina. A thin knife is inserted between
the external and inferior rectus muscles, 8 mm. from the cornea, and passed
toward the center of the eyeball to a depth of about 5 mm. into the vitreous.
The knife is then withdrawn, at the same time making a quarter of a rotation
upon its long axis. This makes a small triangular wound through which
filtration takes place. This operation may be repeated as often as is required.
It reduces the tension preliminary to iridectomy, and is of value especially
in hemorrhagic glaucoma.
Combined iridectomy and sclerotomy is begun the same as anterior sclerot-
omy. The anterior chamber is entered by a puncture i mm. external to the
limbus of the cornea, the knife emerging at the opposite side. It is then
carried upward to the iridocorneal angle, and after the sclera is divided, the
edge of the blade is directed backward and upward so as to bevel the sclera
FIG. 819. FIG. 820.
COMBINED SCLEROTOMY AND IRIDECTOMY.
Fig. 819. — Incision of sclera. Fig. 820. — Iridectomy.
and pass beneath the conjunctiva, making a good-sized conjunctival flap.
This flap is then turned forward, and with a pair of fine curved scissors a
piece of the sclera is cut from the anterior lip of the wound (Figs. 819 and
820). Iridectomy is then done through the wound, and the conjunctival
flap replaced. It is claimed by Lagrange, the author of this operation, that
a communication is established between the chamber of the eye, the peri-
choroidal space, and the subconjunctival connective tissue, thus relieving
the tension in glaucoma.
Cyclodialysis is aimed to form an artificial communication between the
anterior chamber and the suprachoroidal space. It has not yet been deter-
mined how long this communication lasts. Under local anesthesia a con-
junctival flap is reflected, preferably from, the lower outer quadrant of the
eyeball. The flap of conjunctiva is reflected and held back with the retractor.
An opening 2 or 3 mm. long, is made into the sclera parallel to the corneal
margin and about 5 or 7 mm. to the outer and lower side of it. The uvea
should not be injured. A spatula is inserted, separating the ciliary body
from the sclera, and carefully pushed on through the ligamentum pectinatum
into the anterior chamber (Fig. 821). A quadrant of the periphery of the
iris is detached. Through this opening an iridectomy is done. This is the
operation of Heine, and has been reported upon favorably in secondary
glaucoma and in intractable advanced glaucoma (see page 161).
Operations on the Globe. — Enudeation of the eyeball is done for: (i)
malignant growths of the eyeball or orbit which cannot otherwise be removed;
158
SURGICAL TREATMENT
(2) extensive injury, disorganizing the eye; (3) irremovable foreign bodies,
associated with infection; (4) panophthalmitis; (5) painful, unsightly, and
inflamed staphyloma; (6) sympathetic irritation from such lesions as irido-
choroiditis, staphyloma, etc.; (7) eyes which have become blind from glau-
coma, iridochoroiditis, tuberculosis, etc.; (8) blind eyes, with traumatic
iridocyclitis, giving rise to sympathetic ophthalmia, or blind eyes in which
there is much pain. The following instruments are used; speculum, fixation
forceps, strabismus hook, curved scissors, and mouse-tooth forceps. General
anesthesia is to be preferred, although the operation may be done with local
anesthesia. After separating the lids, the conjunctiva and fascia are divided
with scissors around the whole circumference as close to the cornea as possible.
The tissues are pressed backward until the insertions of the recti muscles
are exposed. A strabismus hook is passed under each rectus muscle, begin-
ning with the superior rectus, and the tendon divided close to the sclera. By
inserting the speculum more deeply, so as to retract the divided tissues, the
eyeball is made to move forward, the curved scissors are passed to the rear
and divide the optic nerve and its accompanying structures close to the eye-
FIG. 821. — CYCLODIALYSIS FOR GLAUCOMA.
The incision has been made, and the spatula, held parallel with the surface of the sclera
and ciliary body, is passed into the anterior chamber.
ball. The ball then rotates forward, and the oblique muscles and remaining
structures are divided. The capsule of Tenon should not be injured if the
scissors are always kept close to the eyeball. The hemorrhage is usually in-
considerable. If necessary, it c£n be checked by pressure.
Some surgeons perform a rapid enucleation by seizing a rectus tendon
and adjacent conjunctiva with forceps and dividing them simultaneously.
Then the operation is continued by dividing two more recti tendons and
conjunctiva together, rotating the eyeball, cutting the optic nerve, and
finally the remaining rectus and oblique muscles.
After enucleation the management of the muscles is important. Formerly
the muscles were allowed to slip back, and the wound left open. Each
rectus tendon should be sewed to the conjunctiva in a position corresponding
to its natural course. This may be done after the enucleation, or each rectus
may be sewed to the conjunctival margin as it is divided. The edges of the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 159
conjunctival wound are then united by suture, and the closed eyelids covered
with a gauze dressing. An artificial eye should be inserted in two weeks.
The operation is practically without hazard, even in the presence of
panophthalmitis. Suturing the muscles to the bed in which the prosthesis
is to lie gives considerable muscular control over it. An artificial eye should
at first be worn for a few hours a day; later it may be worn all day, but at
night it should be cleansed with alcohol, dried, and laid aside.
The operation of enucleation is free from the disadvantages presented by
evisceration; it has a far wider application; and is on the whole a more
satisfactory procedure.
Evisceration of the eyeball is a valuable substitute for enucleation. It is
used in panophthalmitis. It should not be done for sympathetic ophthalmitis.
The operation consists in, cutting out the portion of the eyeball at a vertical
plane i mm. posterior to the corneoscleral margin; with a scoop removing
the contents of the ball, internal to the sclera; wiping dry the interior of the
bulb, leaving a clean white sclera; and suturing the opening with a purse-
string suture passed through the conjunctiva. Interrupted sutures and
drainage of the cavity should be used if the operation has been done in the
presence of infection. The operation is apt to be followed by pain; and
subsequent shrinking leaves a stump not so well adapted to an artificial eye
as does enucleation.
Evisceration of the eyeball and implantation of an artificial globe (Mules'
operation) is done as follows: The conjunctiva is divided at the corneoscleral
margin and dissected back as far as the equator of the eyeball leaving the
muscles undisturbed. The anterior wall of the eyeball is cut away at a
perpendicular plane i mm. posterior to the cornea. An evisceration of the
contents of the eyeball is then done with a scoop, removing everything, and
wiping dry the interior to expose the dense white sclera. Hemostasis is
secured by packing the cavity with dry gauze. The opening is then enlarged
above and below by a short incision, and a globe of silver, gold, glass, or
paraffin inserted within the sclerotic cavity. The sclera and conjunctiva
are then sutured separately over this globe. Swelling may be controlled
in a measure by the application of cold over the dressings. Good asepsis is
essential in this operation. According to deSchweinitz, the operation is
indicated in rupture or blinding trauma tism to the eyeball, staphyloma of the
cornea and sclera, complete leukoma, absolute glaucoma, buphthalmos and
non-traumatic iridocyclitis. The chief contraindications are infection and
sympathetic ophthalmia.
Implantation of an artificial globe after enucleation is done immediately after
bleeding has been checked and the muscles sutured to the conjunctiva. A
globe of silver, gold, paraffin or glass is inserted within Tenon's capsule, and
the capsule closed in front of it by a purse-string suture. The internal and
external recti should be brought together, and the superior and inferior
recti thus making a decussation of the recti tendons in front of the globe.
The conjunctiva should then be sutured in front of all.
After remote enucleation of the eyeball, a globe may be inserted by making
a lateral opening through the conjunctiva and by blunt dissection with blunt
scissors creating a cavity in the connective tissue. A globe is then inserted
and the opening closed with sutures.
Operations for old cicatricial contractures of the orbit are called for when it is
desired to implant a prosthesis in an orbit where none had been used. In
cases in which the lids are adherent to the orbital scar, they may be dissected
free and the wounds covered with skin grafts. These grafts may be intro-
duced either before or after making a cavity for an artificial ball. An epithe-
160
S URGICA L TREA TMEN T
Hal lining for the lids is the first essential. Then a cavity for a prosthesis
may be created, either with the view of burying it in connective tissue
and covering it over, or with the view of making a cavity with an epithelial
lining.
Grafting an Eyeball after Enucleation. — This operation may be done for the
purpose of giving a stump upon which an artificial eye may be placed. In
children a rabbit's eyeball may be used. It should be attached by four
sutures through the conjunctiva. The human eye may be transplanted
although much more difficult to obtain. The transplanted globe heals in
place, and shrivels about one-half its size.
Transplantation of Fat into the Orbit. — This operation is done after enuclea-
tion to give a stump upon which to place a false eye for cosmetic purposes.
In performing the enucleation, the conjunctiva should be divided close to the
cornea, and the conjunctiva and the capsule of Tenon should be dissected
back as far as possible. A hook should then catch the superior rectus
muscle, and a double suture of fine chromic catgut pass upward through
the muscle, and through the conjunctiva near its edge just above the muscle
and be tied. The three other recti muscles are similarly sutured to the con-
junctiva. The ends of the sutures are not
cut but are held by clamps. The eyeball
is then forced from the socket, pressed in-
ternally, and the optic nerve divided. As
gentle traction is made on the four sutures
the socket is exposed and dried. A purse-
string suture of chromic catgut is intro-
duced around the cut edge of the conjunc-
tiva. A piece of fat about the size of the
eyeball is removed from the abdominal
wall. It should include the tough subcu-
taneous fascia which should be placed an-
teriorly as the fat is introduced into the
socket (Fig. 822). The purse-string
suture is drawn up and tied. The four
sutures through the muscle are then tied,
opposite to opposite. By the end of three
weeks the sutures are absorbed, and the
prosthesis may be introduced. About
one-fourth or one-third of the bulk of the fat will be absorbed. The false
eye is moved by the muscles in synchrony with the natural eye.
Removal of iron foreign bodies from the interior of the globe has been dis-
cussed (page 129). Small bodies free in the vitreous, gravitate to the bottom.
Their position should be determined by the .r-ray. Then a small incision
may be made through the wall at a suitable position, and the body picked
out; or, if not close to the incision, it may be brought there by the use of
a magnet.
These bodies may best be removed with a large electromagnet. Prepara-
tions for an aseptic operation should be made. The eye is anesthetized.
The patient is placed in a vertical position with the head supported to
steady it. A giant electromagnet, having a conical end to its pole, is
made to approach the eye exactly in front of the center of the cornea. The
magnet should be made first to act at some distance. As it approaches the
eye and the current is opened and closed, the foreign body will often be drawn
around the lens and through the pupil into the anterior chamber. This
usually means considerable wounding of the ciliary tract.
FIG. 822. — FAT TRANSPLANTATION
INTO THE ORBIT AFTER ENUCLEATION
OF THE EYEBALL.
The recti muscles have been pre-
served and sewed to the conjunctiva.
A^purse-string suture is about to close
the conjunctival opening.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
161
It is better surgery to locate the body exactly by the .-v-ray, and, having
made an incision through the sclera as near it as possible, apply the point of
the electromagnet, or an extension point, at the lips of the wound.
Operations for glaucoma are mentioned above (page 131). Iridectomy
(page 154) and sclerotomy (page 156) are the operations most employed.
In simple chronic cases with but slight or intermittent tension, sclerectomy
produces an adequate nitration cicatrix. Iridectomy must be added in the
cases of constant high tension. It is possible to combine these operations in
such a way as to meet the permanent tendency to hypertension in severe
cases. A sclerotomy may be made to produce a fistulous or infiltrating cica-
trix through which the intraocular fluid can escape when tension becomes
high. A sclerectomy is done at the level of the canal of Schlemm. This
should involve the whole thickness of the sclerotic. The incision should
divide the insertion of the ciliary muscle. This incision causes a communica-
tion between the choroidal space and the anterior chamber of the eye. The
opening through the sclera permits free drainage of the intraocular fluids out
under the conjunctiva. By performing iridectomy, the inclusion of the iris
is prevented.
The operation of cyclodialysis (see page 157) consists in making a com-
munication between the suprachoroidal space and the anterior chamber.
Through this channel the aqueous humor escapes. It is indicated in ad-
vanced cases in which iridectomy has
not succeeded in reducing the tension.
It is not as valuable an operation as
iridectomy, though easier to perform.
The wedge-isolation operation of
Herbert is aimed to produce a perme-
able scar. The anterior chamber is
opened with a narrow knife which is
passed horizontally across it. A short
flap of sclera is cut and left attached
at its apex. The direction of the edge
of the knife is then changed so that FlG
two cuts forward and backward are
made, and a narrow strip of sclera is
freed kfrom the flap at the limbus. The operation is subconjunctival. The
wedge of sclera which is detached is left adherent to the conjunctiva. It is
held loosely in the groove which is cut in the sclera. A small iridectomy
may be done to prevent prolapse of the iris.
The operation of Hancock consists in piercing the globe with a sharp-
pointed broad-bladed knife at the lower sclerocorneal junction. The inci-
sion in the sclera is 4 or 5 mm. long. The cutting edge of the knife is down-
ward and the point passes backward and slightly downward. A meridianal
section is thus made which opens both the anterior and posterior chambers
and divides the ciliary body. The knife is rotated slightly as it is withdrawn,
and the aqueous and some vitreous permitted to escape (Fig. 823).
The operation of Abadie makes an incision 1.5 cm. long through the con-
junctiva and subconjunctival tissue meridianally in the upper outer quadrant
of the globe. It begins at the corneal margin, passes toward the equator
and lays bare the sclera for 7 or 8 mm. The lips of the wound are separated
and two sutures passed to be used later in closing the conjunctiva over the
sclera. The globus is then held with forceps and a triangular knife inserted
just behind the iris at the junction of sclera and cornea, and caused to pierce
the globe toward its center. The incision is 7 or 8 mm. long and passes
VOL. II— ii
823. — OPERATION OF
GLAUCOMA.
HANCOCK FO R
162
SURGICAL TREATMENT
FIG. 824. — OPERATION OF ABADIE FOR
GLAUCOMA.
through sclera and ciliary zone. The knife is then removed and the con-
junctival wound sutured (Fig. 824).
The operation of sclerotomy with a trephine, for the purpose of relieving
the intraocular tension of glaucoma is one of the older operations. As it is
now done, a flap of conjunctiva is dissected up toward the cornea and turned
up over the surface of the cornea. With a scleral trephine a small disk of
sclera is removed i or 2 mm. from the apparent margin of the cornea (Fig.
825). An iris repositor is passed
from the trephine opening into the
anterior chamber. The instru-
ment should be kept in close con-
tact with the sclera and the
cornea. This guarantees a pas-
sage for fluid, and constitutes
cyclodialysis in addition to tre-
phining. The instrument is with-
drawn, the flap of conjunctiva is
replaced, and sewed.
The operation of simple trephin-
ing of the sclera, devised by R. H.
Elliot (Ophthalmoscope, Aug.,
1911), is done as follows: An inci-
sion is made running concentric
with the corneal margin and end-
ing on either side about 4 mm.
below the uppermost limit of the cornea and the same distance from the inner
and outer sides of the limbus. The triangular flap of conjunctiva thus out-
lined is dissected up from above the cornea. The flap is turned down on the
cornea, and the dissection continued until the rounded edge of the limbus
can be seen as it overhangs the surrounding scleral tissue. In old cases of
glaucoma the separation of the conjunctiva is carried still further from the
cornea with the aid of the points of the scissors. This permits that the
cornea can be seen to be split. The splitting of
the cornea creates a thin dark-colored crescent,
about i mm. broad which embraces the base of
the flap. When this appearance is created, the
anterior chamber may be entered with a trephine.
In making this dissection the points of the
scissors should be kept directed toward the plane
of the posterior pole of the lens. If this is not
done a puncture may be made in the conjunctival
flap. Connective tissue is carefully cleaned away FIG. 825. — SCLEROTOMY WITH
from the area in which the trephine is to be applied. THE TREPHINE.
This should be as close to the limbus as possible, The eyeball is rotated
or the trephine will not enter the anterior cham- downward, a triangular flap cl
i rp.1 !• i_ij ii_i -i conjunctiva is turned down,
her. The trephine should not be larger than 2 and the trephine opening
mm. in diameter — 1.5 mm. is, perhaps, better, made.
If the trephine fails to tap the anterior chamber,
a curet must be passed in to make the opening (Fig. 826).
As the anterior chamber is entered by the trephine, the fluid flows forth.
If the iris appears at the opening it may be incised in a radial direction. If
it does not return, the bulging piece should be abscissed. Tags of iris should
be removed from the trephine opening. The conjunctival flap should be
replaced. Sutures need not be applied, unless it is found misplaced at the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
163
first dressing. Eserin solution (i : 120) need be dropped in the eye only if
the pupil is found displaced upward. If the pupil is not active and dilated
after the third day, atropin drops should be used.
Removal of tumors of the orbit should not sacrifice the eyeball unless abso-
lutely necessary. For subconjunctival operations, hemorrhage may be
controlled by a spatula pressing the oph-
thalmic and supraorbital vessels upward
toward the roof of the orbit. Temporary
division of the recti muscles may be re-
quired. Cysts, which cannot be removed
without sacrificing the eyeball, should first
be treated by incision, curettage, injection
of some irritating substance such as tinc-
ture of iodin, and the use of drainage. If
this does not effect a cure, it remains to
be determined whether the sinus or the loss of the eye is more objectionable.
Tumors growing from the walls of the orbit should be removed early if they
are of progressive character.
Resection of the outer wall of the orbit is done for exposure of the eyeball
and the other contents of the orbit. An osteoplastic operation is to be pre-
FIG. 826. — SCLERA TREPHINES.
FIG. 827. — RESECTION OF OUTER WALL OF ORBIT.
Showing incision which spares the facial nerve from injury. If the incision is confined to
the external orbital triangle no damage of the nerve is sustained.
ferred. The orbit, posterior to the eyeball, even to the nasal side, may be
exposed. This operation is done for the treatment of disease and the removal
of tumors. The filaments of the facial nerve should be spared as much as
164
SURGICAL TREATMENT
possible. If lines are drawn from the upper and lower borders of the orbital
rim, backward to the condyle of the lower jaw, the triangle thus enclosed will
be found to be quite free from facial nerve trunks. The incision through the
soft parts should lie within this triangle.
A curved incision begins in the eyebrow, at the front of the temporal
ridge, above the external angular process, passes downward, making a curve
with its convexity forward, to the outer border of the orbit, and thence passes
downward and backward along the upper border of the zygoma to the mid-
zygomatic point (Fig. 827). This incision should go down to the bone, and
at the orbit it should open the orbital connective tissue. An elevator is
then used to separate the periosteum from the outer wall of the orbit. This
is reflected inward as far as the sphenomaxillary fissure. With a saw or
burr the bone is cut through in a line from the anterior end of the fissure to a
point above the external angular process of the frontal bone. Another
FIG. 828. — RESECTION OF OUTER WALL OF ORBIT.
Dotted line represents skin incision; heavy line represents bone incision.
division of the bone is made from the anterior end of the sphenomaxillary
fissure, forward and outward through the malar bone to the upper border of
the anterior root of the zygoma (Fig. 828). This wedge of bone, internally
representing outer orbital wall and externally representing the wall of the
temporal fossa, retaining its temporal attachments is pressed outward and
backward. Free access to the orbit is thus secured. The periosteum which
has been reflected inward, should be split from before backward, and re-
tracted upward and downward. The external rectus muscle may be divided
at its insertion and later sutured back in place. With thin retractors and
careful dissection, the eyeball may be held aside and the orbit explored.
Exposure of the optic nerve and vessels is secured by this route. The opera-
tion concludes with suturing the osteoplastic flap back in place by periosteal
sutures.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
165
Operations for Cataract. — The indications for operation (page 132),
the preparation of the patient (page 138), and the anesthetic (page 138),
have been described. The following instruments are required; speculum,
fixation forceps, lid elevator, spatula, wire loop, spoon, probe, curet, cys-
totome, capsule forceps, iris scissors, iris forceps, and cataract knife (Fig.
7660, page 139).
Simple extraction (extraction without iridectomy) is done as follows:
The first step of the operation is the same as that for iridectomy (see page
154). The eyeball is steadied by grasping the conjunctiva with fixation
forceps. The tendon of a rectus muscle may be included in the grasp. If the
right eye, for example, is to be operated on, the surgeon stands behind the
patient, and grasps with forceps in the left hand a fold of conjunctiva and
the tendon of the internal rectus. Some surgeons prefer to grasp the conjunc-
tiva below the cornea. Some surgeons of skill dispense with the speculum
and fix the eyeball and retract the lid by grasping the superior rectus with
forceps. The point of a cataract knife is entered at the corneoscleral junc-
FIG. 829. — INCISION OF CORNEA FOR CATARACT EXTRACTION.
The knife has pierced the cornea, passed through the anterior chamber and emerged
at the corneoscleral border on the other side. It will then cut directly upward, emerging
at the corneoscleral border, leaving a flap of cornea and a wound opening the anterior
chamber.
tion on a horizontal line 3 or 4 mm. below the summit of the cornea, and
passed across the anterior chamber between cornea and iris, to emerge at
the corneoscleral border on the opposite side (Fig. 829). The surgeon should
be sure that the cutting edge is upward before entering the knife. The knife
is then made to cut directly upward, emerging at the corneoscleral border
above and leaving a flap of cornea and a wound opening the anterior chamber.
This flap usually should involve about half of the cornea.
In the second stage of the operation the eyeball is drawn downward
with the fixation forceps, and the capsule of the lens incised. This is done
with the cystotome, which is introduced flatwise through the wound and
then after passing through the iris opening, is turned with its cutting edge
toward the lens. The capsule is incised in such a way as to make a triangle
with its apex downward and its base upward. The transverse part of this
incision, or base of the triangle, should be at the periphery. The triangular
opening thus made lies just within the pupil. The knife should be used
carefully and with little force lest the lens be dislocated. If the anterior
capsule is thickened it may be picked up and opened with capsule forceps.
The third stage consists in the delivery of the cataract. The patient is
directed to look downward or the eye is drawn downward by fixation forceps.
166 SURGICAL TREATMENT
The speculum is then held away from the eyeball by an assistant, or removed
and the upper lid held away from the incision by a lid elevator, in order that
there shall be no pressure on the eyeball. The lower part of the cornea is
now pressed with the convex surface of a metal spoon. Firm pressure causes
the upper margin of the lens to appear in the pupil. The pressure is con-
tinued gently and made to follow the lens as it escapes through the pupil,
and thence through the corneal wound (Fig. 830).
The wound is now inspected. Any cortical tags or bits of capsule should
be removed. The iris should be smoothed out if necessary with a spatula
and the corneal flaps adjusted. Pressure upon the lower border of the
cornea will usually cause the iris to fall in place. Some surgeons prefer to
irrigate gently the anterior chamber with physiologic salt solution. This
washes out loose particles and adjusts the iris. The current should be from
within the chamber outward through the wound.
Simple extraction presents the advantage that the iris is left intact. It
has the disadvantage that the extraction is more difficult.
Combined extraction (extraction with iridectomy) is similar to the above,
excepting that iridectomy is added. The first stage of the operation is the
same, and similar to that of iri-
dectomy. The second stage con-
sists in the performance of iridec-
tomy. The patient is directed
to look downward, or the fixation
forceps are held by an assistant,
who gently draws the eyeball
downward, while the 'surgeon
introduces the iris forceps, grasps
the iris midway between the pupil
FIG. 83Q.-OPERATION FOR CATARACT. and periphery, and with the iris
DELIVERY OF THE LENS. . J L. f , , . . .
, . , , . scissors cuts off a told of iris out
The spoon presses the lower part of the cornea , . , , A .
and causes the lens to move upward through the to tn.e COrneal border. A large
corneal wound. opening in the iris is not neces-
sary. The edges of the coloboma
are smoothed out with a spatula and the iris left smoothly in place with no
part of it engaged in the corneal wound.
In the third stage, the capsule is divided much as in the operation with-
out iridectomy. It may be divided by introducing the cystotome, passing
it to the bottom of the coloboma, and making a vertical incision, passing
to the top of the coloboma, where a transverse cut is made. The incisions
should pass through the capsule, and make the least possible pressure.
The delivery of the cataract is the same as in simple extraction except
that it is more expeditious because of the larger opening through the iris.
Cases in which the ball is hard, the lens large, the pupil not easily dilated,
the anterior chamber shallow, or with ciliary irritation, require the combined
operation. Some surgeons as a routine remove a small piece of iris in all
cases.
The ajter-lreatment in all cataract cases should begin preferably with
placing a piece of soft lint, soaked in i : 5000 bichlorid of mercury solution
upon each closed lid. Over this, sterile cotton is placed to the level of the
eyebrow. All are held in place with adhesive strips making only enough
pressure to retain the dressing. To prevent traumatism during the first
two days, it is well to add an ocular mask. The eye should be inspected
twenty-four hours after simple extraction. If the corneal wound is found
closed, the iris in place, i drop of atropin solution should be instilled. If
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 167
the anterior chamber has not reformed, the atropin should be omitted. If a
prolapse of the iris in the corneal wound is found, the iris should be excised.
Local anesthesia does not act well in the presence of inflammation, and it may
be necessary to use general anesthesia. If combined extraction has been
done, the eye need not be examined until the end of forty-eight hours. The
anterior chamber will usually be found reformed. A drop of atropin solution
should be instilled, and the dressings renewed. Usually the wound will be
found closed at the end of twenty-four hours. Delayed healing may be
caused by a bit of tissue between the lips, which should be removed. If
there is simply a lack of reparative power, it may be stimulated by touching
the wound with silver nitrate stick.
The eye which was not operated upon may be uncovered at the end of
three days; and by the sixth day the affected eye may be left without dress-
ing. During the second week colored glasses should be worn by day, and a
protective covering, to prevent traumatism, by night. Many surgeons
apply no dressing at any stage of the treatment, but simply cover the eyes
with a shield or cage. At the end of six weeks or two months glasses for
distance and for near reading should be adjusted.
A ccidents of treatment may occur. If the iris falls forward in the path of
the knife while the first incision is being made, the knife should continue,
cutting out a coloboma, which later may be trimmed evenly.
Blood in the anterior chamber is expelled by the pressure which expels
the lens. If it is present after expression, it may be removed by gentle
irrigation with salt solution. Remaining blood is absorbed during the first
day or two.
Two much pressure upon the lens may cause it to escape posteriorly. In
such an event the speculum should be removed and all artificial pressure
abated. A loop should be passed behind the lens to bring it forward. Vit-
reous escaping into the anterior chamber should be wiped away. If the
escape of vitreous is sufficient to cause collapse of the eyeball, it should be
filled with salt solution. The same should be done to the anterior chamber
if the cornea collapse.
Intraocular hemorrhage, usually manifested by pain and nausea, and
sometimes by the appearance of blood in the dressings, should be treated
immediately. Morphin is required for the pain. If the hemorrhage is from
the iris and does not escape externally, it may be left to take care of itself;
if oozing through the corneal wound is present, the blood should be washed
out with warm salt solution. If the bleeding continues, adrenalin chloride
may be added to the solution. Hemorrhage from the choroid, displacing
the vitreous, is a more serious condition. If such hemorrhage escapes through
the wound, the loss of the eyesight may be expected. An attempt to save the
eye may be made by washing out the clot with salt solution through an
incision posterior to the ciliary tract. If the bleeding does not stop, adrena-
lin chloride should be added to the solution. Whatever is done the con-
junctiva should be kept clean. If such a hemorrhagic eyeball becomes
infected, enucleation is practised.
Infection following the operation for cataract is rare in these times. Pain,
swelling of the lids, and injection of conjunctiva are the signs which call
attention to infection. Antiseptic washes should be used. If the infection
involves the anterior chamber, it should be irrigated frequently with salt
solution. Some surgeons use weak bichlorid of mercury solution.
Suppuration invading the vitreous usually destroys the eye. In such cases
incision to drain the vitreous posterior to the ciliary tract may be of service.
The appearance of iritis or iridocyclitis between the fifth and twelfth day
168
SURGICAL TREATMENT
augurs bad for the eye. Iritis may be checked by atropin and dionin locally.
Recurring iridocyclitis gives a bad prognosis, unless the disease can be
checked and the closed pupil remedied by iridotomy or iridocystectomy.
As a result of traumatism or some sudden increase of intra-ocular pressure
as may be caused by sneezing or coughing, prolapse of the iris through the
wound takes place. If the prolapse occurs soon after the operation, usually
it will be found slightly adherent to the wound;
in such an event, the prolapsed iris should be ex-
cised, the stump pressed away from the wound and
smoothed out, and the wound edges again smoothly
coapted. A small prolapse which has become ad-
herent may be left until later and then excised as a
staphyloma.
Preliminary capsulotomy for immature cataract
is practised as follows by the method devised by
FIG. 831.— PRELIMINARY Homer E. Smith (Tour. Am. Med. Assoc.. vol. 63,
RT£TT™:cTFOR Sept. 5, IQI4). The peculiar capsulotomy knife
Showing point of en- is used. The length of the blade should be 2 mm.,
trance of knife at upper the point obtuse, the belly rounded, and the edge
outer quadrant of the cornea, acutely sharp. A vertical and a transverse inci-
N, Nasal side; T, temporal sion are macje across the front of the capsule.
The pupil should be dilated with 2 per cent, hom-
atropin and the eye anesthetized. For the right eye the surgeon stands
at the head of the patient and grasps the conjunctiva and internal rectus
with forceps in the left hand. The knife, held as a pen, with the cutting
edge downward, is thrust through the middle of the superior temporal
quadrant of the cornea (Fig. 831); passed across the anterior chamber until
FIG. 832. — PRELIMINARY CAPSULOTOMY FOR IMMATURE CATARACT.
Vertical section through right eye. The knife has pierced the cornea at the point
indicated by the arrow, and passed down to the lower margin of the dilated pupil. The
handle is then moved downward through the positions indicated by i, 2, 3, 4 and 5, as
the blade moves upward. The operator is standing above the patient's head.
the blade reaches the lowest possible point on the dilated pupil at the
vertical meridian of the lens. The handle then describes the arc of a
circle as the blade is carried across the front of the lens cutting through the
anterior capsule along the vertical meridian (Fig. 832). Without removing
the blade from the anterior chamber, it is passed across to the inner side
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
169
and by a similar movement the anterior capsule is incised on the transverse
meridian (Fig. 833).
For operating on the left eye the surgeon stands at the left of the patient,
and the knife enters the cornea at the inferior temporal quadrant. The first
incision in the capsule begins at the top of the vertical meridian of the lens.
After the capsular incisions have been made, the speculum is removed, a drop
of % of i per cent, physostigmin (eserin) solution is dropped in the eye, and
a dressing applied.
Six hours after the capsulotomy the operation for extraction of the cata-
ract is done. The section for removal of the lens should involve the upper
FIG. 833. — PRELIMINARY CAPSULOTOMY FOR IMMATURE CATARACT.
Horizontal section through right eye. The blade of the knife is withdrawn from the
position 5 and is passed to the nasal side (2V) of the dilated pupil. It is then carried suc-
cessively through the positions 6, 7, 8, 9 and 10, thus making an incision in the capsule of
the lens at right angles to the first incision, and passing from the nasal (N) toward the
temporal (T) side. The operator is standing above the patient's head.
two-fifths of the circumference of the cornea. The danger of iris prolapse is
reduced by using atropin immediately after the operation.
Other operations for cataract are used to meet peculiar conditions.
Discission (needle operation) is used in congenital, juvenile, and soft cataracts
in which there may be either complete or partial opacity. The operation is
done as follows: The pupil is dilated and a knife-needle is introduced
at the corneoscleral junction and passed into the anterior chamber.
The point of the instrument penetrates the capsule of the lens and divides it
crucially. Some surgeons cause the point to enter the capsule and then cut
forward. At subsequent operations the lens itself may be slightly scratched.
The effect of this is to admit the aqueous fluid to the lens, which com-
pletes the opacity if not already complete, and acts as a solvent upon the
lens. It is usually necessary to repeat the operation — in some cases several
times before solution is secured. The pupil should be kept dilated and the
eye covered until reaction has subsided. Complete solution requires from
three to six months.
170
SURGICAL TREATMENT
Discission is a dangerous operation because of the possibility of doing
injury to the ciliary tract. Dragging or rough handling must be avoided.
The instruments should be sharp. Atropin must be used freely. Glaucoma
following the operation requires myotics, and, if this fails, iridectomy or
paracentesis.
In the same class of cases in which discission is employed, or in which it
is not desired to repeat the needling, linear extraction may be used. This
operation is applicable especially in soft congenital cataracts and in complete
juvenile cataracts in patients under thirty years of age. It is also used in
traumatic cataract, and in cases in which needling has been followed by
swelling with glaucomatous symptoms. For high progressive myopia, some
surgeons practise discission, followed by extraction or removal by suction.
The pupil should be widely dilated. A keratome is inserted at a point i mm.
within the periphery of the cornea. The instrument is passed onward
until a wound 5 mm. in width is made. Through this the cystotome is
FIG. 835. — INSTRUMENTS USED IN INTRACAPSULAR CATARACT EXTRACTION.
A, Lid elevator; B, spoon; C, knife; D, iris replacer; E, compression hook; F, capsule forceps.
inserted and the capsule of the lens freely incised. Pressure is made with a
spoon or spatula against the cornea below while pressure is also made above
the wound. The pressure should be gentle lest the hyaloid be ruptured and
vitreous escape. Some surgeons insert a fine canula connected with rubber
tubing by means of which the soft lens is removed by suction.
Extraction of the lens -without incision of the capsule is in favor with some
surgeons. The first stages of the operation are similar to the ordinary opera-
tion. It may be done with or without iridectomy. The lens may be lifted
out by means of a curet or loup. Henry Smith perfected this operation.
The surgeons in India deliver the lens through the corneal wound by careful
and systematic pressure, without rupture of the capsule. This gives a clean
result if the surgeon has sufficient skill to perform the operation without the
escape of vitreous. Loss of vitreous is the common accident in inexperienced
hands. Special instruments are necessary (Fig. 835).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 171
The operation in two stages consists in preliminary iridectomy, and
removal of the lens several weeks later, and is practised by some surgeons
as a general rule. It is to be followed in cases in which the cataract is not
ripe, or in which extraordinary care is necessary, as after the loss of one eye.
The dangers of operation by this method are reduced.
Extraction of cataract with capsule after subluxation with capsule forceps is
recommended by Arnold Knapp (Arch, of Ophthal., vol. 44, No. i, 1915).
A drop of atropin is instilled, in addition to the anesthetic solution. The
eye is exposed and steadied by speculum. The speculum is used throughout
the operation unless prolapse of vitreous is threatened. The incision should
involve nearly half the circumference of the cornea. A conjunctival flap
should be made. Iridectomy is done. The capsule forceps are inserted and a
fold of capsule grasped below the center. Care should be taken not to
tear the capsule. The forceps, holding the capsule, are moved in all the
lateral directions until the capsule is freely movable. The forceps are then
removed. With a cataract hook pressure backward is made on the lower
FIG. 836. — INTRACAPSULAR PIG. 837. — INTRACAPSULAR CAT-
CATARACT EXTRACTION. FIRST ARACT EXTRACTION. SECOND
STAGE. STAGE.
Showing point for applying Pressure is continued, the cornea
pressure in extraction of imma- being pressed in behind the lens as
ture cataract. it moves along.
part of the cornea. The lens is seen to rotate and come out of the wound.
It is separated from its attachments by a lateral stroking motion. The
coloboma of the iris should be replaced, the conjunctival flap adjusted, the
speculum removed, atropin ointment is introduced, and both eyes covered
with a dressing. The dressing is left undisturbed for four days unless com-
plications develop. After the fourth day the good eye is left uncovered.
The inlracapsular extraction of immature cataract has come to be a popular
procedure as a result of the work of Henry Smith. The danger of loss of
vitreous has been materially reduced by the use of the spoon and properly
constructed and handled lid retractor. When vitreous escapes, the spoon is
passed behind the lens; pressure is made with a blunt hook upon the bottom
of the lens; this dislocates it upward, and prevents pressure upon the vitreous.
The removal of immature cataract saves the patient the long period of anxiety
and increasing defect of vision entailed by waiting for the cataract to ripen.
The incision involves half the circumference of the cornea. If it passes
172 SURGICAL TREATMENT
into the conjunctiva, some hemorrhage will obscure the operation. Iridec-
tomy is done. The hook of Smith is placed flat against the cornea, and
pressure made toward the optic nerve (Fig. 836). As the lens is dislocated
upward, if the pressure is relaxed too soon the lens will slip back; if the pres-
sure is too great the capsule may be ruptured or the vitreous may escape
(Fig. 837).
The pressure is continued gently, the hook being moved toward the wound
following the lens as it escapes (Fig. 838). If the lens is swollen, it may be
rolled over and brought to the wound opening by pressing the cornea down-
ward (Fig. 839). As the lens escapes, the hook is pressed behind it (Fig. 840).
For intracapsular cataract with a spoon, the cornea is incised, iridectomy
is done, and the spoon is introduced behind the lens. Pressure is made on
the front of the cornea with the compression hook at the lower pole of the
lens. This causes the lens to move upward. The spoon prevents its dis-
placement into the vitreous (Fig. 841).
FIG. 838. — INTRACAPSULAR FIG. 839. — INTRACAPSULAR
CATARACT EXTRACTION. THIRD CATARACT EXTRACTION WITH
STAGE. SWOLLEN LENS.
The compression hook squeezes A lens which is swollen may
the lens out of the opening. be rolled over and brought to
the wound opening by pressing
the cornea downward.
The operation of couching or depressing consists in forcibly pressing the
lens backward so that it is detached and dislocated back into the vitreous
humor. It is rarely used, but it may be employed in patients greatly en-
feebled by old age or other disease. It is used also in the insane or patients
whose actions cannot be controlled, and in cases in which chronic con-
junctivitis or dacryocystitis cannot be cured.
The operation of suturing the corneal wound after cataract extraction is
practised by some surgeons. It is the ideal method of terminating the opera-
tion. It is little employed by ophthalmologists, perhaps, because of their
limited grasp of the general principles of surgery; although any one who is
competent to remove a cataract is competent to close the wound in a surgical
manner. But one suture is used; that should be the finest silk in the finest
possible curved needle. The suture is passed before the tissues are cut.
The suture may be passed vertically or transversely in the cornea and trans-
versely in the episclera. The bite of each suture need not be much more
than i mm. The suture naturally enters and emerges on the surface. The
punctures may be so close together that the knife may pass within i mm. of
them (Fig. 842). The loop is left long so that the threads may be held out of
the way during the operation. After the corneal incision, capsulotomy and
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
173
delivery of the lens, the suture is drawn up and tied snugly. This operation
minimizes the danger of prolapse of the iris and vitreous. A dressing is
applied. The suture is removed on the third day. It may be removed
earlier, as the wound will be found adherent by the end of the second day.
The immediate removal of traumatic cataract should be practised in cases
in which the lens is hopelessly destroyed. As soon after the injury as pos-
sible, when the patient has recovered from shock, the lens should be re-
moved. A local anesthetic may be sufficient, but often, because of inflam-
matory reaction, a general anesthetic is best. If there is much local trau-
matic reaction present, operation should be deferred for four or five days.
Operation should be done before secondary inflammation has developed.
Cases in which there is a laceration of the cornea and decided mutilation of
FIG. 840. FIG. 841.
FIG. 840. — INTRACAPSULAR CATARACT EXTRACTION WITH SWOLLEN LENS.
The cornea is pressed behind the lens as it advances toward its exit.
FIG. 841. — INTRACAPSULAR CATARACT EXTRACTION WITH SPOON.
The cornea has been incised and iridectomy done. The spoon is introduced behind
the lens. Pressure is made on the' cornea with the hook at the lower pole of the lens. This
causes the lens to move upward and be delivered in front of the spoon. The spoon need
not be used except when the vitreous has escaped.
the lens are best treated by cutting the lens with a cystotome and washing
it out. In the young, the lens may be sucked out. A regular typical cata-
ract extraction may be done in some cases. Cases complicated by the pres-
ence of foreign matter require especial care. A typical extraction is best in
cases with foreign body. If washing is practised there is danger of washing
lens and foreign matter back into the vitreous.
Iridectomy should be done in most cases. Foreign body in the iris calls
for iridectomy. The corneal incision should be made near the foreign body.
The use of suction in cataract extraction may facilitate many operations.
Traumatic cataract in children and in the young, seen immediately after the
injury, is best treated by being sucked out. This may be done with a simple
hypodermic syringe. Suction is employed in adults to advantage as a means
of holding and controlling the lens in the ordinary extraction. A cup on the
end of a handle, connected with a vacuum bottle, may be introduced through
the wound, and caused to hold the lens, to rotate it, draw it out, or otherwise
manipulate it.
174 SURGICAL TREATMENT
The vacuum extraction of cataract is based on the hypothesis that cataract
should be removed with the least possible traumatism. For this purpose a
little cupping instrument is made which may be connected with an aspirator.
The cup fits over the anterior surface of the crystalline lens. It is introduced
through the pupil. The iris is not injured. The cataract comes out cling-
ing to the instrument when it is withdrawn. The cup sucks out the cataract
together with the minute shreds of tissue without introducing any instru-
ment behind the lens. This operation may be done in cases of ripe senile
cataract, in unripe, and in overripe cases. This is the method of I. Barraquer
(Siglo Medico, Madrid, Apr. 21, 1917). By thus removing all of the contents
of the capsule postoperative iritis is minimized. Vitreous is not lost because
pressure is not made. Iridectomy is rarely needed, the operation requiring
only the corneoconjunctival incision and the cup. This is probably destined
to supersede the methods of forcible extrusion.
Operations for after-cataract (secondary cataract) vary with the degree of
the opacity. A delicate membrane remaining across the pupil after cataract
operation is best treated by entering a cataract needle as in the operation
of discission. The operation as done by Knapp is as follows: The pupil is
dilated widely and the knife-needle is passed through the cornea 3 mm.
within its margin on a horizontal at a level with its centre. The point is
FIG. 842. — SUTURING CORNEAL WOUND IN CATARACT EXTRACTION.
The suture is passed before the tissues are cut.
passed across the anterior chamber to the opposite side and a horizontal
incision, 4 or 5 mm. long, is made. The knife is then made to cut a perpen-
dicular incision of similar length crossing the first at its center but made by
two cuts each approaching the center. The membrane should be cut, not
torn; thickened places should be avoided; and the vitreous should not be
penetrated. Iridotomy must be substituted in cases in which the mem-
brane is thick and resistant. V-shaped iridotomy is of service.
Operations upon the Eye-muscles. — These operations consist in tenotomy
of the muscles which move the eyeball, and advancement or readjustment
of their insertions. There is a growing feeling that operations for strabismus
should be done early. The sooner tie divergence is corrected the sooner
normal restitution is possible. Children as young as two years old may
be operated upon. Cocain usually suffices. Young children may require
general anesthesia. The internal rectus most frequently requires division;
next in frequency is the external rectus. The other straight muscles some-
times require operation. Strabismus appears usually about the third year
of life. Glasses, exercises of the muscles and improvement of the general
health may fail to secure correction. The internal rectus muscle is inserted
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
175
in the sclerotic about 5 mm. posterior to the border of the cornea; the ex-
ternal, 7 mm.; the superior, 8 mm.; the inferior, 6 mm. The tendons are
about 9 mm. broad. Complete tenotomy of the internal rectus is done for
convergent strabismus. The subconjunctival operation is as follows: The
lids are separated with a speculum. A fold of conjunctiva and subconjunc-
tival tissue at the lower border of the tendon of the muscle is picked up with
fine forceps. An opening large enough to receive a strabismus hook is cut
with scissors. If the cut has not involved Tenon's capsule, it must be picked
up and divided. The wound is held open with the forceps while the strabis-
mus hook is passed beneath the muscle close to the sclerotic and the tip
made to appear under the conjunctiva above the muscle. The hook is now
drawn forward until checked by the insertion of the tendon. The scissors,
having a bulb on one point to prevent wounding the sclera, are inserted in
front of the hook, and by several cuts
the tendon is divided. The hook is
then moved forward, and any un-
divided fibers cut.
The open operation is as follows : A
vertical fold of conjunctiva and under-
lying tissue is picked up with toothed
forceps at the insertion of the muscle
and a horizontal opening made through
it and the capsule of Tenon. Through
this opening the tendon is exposed, the
strabismus hook is passed between the
sclera and muscle, and the latter di-
vided at its insertion. The effect of
the operation may be diminished by
suturing the wound so as to make a
vertical line. Usually the wound is
closed horizontally. The open opera-
tion is to be preferred to the closed
(Fig. 843).
After tenotomy the conjunctival
sac should be washed out and the
patient should immediately wear the ^f tend°n when advancement is to be done.
, „ J The probe-pointed scissors are about to cut
corrective glasses, borne surgeons the tendon.
bandage the eyes for one or two days.
Whatever is done, the same after-treatment should be applied to either
eye.
In some cases with extreme strabismus the inner third of the superior
or inferior rectus, one or both, must also be divided.
The indications for these operations should be studied before the operation
is done. Each case is peculiar. A convergent squint of 15 or 20 degrees is
cured by tenotomy of the internal rectus. Correction should not be com-
plete. A convergence of 2 to 5 degrees after operation will prevent over-
correction or divergent squint.
A deviation over 20 degrees can rarely be cured by this operation. If
the case is one of alternating strabismus, with good vision in each eye, tenot-
omy of each internus is indicated. Should this not cure the disease, the
externus of the most convergent eye should be advanced.
In the case of unilateral strabismus, exceeding 30 degrees, and the eye
amblyopic, tenotomy of the internal rectus must be combined with advance-
ment of the external rectus. In many such cases it is also necessary to do a
FIG. 843. — OPEN OPERATION FOR TENOT-
OMY OF INTERNAL RECTUS.
The suture in the sclera is used to fix
176 SURGICAL TREATMENT
slight tenotomy of the internus of the other eye. Extreme cases demand
division of both interni and advancement of both externi.
At the best, it is difficult to regulate the result of tenotomies; and in
recent years the operation of advancement is much employed.
Certain special conditions require attention. If the capsule of Tenon
is not divided, it will be impossible to pass the hook under the muscle.
Perforation of the sclera may occur unless probe-pointed scissors are used.
Hemorrhage is usually slight; and pronounced hemorrhage is least likely to
occur in the open operation. Retraction of the caruncle occurs because
of retraction of the muscle, some of whose fibers are inserted in it, and
because of later scar contractures of the subconjunctival tissues. To cor-
rect this condition the caruncle should be dissected free and sutured back
in place.
Partial tenotomy (graduated tenotomy) is done for heterophoria, a dis-
turbance of the normal balance of the muscles of the eye, which is not
sufficient to cause strabismus. A transverse opening in the conjunctiva
is made opposite the insertion of the muscle. The tendon is grasped by
forceps at its insertion and the middle fibers divided at their insertion.
The opening thus made is enlarged by cutting upward and downward with
the scissors. The anterior and posterior lamellae of the muscle are left, also
the borders of the muscle. The operation is carried as far as necessary to
give the required relaxation. This may be determined by testing the vision
during the operation.
Advancement (readjustment) consists in bringing the tendon of a rectus
muscle forward to a more anterior insertion. An opening transverse to the
muscle is made in the conjunctiva, at the insertion of the tendon. It should
be about twice the width of the muscle. The conjunctiva between the open-
ing and the cornea should be undermined for a short distance by blunt dis-
section. The tendon is separated from the sclera by passing a strabismus
hook between them. This separation should come well forward to the in-
sertion and surely involve the whole width of the tendon. A curved needle,
threaded with fine chromicized catgut, is passed between the tendon and
sclera and thence through the middle of the tendon close to its insertion.
A similar suture is passed at the other side emerging at the middle of the
tendon near the first suture. These sutures are then tied on the free side of
the tendon, each one grasping half of it, and the ends left long. The tendon
is then divided at its insertion; the needle on the end of each suture is passed
beneath the conjunctival bridge and made to engage the episcleral tissue
nearly as far forward as the cornea; the sutures are tied; and the conjunctival
wound closed with three sutures. The degree of advancement is regulated
by the place of insertion of the episcleral sutures. While the sutures are
being tied, the eyeball should be rotated toward the divided muscle. Both
eyes should be kept bandaged for at least four days.
Instead of a conjunctival incision, a flap of conjunctiva may be turned
back from near the cornea. Some surgeons include only one-third of the
tendon in each suture which is tied around the edge (Landolt) (Fig. 844).
In convergent squint, surgeons are coming more and more to practise ad-
vancement of the external rectus, leaving the internal rectus untouched.
The operation of shortening the muscle consists in making a tuck, folding
the muscle upon the tendon.
The muscle-folding operation is best done with a catgut suture. The
conjunctiva is incised so as to expose the attachment of the tendon. A
loop of the muscle is lifted up on a blunt hook. The needle, carrying a
double thread, is passed through the tendon at its insertion in the sclera and
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
177
then through the muscle posterior to the hook (Fig. 845). Three interlock-
ing sutures suffice. The fold of muscle may be left uncut.
FIG. 844. — ADVANCEMENT OF EXTERNAL
RECTUS TENDON.
The tendon has been caught by two
sutures and divided. The sutures are
now ready for reinsertion.
FIG. 845. — FOLDING OPERATION FOR
SHORTENING MUSCLE.
The tendon is lifted up on a hook,
and three sutures placed through the
fold.
Advancement of the capsule of Tenon is done through an incision, i cm.
long, parallel to the corneal border, and 5 mm. posterior to it. The capsule
is incised on either side of the insertion of
the tendon. Through these two openings
the capsule and tendon are undermined,
and sutures passed transfixing the tendon,
capsule and conjunctiva, and thence
through the sclera near the cornea. This
makes a fold in the tendon and advances
the capsule. It is used in slight diver-
gences.
Operations on the Lacrimal Apparatus.
Enlarging the lacrimal canals to give better
escape for the tears, should first be at-
tempted by the use of lacrimal sounds, if
nonoperative treatment has failed. These
sounds are from i to 3 mm. in diameter.
The passage of sounds in the nasal duct, it
should be remembered, is through a bony
canal, which is directed downward, slightly
backward, and slightly outward. The
probe should first pass horizontally inward
in the canaliculus until it reaches the lacri-
mal bone, and thence downward into the
nasal duct (Fig. 846). If the canaliculus
cannot be entered, it must be cut. The
lower one usually is dealt with. A fili-
form bougie can often be made to enter
the opening and a small eye-knife passed
along beside it; or the special canaliculus
knife, with a probe point may be used.
The canal should be cut upward and backward. When this has been done,
sounds can be introduced. Strictures of the nasal duct may also be divided.
VOL. II— 12
FIG. 846. — PASSING LACRIMAL PROBE
LACRIMAL DUCT.
THROUGH
Note that the probe passes down-
ward, forward and outward.
178 SURGICAL TREATMENT
Sometimes when the punctum will not receive the point of a lacrimal syringe,
it may be dilated with a silver pin.
Excision of the lacrimal sac is required when its infection is intractable.
The sac should first be washed out with antiseptic solution. An incision,
2 cm. long, is made along the inner margin of the orbit, the center of the
incision being opposite the caruncle. The upper border of the sac is a trifle
higher than the level of the upper punctum. The sac lies close to the perios-
teum in the groove formed by the lacrimal bone and the nasal process of the
superior maxilla. The tendo oculi and the tensor tarsi muscle, which covers
it, need not be divided. The sac should be dissected free, after the manner of
removal of a cyst, and cut off at the nasal duct. If the operation is intended
to eliminate the lacrimal drainage system, the canaliculi also should be
destroyed. Epiphora follows this operation; and the only excuse for its
performance is that a discharge of tears is less objectionable than a discharge
of pus. Usually dacryocystitis can be cured; consequently this operation
is rarely justified. Skillful surgeons cure dacryocystitis in preference to
performing dacryocystectomy.
In chronic suppuration in the lacrimal sac a chip of the nasal process of
the superior maxilla and the lacrimal bone may be removed. The inner half
of the lacrimal sac is then removed. A sound is passed, and a free opening
established.
In skilled hands the endonasal approach to the lacrimal sac is to be
preferred. It restores better the natural pathway of tears, probing is made
unnecessary, the lacrimal gland is spared, and scar is avoided.
Endonasal operations on the lacrimal sac avoid skin incisions, and in the
cases of stenosis give a better access for free opening and drainage. The
operation of West is applied to the lacrimal sac. A quadrangular flap of
mucous membrane, with its base below, is dissected free along the inner side of
the nasal process of the inferior maxilla. The flap should be at a position
opposite the lacrimal sac. The area thus denuded represents a space
limited by the anterior extension of two lines: the upper marks the attach-
ment and the lower the inferior border of the middle turbinated bone. A
part of the posterior border of the nasal process is cut away with the chisel.
The lacrimal sac is exposed, and its inner wall cut away. The posterior
part of the mucous flap opposite the sac is removed. The flap is replaced
and held in position for a day with gauze packing. The nose should be
kept free from crusts and the sac should be irrigated through the canaliculus.
The operation may be facilitated by first passing a probe and cutting down
upon it from within .
Removal of the lacrimal gland is accomplished through an incision begin-
ning at the middle of the upper orbital border, and carried outward and down-
ward just below the level of the outer canthus. The fascia is divided, and
the gland is found in the depression of the frontal bone, at the upper and outer
aspect of the orbit, just behind the orbital margin. It measures about 1.5 cm.
by 0.5 cm. All bloody oozing must be checked so that the gland can be dis-
tinguished from the surrounding connective tissue and fat.
The palpebral portion of the gland lies anteriorly and is sometimes re-
moved instead of the whole gland. This may be reached through the con-
junctiva. The upper lid is everted, the eyeball turned downward, and the
enlargement under the conjunctiva at the outer part of the lid is recognized
as the gland. This is grasped with forceps, and excised through a wound in
the conjunctiva. The wound should be sutured.
Blindness with brain tumors and steeple-skull may be averted by
decompression operations.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
179
Treatment of diseases of the eye by subconjunctival injections has a wide
range of application. The best points for injection are midway between the
recti muscles, and as far from the cornea as possible. Fluid should be used
to the amount of i to 2 c.c. (15 to 30 minims). Injections may be made
painless by adding acoin to the solution. When mercuric solutions are
indicated, acoin (i per cent.) may be combined with a 1:1500 cyanide of
mercury solution. Morphin and dionin, 0.008 Gm. (% grain) each, may be
added to the solution if much pain is anticipated.
After mercurial injections extreme edema develops. It may extend
over the whole side of the face and last for three or four weeks.
The use of salt solutions and glucose is discussed under Glaucoma (pages
131 and 132). Dionin has a wide range of usefulness (see page 118).
THE NOSE
Anatomy. — For purposes of treatment the nose includes the two nasal cavities which are
separated by the septum, the accessory sinuses which communicate with the nasal cavities,
and the external nose. The septum (Fig. 748) is composed of bone and cartilage, covered
with mucous membrane.
iL^i.- .. .. — _J
FIG. 847.- — NASAL CAVITY.
Section at a vertical transverse plane, looking forward through nasal cavities.
cavities are above and at the sides.
Orbital
Of the three turbinated bones (or turbinals), the two upper are part of the ethmoid, the
lower is a separate bone. The superior meatus is situated between the superior and middle
turbinals, and into it open the sphenoidal sinus and the posterior ethmoidal cells. The
middle meatus is between the middle and lower turbinals, and into it opens the frontal
sinus, the maxillary sinus, and the anterior ethmoidal cells. The inferior meatus is between
the lower turbinal and the floor of the nose, and contains the inferior orifice of the nasal
duct which is about 2 cm. (% inch) from the floor of the nose (Fig. 847).
The several accessory sinuses all communicate with one another and with the nasal
cavity. The largest, the antrum of Highmpre (maxillary sinus), opens in its upper part
and consequently does not drain well when infected (Fig. 848). The frontal sinus lies in
180
SURGICAL TREATMENT
the frontal bone just above the inner aspect of the orbit. The ethmoidal sinuses are in the
body of ethmoid bone; and the sphenoidal sinuses are in the body of the sphenoid. All of
these sinuses are lined with epithelium.
Instruments. — For the treatment of diseases of the nose certain special
instruments are required. These are nasal specula (Fig. 849), tongue
depressor, illuminator, applicator, and atomizer (Fig. 850). An electric
head lamp is most useful (Fig. 851).
For nasal splint purposes many devices are used. A most effective splint
is made of simple soft rubber tubing, large enough to fill the nostrils. The
tubing should be perforated with fenestra. It may be wrapped with gauze
FIG. 848. — NASAL CAVITIES AND ACCESSORY SINUSES.
Section at a vertical transverse plane, looking backward. Maxillary sinuses are
below and laterally; orbital cavities are above and laterally; ethmoidal sinuses are in-
ternal to orbits.
or it may lie against the mucous membrane. Such pieces of stiff rubber
tubing, about 2.5 cm. (i inch) long, are self-retaining if the front end lies just
within the anterior opening and is caught by the upper fold of the nostril.
Tubes of this sort do not interfere with breathing as does a solid packing.
In other cases an effective splinting of the nose may be accomplished by
packing the nose with gauze. A rubber tube, such as a piece of catheter,
should be first inserted and the gauze packed about this. Gauze may thus
be packed into the nose to make pressure where desired. The gauze may be
controlled better if a sheet of rubber dam is made to surround the tube and
the gauze is packed inside of the rubber dam as an envelop. The rubber
dam should be perforated so that discharges may pass into the gauze.
A mechanical device of much value is the splint contrived by W. W.
Carter (Jour. Am. Med. Assoc., vol. 53, Dec. 4, 1909). This splint is in the
form of a clamp which embraces the nose externally. A bobbin is inserted
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
181
in each nostril and connected to the splint externally by a silk thread which
is passed through the wall of the nose (Fig. 852).
Other splint methods are described under Fractures of the Nose
(Vol. I, page 539). See also the packing methods used in epistaxis.
FIG. 849. — XASAL SPECULUM.
Anesthesia.— For purposes of local anesthesia of the mucous membrane
cocain solution applied directly is used. The part to be operated upon
should be well exposed by means of the nasal speculum, mucus wiped away,
FIG. 850. — ATOMIZER.
and a 4 per cent, solution of cocain, made up with normal salt solution, should
be applied with cotton or gauze on an applicator or forceps. It should be
remembered that only the solution which touches the spot is effective, and
that it is only necessary to anesthetize the area where pain might be inflicted.
182
SURGICAL TREATMENT
FIG. 851. — ELECTRIC HEAD LAMP.
PIG. 852. — NASAL SPLINT.
The metallic bridge presses on the outer parts of the nose; the bobbins are placed within
the nostrils. The threads are passed through the wall of the nose and made fast to the
outer bridge.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 183
For operation upon a deviated septum the solution should be left in contact
with the parts for twenty minutes. To prevent its absorption and action
beyond the area of operation, the saturated pledget of cotton may be enclosed
in a little pocket of rubber tissue having an opening on one side where the
cotton is exposed. The lines of incision may be painted with a 10 or 20
per cent, solution. Before operating, adrenalin chlorid solution should be
applied to make the effect of the cocain more lasting. For small operations
the solution need be applied only a few minutes.
It is always undesirable to use cocain solution in an atomizer because of
the uncertainty of the dosage, the large area exposed to absorption, and the
uncomfortable sensation caused in the throat. The substitutes for cocain
are also used (see Local Anesthesia, Vol. I, page 127).
Local Vasoconstriction.- — For purposes of hemostasis and local vaso-
constriction, adrenalin chlorid is used. To produce local vasoconstriction,
a i : 1000 solution is applied directly the same as the anesthetic. The use of
this substance causes a blanching of the mucous membrane. In local
congestion a i : 5000 or a i : 20,000 solution is employed. As the effect wears
off, it may be reapplied. It is even more effective when used in an oint-
ment or in liquid petrolatum.
Cleansing and Antiseptic Preparations. — Sterilized normal salt solution
has the widest range of usefulness for cleansing the nasal mucous membrane.
When slight antisepsis is desired the following is useful: Sodium bicarbonate,
4 Gm. (i dram); sodium biborate, 4 Gm. (i dram); phenol, 2 Gm. (^
dram); glycerin, 30 c.c. (i ounce); water, 1000 c.c. (i quart). This is used
for irrigation or as a spray and is unirritating, if applied warm. Another
useful preparation is made by substituting for the phenol in the above
combination the following: sodium salicylate, 0.2 Gm. (3 grains); menthol,
0.06 Gm. (i grain); and thymol, 0.06 Gm. (i grain). There are proprietary
preparations, such as alkalol, borolyptol, glycothymolin, and listerin, all of
which are of value. As a protective application to the mucous membrane,
liquid petrolatum is of service. It may be used to carry bland antiseptic
substances which are not soluble in water. Camphor, 0.6 Gm. (10 grains),
to liquid petrolatum, 30 c.c. (i ounce), is sedative and mildly astringent.
Menthol, substituted for camphor in the same amount, used with an atomizer,
is analgesic as well as antiseptic.
A solution of antipyrin, 0.6 to 2 Gm. (10 to 30 grains) in 30 c. c. (i ounce)
of water used with the atomizer, is antiseptic and vasoconstricting. A 50
per cent, solution painted locally is decidedly analgesic.
A powder which has analgesic and antiseptic properties for use in acute
congestive conditions of the nasal mucous membrane is the following:
menthol, 0.06 Gm. (i grain); sodium bicarbonate, 0.12 Gm. (2 grains),
magnesium carbonate (light), 0.2 Gm. (3 grains); cocain hydrochlorate,
0.25 Gm. (4 grains); and milk sugar, 6 Gm. (90 grains). This is employed
as a snuff, the dangers of cocain being borne in mind.
For use in the nebulizer the following is useful: oil of cinnamon, 1.2 c.c.
(20 minims); oil of eucalyptus, 1.2 c.c. (20 minims); menthol, 2.5 Gm.
(40 grains) ; camphor, 5 Gm. (80 grains) ; fluid petrolatum, 240 c.c. (8 ounces).
An effective antiseptic, analgesic, vasoconstrictor preparation is — adrenalin
chlorid solution (i :iooo), 1.2 c.c. (20 minims); menthol, 2.5 Gm. (40 grains);
oil of gaultheria, 1.2 c.c. (20 minims); glycerin, 60 c.c. (2 ounces); water,
240 c.c. (8 ounces).
Injuries of the Nose. — Wounds of the nose should be treated with especial
reference to cosmetics. Skin edges should be sutured with niceness. Frac-
tures of the nose have been discussed (Vol. I, page 539).
184 SURGICAL TREATMENT
Epistaxis (nosebleed), may result from disease or injury. Usually disease
is the cause, and when the constitutional or local disorder is removed, the
attacks cease. In most cases the bleeding subsides spontaneously. In
children, foreign bodies should be thought of. Stimulation of the
vasoconstrictor nerves by stretching the cervical sympathetic in the following
manner stops mild nosebleed: The surgeon stands behind the seated patient,
places his hands at the sides of the head and under the angles of the jaw,
and lifts the head upward, at the same time rotating the face slightly upward.
Slight bleeding may be checked by elevating the head, inhaling through
the nose and exhaling through the mouth. Pressure upon the nasal alae
is of service. Snuffing into the nose iced water, powdered alum, tannin,
10 per cent, solutions of these drugs, or vinegar is useful. Sodium perborate
powder insufflated into the nose with a blower checks small hemorrhages.
Other astringents are employed, such as acetate of lead, sulphate of copper,
sulphate of zinc, in 10 per cent, solutions. These may be used on pledgets
of gauze.
It is best to locate the site of the bleeding, if it is not easily stopped, and
apply the necessary treatment to the bleeding point. Usually it comes from
a small vessel in the anterior lower part of the septum, which may be dealt
with directly. If the bleeding is a general oozing from a congested mucosa,
adrenalin (i : 1000) applied on a pledget, may control it. This is rarely the
case, and when it is, it is difficult to bring the drug in contact with the mucosa
because of the blood.
Ulcerated spots which are bleeding may be touched with the silver nitrate
stick or with 15 per cent, solution of chromic acid. Collodion applied to the
bleeding region is of service. Simple pressure may be made by grasping the
nose between the fingers and holding the nostrils pinched together. If the
bleeding is from an anterior vessel this suffices.
Of more value than all of these tentative procedures, is the usual surgical
treatment of hemorrhage, namely, pressure upon the bleeding vessel. This
should be done by the aid of sight. A speculum should be introduced and
with a good light the bleeding point should be discovered. Gauze should be
packed directly upon it and that part of the nose filled with gauze. A rubber
tube may be admitted and the gauze packed around it. This is the best
treatment of intractable cases.
When the bleeding point cannot be seen, then simple packing of the lower
chambers of the nose should be practised. The packing need not involve the
extreme posterior part unless it is known that the blood comes from there.
In these cases needing gross packing, pressure is best made by means of a
packing of gauze. A piece of fine sterile muslin, linen or rubber dam, about
15 cm. (6 inches) square, should be folded over the end of a pair of forceps
or other straight instrument, which should impinge against its center.
The instrument, carrying the square should be passed back beyond the bleed-
ing point to the posterior wall of the pharynx. The edges are spread out
externally on the face. The instrument is withdrawn, and the end of a
sterilized gauze bandage is passed with a straight probe or forceps through
the anterior nares and is packed inside of the square well back into the nose.
The bandage should be packed in with considerable force until the nose is
full. In most hemorrhages this suffices. The gauze should be about 2.5 cm.
(i inch) wide. It will remain sweet and cause less irritation if it is impreg-
nated with some mild antiseptic, such as 8 per cent, solution of antipy-
rin, europhen powder, or the pulvis antisepticus of the National Formulary.
Instead of the square described above, the thumb of a large, thin rubber
glove may be covered with a mild antiseptic powder or ointment and inserted
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 185
in the nose. The open end anteriorly is held open with four hemostatic
clamps while the interior of the finger is packed with dry gauze. This
packing is continued until the rubber finger is distended sufficiently so that
its pressure stops the bleeding. If desired, more pressure may be secured
by wetting the gauze after it is inserted. This gauze may be removed with-
out fear of pain or of reawakening hemorrhage. Another device is a simple
cigarette roll of gauze enveloped in rubber tissue.
Whatever method of packing is used, it should be removed at the end of
twenty-four or forty-eight hours, and renewed if necessary. The gauze pack-
ing is first pulled out. The external covering should be left for twelve
hours longer.
When these methods fail, or when the bleeding is from a vessel far in
the back of the nose, packing of the posterior naris is called for. This is
easily done by the aid of the canula of Bellocq (Fig. 853), a rubber catheter,
or any other instrument which can be made to carry a loop of string to the
back of the nose. The instrument is armed with a string, and passed from
before backward through the nose. When the string appears below the palate
it is seized in the mouth with long forceps and drawn forward. A plug of
gauze or wool large enough to plug the naris is tied to it. This is then
pulled back through the mouth and up over the palate by making traction
FIG. 853. — CANULA OF BELLOCQ.
upon the other end which emerges through the anterior naris. The pos-
terior end may be left emerging through the mouth for removing the plug.
The nasal string may then be tied down upon an anterior plug, thus effectually
occluding the nose anteriorly and posteriorly. It is well to fill the nose with
gauze before tying in the anterior plug. In some cases each nostril may re-
quire to be plugged in this way.
Packing of the nostrils should not be so tight as to cause pressure-slough-
ing of the mucous membrane, which sometimes occurs in unskillful hands.
The amount of pressure sufficient to stop the bleeding does not require to
be great. Packing should not be left in longer than two days. If these
rules are not observed, undrained septic material may accumulate and pro-
voke serious infection. After carefully removing the packing, the nasal
cavity should be irrigated with warm solution, and the patient kept quiet
for several days.
The surgeon should bear in mind that nose bleed is often salutary. If
the blood-pressure is above 160 mm. the surgeon should allow the bleeding
to continue. In all cases the patient should be kept quiet. Morphin may
be used if necessary. The feet should be made warm. Constitutional
causes should be looked for and remedied by the physician.
186 SURGICAL TREATMENT
Infections of the Nasal Cavities. — Simple acute rhinitis should be met by
the correction of constitutional derangements of etiologic importance.
Fresh air and freedom from auto-infections are essential. Locally the nose
should be irrigated or sprayed with one of the cleansing antiseptic appli-
cations (page 183). Adrenalin chlorid, combined with one of these or
alone, contributes much to the comfort of the patient and shortens the
disease. Hot applications to the nose and brows relieve the feeling of ten-
sion and increase the curative hyperemia. When the congestion is extreme
and the discharge disagreeable, comfort is secured by the internal use of
camphor, 0.03 Gm. (% grain) ; extract of belladonna, 0.007 Gm. (% grain) ;
quinin, 0.06 Gm. (i grain); every hour until dryness of the mucous mem-
brane is secured.
After the acute stage the nostril should be kept washed with one of the
alkaline antiseptic solutions, which may simply be poured into the nose and
allowed to run back to the pharynx. If the discharge continues and is thin
and profuse, astringents, such as 2 per cent, formalin or chlorid of zinc
solution, may be used. Or a few drops of watery extract of hydrastis (i part)
in water (3 parts) may be introduced in the nostrils three times daily.
For the prophylaxis of this condition free nasal breathing is essential.
Persons with narrow nostrils or nasal obstructions should have the condition
corrected by dilatation, plastic operation, or removal of the obstruction.
In the presence of nasal infection, blowing the nose does not give good
drainage. It drives infective material into the accessory cavities. Better
cleansing and some increase of hyperemia is secured by forcible inhalation
through the nose, and expectoration of the material thus sucked back through
the posterior nares. Blowing the nose is unsurgical.
In young children, the local treatment should consist in dropping into the
nose warmed normal salt solution, followed by warmed boric acid solution
(i per cent.). The nose is emptied by grasping it between the ringers, and
drawing them forward a few times. After the cleansing a few drops of
liquid petrolatum may be introduced.
Membranous rhinitis should first have remedied the underlying con-
stitutional disorders. A warm alkaline douche should be used often, and
hydrogen peroxid several times daily. After the membrane has come away,
one of the oily preparations should be employed.
Chronic Rhinitis. — Simple chronic rhinitis demands the discovery and
removal of the cause and relief of the local disturbances. Constitutional
toxemias play an important role, and local treatment is of little avail unless
the general disorders are corrected.
The suction treatment of rhinitis is of decided value. A negative pressure
of 120 mm. Hg. is used. This not only gives the benefit of suction to the
diseased mucous membrane but also cleans out the accessory sinuses.
Hypertrophy of the turbinates, remaining after the above conditions
have been met, if sufficient to cause some obstruction, should first be treated
by compression. This is accomplished by means of a silver tube which shall
crowd aside the swollen structure. This should be worn at first for a few
hours each day; and later it may be worn all day. Another method consists
in making multiple incisions down to the bone. Only when there is an actual
increase in the bony structure is the bone to be removed.
The operation of removal of the turbinate bone is not called for if it is not
producing obstruction. Nor should the operation leave one nasal passage
larger than the other. As little scar as possible should be left. Cauteriz-
ation is objectionable. A portion of the bone is best removed by making
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 187
an incision through the soft tissues, elevating them from the bone, and
cutting out the latter with bone forceps.
Hyper plastic rhinitis should be treated at first as simple chronic rhinitis.
The mucous membrane being gotten into the best condition possible, removal
of hypertrophied tissue is called for. This removal should include the bony
turbinate tissue if it also is hypertrophied. The object of the operation is
to give adequate breathing room. Many methods of operating have been
devised — complicated by a multitude of names and apparatus. Simple
surgical principles require the removal of the obstructing tissue with as little
traumatism, scar and hemorrhage as possible. Cocain and adrenalin
chlorid make the operation simple. Anterior hypertrophies are easily
removed, the surgeon using scissors, cutting forceps, wire snare, saw,
saw-scissors, or knife, whichever suits his convenience. It is neither neces-
sary nor wise to perform long and extensive operations. Several sittings
may be given to aggravated cases. Some surgeons employ the actual cau-
tery, galvanocautery, or chromic acid cauterization to destroy anterior
hypertrophies. These methods require especial skill, should not be used
posteriorly, leave much scar, and ultimately do not give as good results as
the cutting operations. A clean operation may be done by making a V-
shaped incision or cutting out an ellipse and undermining the mucosa so
that it falls together over the wound.
Hypertrophies in the posterior part of the nose are best removed by the
snare. In order that it shall engage posteriorly a mirror in the back of the
mouth or the finger passed up back of the palate may be of assistance.
The wire should be tightened slowly to minimize bleeding. Posterior hyper-
trophies which cannot be snared are best removed with scissors.
After these operations the cavity should be cleansed several times daily
with an alkaline antiseptic wash.
A trophic rhinitis requires cleansing of the nose several times daily with an
alkaline antiseptic wash. Crusts must be kept removed. The use of an
oily application once or twice daily is of service. A good preparation is oil
of eucalyptus, i part, in liquid petrolatum, 80 parts. Stimulation and anti-
septic action may be secured every third day by the insufflation, after cleans-
ing and drying the nose, 0.3 or 1.2 Gm. (5 or 20 grains) of silver nitrate in
30 Gm. (i ounce) of stearate of zinc.
The method of Gottstein has found much favor. This adds to the cleans-
ing treatment the application of a roll of absorbent cotton placed the full
length of the floor of the nasal cavities. A cotton cylinder is made by rolling
the cotton about a smooth applicator to a bulk which will easily pass through
the nose. It is placed upon the floor of the nose and the applicator with-
drawn by turning it in the opposite direction. The patient should do this
himself, removing the plugs when they become saturated. This treatment
stimulates the mucous membrane, removes discharges, and prevents in-
spissation. It is curative in a small proportion of cases. When discontinued
it is apt to be followed by recurrence of the unpleasant symptoms.
The important feature in the treatment of this disease is the removal of
exciting causes both constitutional and local. Diseases of the accessory sin-
uses especially should be cured. When infection gives rise to profuse purulent
discharge, astringent douches should be used. Sulphocarbolate of zinc, 1.2
Gm. (20 grains) in 30 c.c. (i ounce) of water is of value.
Scab formation in the nose requires the treatment given above for atrophic
rhinitis. lodid of potash internally in large enough doses to keep the nasal
secretion in a thin fluid state also prevents scab formation.
Ozena is a symptom of nose disease which requires treatment according
188 SURGICAL TREATMENT
to its etiology. Besides remedying the local disorder, vaccine treatment has
proved of value. The typical symptoms are found associated with the pres-
ence of the Coccobacillus fcetidus ozcena of Perez, and most gratifying results
have been obtained by vaccine treatment with this organism. Vaccine treat-
ment with Micrococcus catarrhalis of Friedlander is useful in some cases.
Specific Nasal Infections. — These infections require the same treatment
as in other parts (see Syphilis, Tuberculosis, Glanders, Leprosy, Actinomy-
cosis, Rhinoscleroma). The nose should be kept cleansed, and obstructions
should be removed.
Tumors. — Benign tumors of the nasal cavity should be removed if they
cause obstruction, irritation, or reflex disturbances. Usually they should be
removed. Pedunculated tumors are best treated by means of the wire
snare. The constriction should be made slowly to avoid bleeding. Cysts
may often be incised and curetted. In removing sessile growths a curved
incision, turning a flap of mucosa upward, is to be preferred. Angiomata
may be removed by the snare, ligature, excision, or cauterization. Malig-
nant tumors should be removed if recognized early. Tumors which are not
easily accessible are approached by an osteoplastic flap (see Resections of
the Superior Maxilla, Vol. I, page 717).
Rhinophyma, the unsightly result of acne rosacea, may be excised with
much satisfaction. Under general anesthesia, an incision is carried around
the anterior borders of the alae and across the middle line. If necessary, this
may be joined by a median incision on the dorsum of the nose. The redun-
dant tissue is dissected up from the nasal cartilages in the form of a flap. The
redundant part of this flap is then cut off, and the wound closed. Irregu-
larities remaining may be shaved off at a later sitting. This latter step of
the operation is feasible because of the great depth to which the skin follicles
penetrate in this disease. In aggravated cases the mass may be removed
as a tumor and the remaining surface covered with skin grafts (see Plastic
Operations, Vol. III).
Foreign Bodies. — Foreign bodies may be removed by grasping them with
curved forceps. Rhinolilhs sometimes require to be crushed by strong for-
ceps and washed out. Smaller bodies may often be washed out, or blown
out by having the patient inspire, block the other nostril and mouth, and
exhale forcibly through the affected nostril. Animate foreign bodies, such as
maggots, insects, leeches, intestinal worms, etc., may usually be washed out
with mild antiseptic solution. If this fails, chloroform is effective. It
should first be used by inhalation through the affected nostril, preferably in
strong vapor as secured by the Junker inhaler. This failing, the fluid should
be injected into the nose. It should be diluted with equal parts of water,
and the patient should be anesthetized on account of the pain. Other sub-
stances, such as turpentine, formalin solution, and iodoform emulsion are
used. A foreign body in the nose of a child may be removed by inserting a
rubber tube in the other nostril, covering the child's mouth with the hand, and
blowing suddenly into the tube.
Foreign bodies in the accessory sinuses or buried in the tissues often
require a cutting operation for their removal.
Malformations of the Nasal Septum. — Deflections of the septum require to
be corrected because of the inequality of caliber of the nasal passages which
are caused by them. If there is no inequality or obstruction, operation is
not necessary. In deflections of the septum, the turbinates in the enlarged
nostril will be found hypertrophied. This hypertrophy is compensatory and
physiologic, and will usually correct itself after the deflection has been cured.
In mild cases of deviated septum, if the cartilage is soft, as determined by
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 189
pressure of the finger, no operation is needed. The septum should be pressed
in place and held by means of a nasal tube (Fig. 854). Such a tube should
be entirely in the nasal cavity. The tube is best made of silver, in order that
its shape may be changed. Hard rubber is also used. In lieu of such an
appliance, ordinary rubber tubing may be employed. Soft tubing may be
reinforced by drawing a second tube inside of it. The inner tube may be
one of smaller caliber or of the same as the outer tube but made to fit by
having a longitudinal section removed. The tube should have its ends
smoothed and be perforated for drainage. It should not make much pres-
sure. At first it should be worn for a few hours each day. As tolerance
develops, it may be worn all day. Several times daily the nose should be
irrigated with cleansing solution. Ulceration from pressure should not be
permitted. After a while the tube may be left out for a day at a time, or
worn on alternate days. The surgeon should keep in touch with the condi-
tion. The change of position and the pressure set up a slight inflammation
which ultimately fixes the parts in their new position. Six weeks at least
are required for the completion of the cure; but
for several weeks longer the septum should be
watched, and treatment renewed if there is a
tendency to relapse.
Bulges of the septum, involving one side
only, are best treated by cutting the deflection
as though it were a tumor. A curved incision
with its convexity downward, reaching to the
bottom of the bulge, is used to turn up a flap
of mucous membrane. The deformity is then
cut off with a sharp knife, saw, or forceps, and
the mucous membrane flap replaced, to be
held by a suture or tampon (Fig. 469). FlG 8-4._^NASAL TUBULAR
In cases in which the septum is not easily SPLINT.
pressed in place, and this is the case in most in-
stances, it must be incised to render it flexible. The incision has the ad-
vantage also of producing plastic inflammation. In incising a deflected
septum it is usually best to make a groove rather than a simple incision,
the removal of tissue facilitating the change of position. A V-shaped file
has been invented for this purpose by G. Fetterolf. In making such in-
cisions, wherever possible, it is best to turn up a flap of mucous membrane
so that the wound of the cartilage is covered after the operation. When this
cannot be done the results from a practical standpoint seem to be about as
good if the mucous membrane and cartilage incisions are made by the same
stroke. If within reach, a suture may be put in the mucous membrane flap;
or it may be held in place by the nasal tube. Unless much care is taken in
its adjustment, it will curl up. Some of the usual conditions to be met and
the incisions required are shown (Fig. 855). The incisions in the cartilage
are made with an angular knife (Fig. 856) which is made to cut out a long
ellipse involving nearly the whole thickness of the septum. It is best to
avoid passing through both mucous membranes of the septum.
These operations may be done under cocain anesthesia, although in aggra-
vated cases, general anesthesia is more satisfactory. Adrenalin may be
depended upon to keep the field free from blood. For bending the septum
into place and making temporary overcorrection, septum forceps (Fig. 857)
are used. I have found strong pedicle forceps sufficient, both for grasping
the septum and for dilating an occluded nostril. After the operation the
nasal tube should be used as above described. In some cases a tube in each
190
SURGICAL TREATMENT
nostril is useful. The parts do not become much fixed with exudate until
after forty-eight hours. If there is great swelling the tube should be re-
moved for several hours each day.
The incisions usually required are two parallel incisions, one on either
side. In irregular deflections, I have secured perfectly satisfactory results
by making an H incision or an X incision, involving the whole thickness of
the septum. These wounds may be expected to heal without leaving a per-
foration; although the operation is not the ideal one. The operator should
FIG. 855. — DEFLECTIONS OF THE SEPTUM.
i, If the cartilage is soft, this can be corrected by pressure alone; 2, does not require
treatment; 3, mucous membrane flap should be elevated and the bulge removed along the
dotted line; 4, showing mucous membrane flap elevated and gutter of cartilage to be re-
moved, after which pressure will correct the deformity; 5, gutters of cartilage in three
places must be removed and correction maintained by pressure of a tube in the nostril;
6, this must be treated by removing a piece of the septum as shown between the two in-
cisions; 7, the condition in 6 is corrected in this; 8, flaps of mucous membrane are reflected
and a segment of the over-riding cartilage removed; g, correction of 8 is shown in this.
not be satisfied until he has broken up the resistance of the septum, and made
it possible to keep it in its new position without undue pressure. No opera-
tion is adapted to all cases; the peculiar conditions in each case should be
met. If the surgeon has in mind a sufficient number of expedients, every
condition can be coped with.
The submucous resection of septal cartilage has certain advantages over
the other operations, especially in angular deflections with redundancy of
tissue. If there is obstruction due to hypertrophied turbinates that should
first receive attention. The operation may be done in either nostril. If
possible it is best done on the convex side. If done in the concave side more
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
191
room is had. The surgeon stands on the side to be operated upon. For a
right-handed operator, the left nostril is most accessible. Local anesthe-
sia is used in adults. The deflected septum should be forced back by
instruments or with the finger to render it pliable. The nose is held open
with retractors. A vertical incision is made along in front of the deflection,
if possible posterior to the free anterior border of the septal cartilage.
It should pass down to the floor of the nose. It should curve backward at
its lower end, and proceed back below the deflection. The incision should
pass through the mucous membrane and slightly into the cartilage. A
FIG. 856. — ANGULAR KNIVES USED FOR OPERATIONS ON THE SEPTUM.
sharp and narrow elevator should be inserted and the mucous membrane
and perichondrium covering the deformity lifted away from the cartilage as
far back as possible. With a sharp curet or swivel knife an opening is
scraped through the exposed cartilage. Through this opening the elevator
is passed and the mucous membrane and perichondrium lifted away from
the septum on the other side.
Care should be taken not to penetrate the mucosa. The bulging part
of the septum is now cut away by pieces with the fine rongeur forceps. As
•
FIG. 857. — SEPTUM FORCEPS.
For holding, bending and shaping septum.
the morcellement progresses the elevation of the uncut mucosa proceeds, a
finger in the nostril protecting it from penetration. The operation may be
continued until all of the bulging cartilage has been removed. It is necessary
to leave a bridge of cartilage at the anterior border to prevent falling of the
tip of the nose. The flap of mucous membrane is put back in place and fixed
by one or two sutures or it may be held by a carefully applied tampon. The
tampon should be saturated with petrolatum. The dressing may be removed
in twelve hours. Some surgeons obviate the need of dressing by passing a
few quilting sutures through and through. Fine catgut is used. No nasal
192 SURGICAL TREATMENT
tube is required. The lines of incision through the mucous membrane may
vary to meet the conditions present. After resection of the septum, there
is danger of deformity if the nose receives a traumatism which flattens it.
Instead of making an incision with the horizontal limb posteriorly, many
rhinologists prefer to make the vertical incision at the back of the deformity,
and carry the horizontal incision forward from its lower end. Whatever
operation is done, sharp edges and angles projecting under the mucous mem-
brane should be removed.
The transplanting of cartilage is practised with success in many of these
cases. The cartilage which must be removed from the septum is excised
in the form of a piece, large enough for use, and placed in warm salt solution.
One or two pieces may be employed. These pieces are placed between the
mucous flaps, and the wound sutured. This operation may also be used in
the treatment of perforation of the septum.
Lateral deflection of the nose is treated by making a short incision parallel
with the long axis of the nose, at the anterosuperior border of the convex side,
about the junction of the cartilage and nasal bone; through this a narrow
FIG. 858. — METHOD OF USING RUBBER TUBES TO SUPPORT A DEPRESSED NOSE.
Three tubes are here shown. The lower outer one is split lengthwise. The tubes
should be of thick rubber. If they are too soft they may be reinforced by drawing one
inside another. This apparatus may be held together by two silk sutures or silver wire
at either end. It is of use also in fractures of the nose. A new set must be made often,
as the tubes soon lose their resiliency.
knife cuts out an ellipse of cartilage, along the lower border of the nasal
bone and the upper part of the nasal margin of the superior maxilla. If
possible this operation should not open the mucous membrane, but if it does,
no great harm is done. The removal of this ellipse should allow the nose to
be pressed over in its normal line. A suture of chromic catgut should be
put through the cartilage below and caught in the periosteum above without
penetrating the skin. The skin wound should be sutured and the nose held
in a corrected position by a pad of gauze and adhesive strips. At least a
month should be given to the consolidation of the cartilage. Deflection of
the septum, which is usually present in these cases, should also be treated.
Saddle-nose. — This condition, due to disease destroying the lateral and
triangular cartilages or to injury displacing them backward, should, if pos-
sible, be treated in its early stages. After an injury the depressed and broken
cartilages should be lifted up by instruments passed in the nose. They may
be kept elevated by the introduction of perforated rubber tubes, preferably
a large one below supporting a smaller one resting upon it (Fig. 858).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
193
In old cases there is often depression of the nasal bones and sometimes
separation of the nasal processes of the superior maxilla. This should first
be corrected. A short incision is made along the front edge of the nasal
process and an osteotomy done, severing the process from the body of the
bone. This is done on each side. The nasal bones are then broken loose
from their attachments by forceps thrust into the spaces made by elevating
the skin and mucous membrane from their upper and lower surfaces. The
bones, thus loosened, are elevated within the nose by a rubber or metal
splint, and the nasal processes compressed from the outside (see Fractures
of the Nose, Vol. I, page 539). After the bony parts have healed, in about
two months, an attempt to restore the soft structures may be made.
There are many operations confined to the intrinsic structures of the
nose, for this purpose, none of which is wholly satisfactory. A procedure
applicable to the largest range of cases will be described. An incision is
carried around the anterior margins of the alae and tip of the nose, and the
skin dissected free as far back as the bony margin of the nares. A flap is
FIG. 859. — SADDLE-NOSE, TREATED BY SWINGING UP HALF OF THE LATERAL CARTILAGE
FROM EITHER SIDE.
then cut from the upper part of the lower lateral cartilage. This flap should
represent about half of the lateral surface of the cartilage and have its base
toward the median line (Fig. 859). This is done on each side. A suture of
chromic catgut is then passed through the junction of the upper lateral and
septal cartilage close to the nasal bones. This suture should cross the median
line from one side to the other and include only enough of the cartilage to
give a good hold. Each end of this suture is then passed through the outer
end of the flap of cartilage. As the suture is drawn up and tied, the flaps
are drawn up to the median line at the nasal bones and made to overlie the
superior lateral cartilages which are usually atrophied and depressed. The
skin flap is then brought down and sutured in place.
At the same time that this operation is done or at another sitting, the
septum should be straightened and elevated. Usually it is found distorted
and depressed. A good practice is to make long horizontal incisions through
one mucous membrane and the cartilage at each bend, and not only correct
the deflections but insert such a nasal tube as shall lift up the whole nasal
bridge.
VOL. II— 13
194
SURGICAL TREATMENT
A method which I have applied with better success than it deserves con-
sists in the introduction of a bridge of hard rubber under the skin. A waxen
impression of the contour of the nose is first made, and a bridge of hard
rubber constructed which shall fill the depression (Figs. 86e and 861). The
FIG. 860 — SADDLE-NOSE BEFORE OPERATION.
prosthesis should be perforated to permit the ingrowth of fixing tissues. The
skin should be dissected up from the edges of the alae and tip of the nose back
to the 'nasal bones and nasal process. Bleeding should be stopped and the
prosthesis slid into place, to be covered by the skin. The operation must
FIG. 861. — SADDLE-NOSE TREATED BY THE SUBCUTANEOUS IMPLANTATION OF HARD
RUBBER PROSTHESIS.
This is a case operated upon by the author twenty years ago, before osteoplastic surgery
had been perfected. The picture shows the condition three weeks after operation.
be clean. It has the disadvantage of leaving a foreign body which may at
any time make trouble. If the septum is not straightened and the bridge
lifted up the physiologic defect remains.
The same objections inhere in the use of paraffin. It has been much
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 195
employed for the cosmetic treatment of saddle-nose. It is more prone to
cause ulceration and abscess than one might judge from the literature (see
Paraffin in Surgery, Vol. Ill) .
The plastic operations, in which tissues external to the nose are used, is
described elsewhere (see Plastic Operations on the Face, Vol. Ill) .
Collapse of the Alee. — -This condition may be remedied by systematic ex-
ercise of the dilator muscles of the nostrils. The use of a perforated silver
tube, placed just within each nostril, and worn as many hours of the day as
possible, not only helps correct the deformity but gives better breathing.
When these methods do not suffice, the nasal openings may be enlarged by
carrying the bases of the alae slightly outward; or by making a horizontal
incision through the middle of each ala and closing it as a vertical wound.
This latter procedure is indicated when the edges of the alag are curled
inward (see Plastic Surgery of Face, Vol. III).
Nasal Synechia. — When the condition interferes with nasal respiration,
it should be operated upon. Bony growths should be removed by the saw
or forceps. Synechia of soft structures may be divided with the knife. If
possible, tissue should be removed so that there is enough separation to pre-
vent recurrence. The wound surfaces should be kept covered with gauze.
Frequent cleansing should be practised. Exuberant granulations, if they
coalesce, will defeat the operation. They should be suppressed with silver
nitrate.
Perforation of the Septum. — This condition, if due to ulceration, should be
met by treatment of the infection and necrosis. When the perforation is
clean and no ulceration is present it usually requires no treatment. If treat-
ment is called for, a sliding flap of mucous membrane on either side, not taken
from opposite areas, may be used.
Acute Catarrhal Inflammation of the Antrum of the Superior Maxilla. —
This should be treated as acute rhinitis. To facilitate drainage through the
one small opening into the nose, adrenalin chlorid solution should be applied
to the orifice. This is located just above the middle of the inferior turbinate
bone, a trifle below the level of the floor of the orbit. Ichthyol, 25 per cent.,
in hydrated wool fat, may be applied to the middle fossa of the nose. Should
secretions be retained, drainage at a dependent place becomes necessary.
Any diseased teeth should receive attention.
Chronic Catarrhal Inflammation of the Antrum.— This may be cured by
irrigation of the antrum through the ostium. Rarely can this be done easily
or satisfactorily. Usually drainage at the lower part of the antrum, as for
empyema, is required before a cure is affected.
Empyema of the Antrum. — This should be treated by first emptying the
cavity of pus. The place of choice for drainage of the antrum must depend
upon the cause of the suppuration. If it is of dental origin, the offending
tooth should be extracted and the antrum opened through its socket. In
infection of nasal origin, the nasal disease should receive treatment. Many
surgeons prefer to make an opening from the inferior fossa of the nose into
the antrum. This should be made at a level with the floor of the nose below
the natural opening, about 3 cm. behind the anterior end of the inferior
turbinate. A sharp-pointed curved knife or an angular knife is used to
make a small V-shaped cut. A trocar may be used. Through this open-
ing the antrum may be irrigated and treated as any other abscess cavity.
Insufflations with boric acid or iodoform are also used. Such an opening
should be enlarged, if drainage is not adequate.
For drainage of the antrum, preference is to be given to the opening
through a tooth socket. Rarely is it necessary to sacrifice a sound tooth.
196 SURGICAL TREATMENT
When there are no diseased teeth an opening may be drilled in the interval
between the first molar and bicuspid teeth on the palate side. If there is a
diseased tooth or an absent tooth between the first bicuspid and the first
molar, the opening should be made in its socket. The opening can best be
made with a dental drill, although a hand drill suffices. The hole should
be not smaller than 5 mm. in diameter. Local anesthetic injected into the
gum gives analgesia. After the cavity has been washed out the opening
should be kept plugged with gauze. Irrigation should be practised daily.
A small canula of silver, slightly flanged at the upper end, may be fitted in
the opening. Food does not enter this small opening. The patient can
make the daily irrigations with a hand bulb syringe. If the tube or gauze
packing is left out the sinus usually will close spontaneously.
If the secretion does not steadily diminish, and has not ceased entirely
in the course of three or four months, it should be assumed that there is
present a local disturbance which requires more radical treatment for its
removal. Granulations, a foreign body, a polyp, or necrosis of the walls of
the sinus may be present.
The sinus not healing, free opening of the antrum should be made. The
operation may be done with local anesthesia. An incision is made through
the mucous membrane and periosteum horizontally along the outside of the
alveolar process from the canine tooth to the second molar. The soft tissues
are elevated upward away from the bone, and the wall of the antrum opened
by a trephine or chisel. The opening should be enlarged with the rongeur
until the interior of the sinus can be freely inspected. If, on account of
bleeding, a good view cannot be had, the cavity may be packed with gauze
and further treatment deferred. Inspection should reveal the cause of the
continued suppuration. Granulations should be cut down and cauterized,
tumors, foreign material, or necrosed bone should be removed. Septa, which
are retaining secretions, should be broken down. If there is disease of the
ethmoid cells, communicating with the antrum, the ethmoid should be
curetted out. The subsequent treatment should consist in daily irrigation
and packing with gauze. Iodized gauze answers admirably. The opening
into the mouth will persist for months or years, and may never close. The
patient should learn to irrigate it and care for it daily. A rubber or gold
obturator should be made by a dentist to cover it.
When it becomes necessary to secure a large opening for free drainage,
the opening should be made in the nose. Such an opening may be expected
speedily to cure chronic suppuration. The anterior half of the inferior
turbinated body should be removed. An opening extending from the floor
of the nose as far up as the middle meatus is made. If it is desired to make
a permanent opening, the mucous membrane should be removed. This is
done in bad cases. If temporary drainage is aimed at, the mucous membrane
should be elevated on either side of a vertical incision in the outer wall of
the nose, and bone alone removed. The mucous lining of the antrum is also
retained. This constitutes a submucous resection of the outer wall of the
nose. A burr or a chisel may be used for this operation. Free drainage
having been secured it is best not to destroy the mucous lining of the antrum
by curetting. The drainage alone will suffice to cure most cases of
suppuration.
When the patient wishes to be rid of the opening at the price of cosmetics
or when the treatment requires more radical measures, obliteration of the
antrum may be done. The elevation of periosteum and soft tissues from the
front of the bone should be carried up to the infraorbital canal, inward to
the nose, and outward to the malar bone. The whole front wall of the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 197
antrum should then be cut away. The mucous membrane lining the antrum
should be destroyed by the curet. The soft tissue covering its front is
then pushed into the cavity so that it snugly enters it. An internal and
external vertical incision of the periosteum may be required. A ball of
gauze is applied to the skin of the face to keep the soft tissues pressed into
the antrum. Bonninghaus, in performing this operation, cuts away the
inner bony wall of the sinus, leaving the nasal mucosa which may be pushed
outward by packing gauze about a rubber tube in the nose. It is possible
to expose the antrum by lifting up an osteoplastic flap, made by dividing all
of the margins of the anterior bony wall, except the upper which is to be
broken. This gives free access, by means of which the interior may be
treated, curetted, or cauterized, packed with gauze and drained either through
the mouth or lower nasal fossa.
Instead of pressing the tissues of the face into the cavity, the antrum
may be filled with fatty tissue transplanted from elsewhere. After removing
the facial wall of the antrum, the mucous lining should be destroyed with
the sharp curet, this destruction should be complete and should be supple-
mented by the cautery if necessary. The cavity should be packed with
gauze until a lining of granulations appears. Then a piece of fat should be
cut from the abdomen, in the shape of the cavity and inserted. It should
approximate the shape and size of the cavity. The skin should be closed over
it, and its primary union should be expected.
The closure of sinuses between the maxillary antrum and the mouth is
not difficult. It is often difficult to keep such a sinus open. To close a
sinus which refuses to close, an opening should be made between the nose and
the antrum to provide drainage ; necrotic bone of the alveolar process should
be removed; a flap of alveolar mucous membrane should be dissected back
on either side of the opening; if possible a flap should be lifted up within
the antrum; the mucous membrane is then sutured in the mouth; fine silver
wire or horsehair should be used for the suture.
Tumors of the Antrum. — Tumors require the same treatment as when
arising in other parts. Benign growths, such as mucocele, cysts, and polyps
may be approached by the same routes as described for empyema. Mucocele
usually requires curettage of the antrum.
Foreign Bodies in the Antrum.- — Whether foreign bodies are inanimate
or animate, an artificial opening is required for their removal. This is
best made in the lower fossa of the nose, where, by means of irrigation, the
material may be brought to the mouth of the opening. Animate things
may be dislodged by the methods given for the nasal cavities.
Suppuration of the Ethmoid Sinuses (Consult Fig. 848).— Operations
upon the ethmoid sinuses for septic conditions are dangerous because of the
frequency with which meningitis develops in these cases. In certain rather
rare cases, there is natural drainage, and by irrigation and treating the sinu-
ses with hot air, healing may be brought about without operation. Usually
better drainage must be provided. Hypertrophy of the nasal mucous
membrane should be cured. To reach the ethmoid cells, the anterior two-
thirds of the middle turbinate bone must be removed. This wound overlies
the cells. The ethmoid cells are opened with a sharp curet or gouge. Gen-
tle curettage should be practised. Care should be exercised in curetting
out the ethmoid lest the cribriform plate above or the outer wall be punctured.
The cavity should be kept irrigated and dried out with hot air. Irrigation
should never be forcible lest infection be driven into adjacent spaces.
The older the disease the more thorough should be the curettage. Acute
198 SURGICAL TREATMENT
cases should simply have the nasal opening made, but no curettage or other
traumatism.
Operation on the ethmoid cells by the orbital route is called for when the
outer wall of the ethmoid has become perforated and infection of the orbit
is present. Some days before this operation is undertaken, the nose should
be cleared of obstructive disease, and the anterior two-thirds of the middle
turbinate bone removed. A curved incision is begun at the supraorbital
notch, carried inward just below the upper margin of the orbit, and thence
curving downward on the inner side of the orbit nearly to the infraorbital
foramen. This incision passes through skin and periosteum. This flap
is then elevated from the bone until the orbital surface of the ethmoid
(os planum) is exposed. The os planum is freely opened with a gouge, and
all suppurating cells exposed and curetted. The anterior and posterior
cells should be made to communicate and an opening made in the nose. This
operation allows of inspection of the sphenoid cells and the frontal sinus. If
infection does not extend into these, a light packing of gauze should be intro-
duced, brought out through the nasal opening, and the orbital wound sutured.
This external operation gives an approach which permits the operator to see
what he is doing, and to determine whether infection has extended into the
adjacent sinuses.
The after-treatment should provide an unobstructed nasal exit for
discharges, but much care must be used in irrigation.
Suppuration of the Sphenoid Sinuses. — This condition usually follows
disease in the adjacent sinuses, and, therefore, often may be treated in con-
nection with the preexisting disease. Both sinuses may be involved at once,
but usually the infection is unilateral. The first essential is the treatment of
any nasal inflammation which may be present. Nasal drainage should be
made perfect. A mild alkaline antiseptic wash should be used. The middle
turbinate is the guide. If the upper border of this bone is followed it leads
to the sphenoid sinus. Some surgeons prefer to remove the middle turbinate
some days before in order to have a clear view. A probe-pointed irrigator
should be introduced into the sinus through the natural ostium. If the
opening is free the sinus may be washed out; if the irrigator fits snugly, it
should be aspirated. The application of adrenalin will cause the swollen
mucosa to contract. If treatment by irrigation is not effective, or if urgent
symptoms demand immediate and free drainage, the opening should be
enlarged. The sinus should be opened with a gouge or small sharp curet
(Fig. 483). Often the mouth of the sinus close to the septum can be seen
discharging pus, and a probe can be introduced as a guide. The floor of the
sinus may be broken away freely in all directions, but it is dangerous to
traumatize the roof or outer wall. If the nose is free of obstruction, and the
middle turbinate has been removed, this is not a difficult operation. Cleans-
ing of the nose is the essential part of the after-treatment.
Extranasal approach to the sphenoidal sinus is described under Opera-
tions on the Pituitary Body, page 82. The sphenoid may be opened through
the frontal sinus when the latter also is diseased. It may be opened
through the ethmoid sinuses when they are diseased.
The direct approach through the nose is the same as for the first steps of
the intranasal operations to expose the pituitary body. Ordinarily 20
per cent, cocain solution, in i : 1000 adrenalin is applied to the lateral wall
of the nose and the septum. The posterior half of the middle turbinate is
then removed. The posterior ethmoidal cells are then broken through with
hook and curet. This breaking down of cells is carried back into the sphe-
noid. If the anterior wall of the sphenoid sinuses is thick, a stronger in-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 199
strument may be required. Curetting granulations out of the sinus is rarely
justified. It may be done only in the old chronic cases, and then with the
greatest care.
Acute Catarrhal Inflammation of the Frontal Sinuses. — This condition
should receive the same treatment as acute catarrhal rhinitis with which
it is commonly associated. Hot applications over the brow and hot nasal
douches are of service. Swelling of the mucosa can be allayed and better
drainage secured by the application of adrenalin solution or cocain (4 per cent) .
to the middle fossa of the nose. A drying of the excessive secretions may be
secured by the internal use of belladonna.
Chronic Catarrhal Inflammation of the Frontal Sinus. — This condition
should be treated the same as chronic catarrhal rhinitis. A tampon, satu-
rated with a 10 to 25 per cent, solution of ichthyol, placed in the upper part
of the nose, is of help. When secretions are retained, the treatment becomes
that of empyema. Adrenalin applied to the mucous membrane in the upper
part of the nose helps the drainage.
Empyema of the Frontal Sinus. — Any nasal disease present should receive
treatment. By applying adrenalin to the upper part of the nose cavity, the
shrinkage of the mucous membrane may be relied upon to give better drain-
age. If drainage is still hindered by swelling of the mucous membrane, the
front half of the middle turbinate bone should be removed and the opening
into the nasofrontal duct enlarged. Sometimes irrigation of the sinus, by
means of a curved canula, can be conducted through the nose. In most
cases when empyema has developed the presence of granulations, swollen
mucosa or necrotic material prevents this. The conditions to be met are
similar to those in the antrum. Before any operation, all obstructions in the
nose should be removed; and the ethmoid cells should be examined for
empyema and, if necessary, freely curetted.
The free opening of the frontal sinus is best accomplished as follows: An
incision is begun at the supraorbital notch and carried inward just below
the superior margin of the orbit to the nasofrontal juncture. This should
divide skin, muscle and periosteum. The periosteum and soft parts are then
elevated from the bone with a periosteal elevator and retractors inserted.
A small trephine, about i cm. in diameter, is applied to the frontal eminence.
The opening should be i cm. external to the median line, on a level with the
upper border of the orbit. Granulation tissue and detritus should be removed
from the sinus, the nasofrontal duct enlarged, the interior dried and treated
with tincture of iodin or nitrate of silver solution, and a wick drain inserted into
the duct and passed on into the nose. Usually the communication with the
nasal cavity must be enlarged before the drain is inserted. The skin wound
is closed with a subcuticular suture. The drain is drawn out through the
nose on the second day. If caries of the ethmoid is present, it should be
curetted by way of the frontal sinus. When this is necessary, a large open-
ing should be. made into the nose and a packing of nosophen gauze brought
out through the nose.
The sinus may be reached by retracting the periosteum and soft tissues
from the inner, upper, and anterior aspect of the orbit. The floor of the
sinus is here opened, and treated as above. This opening is so close to the
os planum of the ethmoid, that the ethmoid cells are easily opened at the
same time.
Daily irrigations of the upper nose and sinuses should be practised.
When there is necrosis of bone or when after many weeks the sinus refuses to
heal, a radical operation for its obliteration should be done.
H. A. Lothrop (Annals of Surg., vol. 59, 1914) devised an operation which
200 SURGICAL TREATMENT
is less formidable. It begins with an incision along the inner part of the
superior orbital margin and curves downward toward the inner canthus.
The supraorbital nerve should not be cut. The incision is about 2.5 cm.
(i inch) long. The bone is bared by lifting up a flap of soft parts and perios-
teum. An oval opening about 2 cm. (% inch) long is made into the sinus.
Pus and granulations are removed, and a probe is passed through the ostium
into the nose. This probe is left in place as a guide. A small curved curet
is then passed down in front of the probe and the cells on the floor of the
sinus broken up. The posterior angle of the sinus should be avoided on
account of its closeness to the cribriform plate. With a burr or rasp the
dense bone between the floor of the sinus and the base of the nose is reamed
out. This bone includes the nasal crest, the spine of the frontal bone, and
the end of the nasal process of the upper jaw. The interfrontal septum
also should be cut away with the burr to open the other sinus for exploration.
Next the perpendicular plate of the ethmoid should be removed. Through
the large opening thus made the dense bone below the opposite sinus is
FIG. 862. — LINE OF INCISION FOR WIDELY OPENING BOTH FRONTAL SINUSES.
burred away, until there remains a thin shell of bone representing the two
sinuses. Even when only one sinus is infected, experience has showed the
wisdom of opening both. Sufficient bone should be removed from the per-
pendicular plate to open, the ethmoid cells. If the maxillary antrum is
infected, a large opening should be made in the nose below the inferior tur-
binate. The periosteum-skin flap is sewed back in place and the wound
closed without superficial drainage. Subsequent treatment may be applied
through the nose. Some surgeons complete the operation by placing a rubber
tube in the sinus and the nose, passing a wick drain through it, and filling
the sinus with the wick. The wick can be withdrawn through the nose
leaving the tube in place.
For the wide opening of both frontal sinuses an incision should be made in
the bed of the eyebrows. These two incisions should curve downward and
join by crossing the nose just above the place where the bow of spectacles
would rest. A practically concealed incision is thus made (Fig. 862).
The frontal flap of scalp is dissected up and retracted. An osteoplastic
flap, broad above and narrow below, representing the anterior walls of the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 201
sinuses, is next cut. This may be done with a small drill to make the holes,
followed by the wire saw. After the first holes have been bored, a fine probe
may be used to determine the size of the sinus. The flap is left attached at
its base at the root of the nose. The flap is turned down by fracturing across
the base, the periosteum being left unbroken (Fig. 863). The diseased sinus
is treated, the opening into the nose enlarged, drainage into the nose provided,
the osteoplastic and scalp-flaps replaced, and the wound sutured.
Sinus infections perforating into the orbit may come from the frontal or
ethmoidal sinuses. They are best exposed by an incision along the inner
border of the orbit. If necessary the incision may be extended upward below
the eyebrow. After elevating the soft tissues with the periosteum, the
diseased sinus may be opened, curetted and drained.
The intranasal treatment of sinus infections should always be considered
before external operations. The sinuses naturally drain into the nose.
By patiently cocainizing the mucous membrane, the entrance of the sinus
FIG. 863. — OPERATION FOR WIDELY OPENING BOTH FRONTAL SINUSES.
Showing scalp retracted upward, bone-flap turned down and probe enlarging opening
into nose.
may be reached and a free drainage secured. Even in cases in which there
are swelling, edema, redness, and heat showing on the face, intranasal treat-
ment may obviate extranasal operation.
Intranasal drainage of the frontal sinus may be accomplished in most
cases. Local anesthesia suffices. In chronic cases, the anterior end of the
middle turbinate is removed and the nose well cleansed. The preliminary
steps may be taken in a few days before operation on the sinus. Under local
cocain and adrenalin influence a probe is passed into the nasofrontal sinus.
The sinus having been located, the opening is enlarged with the burr operated
by an engine, or it may be rasped out. The sinus should be irrigated with
warm salt solution. Some rhinologists place a tube in the sinus, fix it in the
nose, and irrigate through it daily with warm boric solution. Care should
be taken not to penetrate the cribriform plate of the ethmoid.
If the usual treatment of frontal sinus disease by suction and irrigation
fail, a more radical operation may be done. The anterior end of the middle
turbinate is cut off and the anterior ethmoidal cells cut away with biting
forceps (Fig. 864). The inner wall of the ethmoidal labyrinth should not
202 SURGICAL TREATMENT
be injured. The operation should keep close to the orbital wall, which should
not be penetrated. A curved curet, rasp, or forceps easily enters the frontal
sinus (Fig. 865).
For obliteration of the frontal sinus, the operation of Killian is performed as
follows: (a) An incision is carried from about the junction of the upper and
FIG. 864. — NASAL APPROACH TO FRONTAL SINUS.
The anterior end of the middle turbinate has been removed, and the forceps are cutting
away the anterior ethmoidal cells.
outer margins of the orbit inward along the upper margin to the root of the
nose, lying wholly in the area of the eyebrow. The incision then passes
downward upon the nasal process of the superior maxilla, following the
margin of the orbit, and curves outward to end below the inner canthus
FIG. 865. — NASAL APPROACH TO FRONTAL SINUS.
The forceps enter the frontal sinus after removal of its floor.
(Fig. 866). One or two transverse cuts across the wound may be made in
order to facilitate exact coaptation at the close of the operation. The
incision is carried to but not through the periosteum. The overlying soft
tissues are dissected back and retracted on either side of the incision, uncover-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
203
ing the superciliary ridge, the nasal eminence, and the anterior aspect of the
upper and inner walls of the orbit, (b) An incision is made through the perios-
teum parallel to the supraorbital margin, and 5 or 6 mm. above it. This
FIG. 866. — OPERATION FOR OBLITERATION OF FRONTAL SINUS.
Skin incision which is carried down to the periosteum.
FIG. 867. — OPERATION FOR OBLITERATION OF FRONTAL SINUS.
The soft tissues are retracted. Lines show periosteal incisions.
extends from the outer end of the skin wound to the median line at the root of
the nose, (c) Another incision through the periosteum begins at the anterior
aspect of the juncture of the upper and inner orbital walls just internal to
204
SURGICAL TREATMENT
the attachment of the pulley of the superior oblique muscle, and follows
the line of the descending skin incision to its termination (Fig. 867). (d)
The periosteum is then elevated from the superior incision upward over the
anterior wall of the frontal sinus; and from the inferior periosteal incision
it is elevated backward, exposing the bone of the inner and upper walls of
the anterior part of the orbit. Between these two areas of denuded bone,
there remains a strip of periosteum which is to be left covering a bridge of
bone intended to support the soft parts at the close of the operation, (e)
The wall of frontal sinus should then be opened by a small trephine, or gouge
applied just above the periosteal bridge. The lining mucous membrane of
the sinus should not be ruptured, and should be carefully pushed away from
the bone as the anterior wall of the sinus is freely removed by gouge or
rongeur. As the bone is cut, the mucous lining is kept pushed away with a
probe or fine elevator. If a rongeur is used the edges of the bony opening
should be smoothed with a chisel. All of the angles of the sinus should be
FIG. 868. — OPERATION FOR OBLITERATION OF FRONTAL SINUS
The sinus has been uncovered, leaving bridge of bone. The floor of the sinus is to be
removed with chisel. The ethmoidal cells are exposed.
uncovered. (/) Having done this, the lining of the sinus should be liberated
throughout the rest of its extent, and removed. The presence of granula-
tion tissue will often cause the mucosa to tear, and require the use of the
curet. All of the soft contents of the sinus should be removed, and septa
broken down.
(g) The floor of the sinus is then removed with the gouge. The bone is
thin. An opening into the orbit results (Fig. 868) . The nasal process of the
superior maxilla is removed, and the removal of the floor of the sinus com-
pleted throughout. In order to avoid tearing the nasal mucous membrane,
it should be perforated with the point of a knife at the edge of the nasal bone;
then with a probe-pointed scalpel the incision should be continued upward
and backward to a point 5 mm. below the cribriform plate of the ethmoid;
from here the incision should pass a short distance downward to make a
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 205
tongue-shaped flap. This flap is turned outward and used to cover the parts
of the wound adjacent to the nasal cavity. A permanent communication
is thus established between the frontal sinus and the nasal cavity.
(h) Next the ethmoid cells, anterior and posterior are examined, and, if
found diseased, removed with the curet. The middle turbinate may also
be removed. At this stage the sphenoid sinus is accessible, and, if diseased,
its anterior wall may be opened and the sinus curetted. If necessary, in
order to reach the posterior ethmoid cells and the sphenoid cavity, a part of
the nasal bone may be cut away, (i) The wounds should be irrigated; and
a wick drain should be passed from the outer part of the frontal sinus inward
through the nasofrontal opening into the nose. The soft parts are then
replaced, and carefully sutured with the view of securing primary union.
(/) The patient should lie on the sound side. Care should be taken that
he does not blow his nose lest septic material be forced into the sinuses. The
drain should be removed through the nose on the second day, the sutures on
the fifth day. The after-treatment consists in keeping the nose clean. If
irrigation becomes necessary it should never be used with sufficient force to
drive fluid into the sinuses. Granulations springing up about the naso-
frontal orifice should be suppressed with silver nitrate. From two to six
months are required for healing. The depression at the brow may later be
remedied by an osteoplastic operation.
NASOPHARYNX AND FAUCES
The inflammatory diseases of the nasopharynx (Fig. 869) require about
the same treatment as those of the nose.
In hyperplastic nasopharyngitis, the hypertrophied tissue should be
removed, either by a snare passed through the nose and guided by pharyngeal
illumination, or by the retropharyngeal snare (Fig. 870) or cutting-forceps
(Fig. 871). In syphilitic pharyngitis, adhesions are prone to develop between
the soft palate and posterior pharyngeal wall. Such adhesions should be
divided, but unless the palate is kept retracted anteriorly, they surely will
reform. This is prevented by the use of a palate retractor, which the patient
should use twice daily, drawing the palate forward. No operation should
be done until the patient is thoroughly under antisyphilitic treatment.
Local antiseptic applications should be used.
Retropharyngeal Abscess. — The treatment of this disease depends upon
its cause (see Abscess, Vol. I, pages 251 and 258). As a rule, it may be said
that all abscesses except those of tuberculous origin should be opened. In
order to avoid edema of the glottis, evacuation of the abscess is often urgent.
In acute abscess evacuation is always imperative. A local anesthetic suffices
except in the case of children or very nervous persons, when general anesthesia
is used. The operation should not be done with the patient fully narcotized.
A mouth gag, a tongue depressor, and a long straight bistoury are required.
If there is danger of wounding the palate or tongue, the blade should be
wrapped with adhesive plaster excepting its point. The operation should
be done with the patient's head lowered so that the pus shall run up into the
nose and mouth rather than downward. This is because of the great danger
of aspiration of infective material into the trachea. The danger is an immi-
nent one, because of the closeness of the pus to the glottis, and the large
amount which may at one moment bathe the epiglottis. It is certain to be
inspirated if the patient happen to inhale at the moment it gushes forth.
The head should be kept dependent not only at the operation but for several
hours afterward, until the pus has become evacuated.
206
SURGICAL TREATMENT
A less dangerous route is through the side of the neck. This is by all
means indicated if enlarged or suppurating lymphatics are present. An
incision is made along the anterior border of the sternomastoid muscle
FIG. 869. — ANATOMY OF NASOPHARYNX AND FAUCES.
which should be retracted strongly backward. The deep fascia is divided
posteriorly and the sheath of the carotid and internal jugular retracted for-
ward. With the anterior scalenus muscle as a guide, a blunt dissection is
FIG. 870. — SNARE FOR REMOVING PEDUNCULATED GROWTHS FROM NASOPHARYNX.
carried directly inward to the space between the longus colli and the con-
strictors of the pharynx, where the abscess will be found. A drainage tube,
a few sutures, and a copious dressing complete the treatment.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
207
Abscess due to spinal caries should be opened externally through the neck
and with great aseptic care. A small incision is made posterior to the sterno-
mastoid muscle, the fascia is divided, and a pair of forceps inserted through
the tissues to the front of the transverse processes. The abscess having been
located, it is given the necessary treatment.
Diphtheria (Klebs-Loffier membranous pharyngitis) is quite as much
a surgical disease as erysipelas, hospital gangrene, or suppurative tonsillitis.
Its treatment should best be carried out by the laryngologist. It will be
found best described in works on internal medicine. The pediatrists have
the most experience in its treatment. Briefly: The strength of the patient
should be conserved. Diphtheria antitoxin should be injected as soon as the
diagnosis is made. The curative dose is 1000 antitoxic units. The earlier
the injection, the better the results. Persons who have been exposed should
be immunized with an injection of 500 units. The patient should be isolated.
If the symptoms grow worse the antitoxin should be injected every six
hours, increasing the dose 1000 units at each injection. If begun early one
or two doses suffice. Usually three doses are enough. Laryngologic skill
is required in the local examinations and applications, to inflict the least
FIG. 871. — CUTTING FORCEPS FOR REMOVING GROWTHS FROM THE NASOPHARYNX.
strain upon the patient. If a weak solution of iodin does not keep the throat
clean, peroxid of hydrogen may be used. When the false membrane reaches
the upper part of the pharynx or nose the parts should be sprayed every hour
with equal parts of hydrogen peroxid, cinnamon water, and watery extract of
witch hazel. Loose pieces of membrane should be removed with forceps or
swab. Progressive asphyxia, as shown by dyspnea, stridor, cyanosis, and
retrocession of the soft parts of the chest wall during inspiration, calls for
intubation or tracheotomy (pages 226 and 237).
Tuberculosis of the pharynx should be treated the same as tuberculosis
elsewhere. The constitutional treatment is most important. Pain may be
relieved temporarily by cocain or orthoform locally. Dilute nitric acid in an
equal amount of water, applied directly to ulcers or used as a spray, relieves
pain. Pineapple juice as a local application is also of value. If all of the
ulcerated area can be brought into view, good results follow its complete
excision by means of the sharp curet. Lupus is best treated by curettage
of ulcers and nodules. The object of the treatment should be to remove
all of the diseased tissue. Antiseptic astringents should be used in the
wounds (see Tuberculosis, Vol. I).
208 SURGICAL TREATMENT
Glanders, actinomycosis, herpes, and mycosis should be treated accord-
ing to the rules given elsewhere. Mycosis is best treated by cleansing with
hydrogen peroxid and touching the infected areas with tincture of iodin once
daily. The cautery may be required in obstinate cases. Keratosis of the
pharynx and tonsils is best treated by curettage followed by chromic acid
(30 per cent.).
Tumors of the Nasopharynx.— Benign tumors are usually fibromata which
when pedunculated can be removed with the snare. Sessile fibromata usually
require an osteoplastic operation to gain access. Temporary resection of the
superior maxilla is often necessary (see Operations on the Superior Maxilla,
Vol. I, page 717). In the case of large tumors, temporary occlusion or liga-
tion of the external carotid arteries facilitates the operative work. Prelimi-
nary tracheotomy is to be done if the tumor is of such size as to occlude the
pharynx. The injection into the substance of the tumor of monochloracetic
acid in saturated solution has been reported curative.
Adenoids of the nasopharynx should be prevented by securing the best
hygiene for the child. Next to a good general bodily vigor, fresh air is most
important. This is not an all-important factor because children of good
general health, who live out of doors day and night, still develop adenoids. A
damp climate, especially in which there are sudden and great changes of
temperature, seems to be an etiologic factor. Children which are reared in
climates where the temperature is equable, where the air is less damp than
at the seashore, and where they live out of doors most of the day, are least
prone to have adenoids. Dirty and dusty air aggravates the disease. Ane-
mia and toxemias are also causative.
Adenoid vegetations should be cured because they cause obstruction to the
free passage of air through the nose, distortions of the bony framework of the
nose, mouth, pharynx, ear, and thorax, mental defects depending upon these
conditions, diseases of the structures adjacent to the nasopharynx, and a
general deterioration of health and physique. Successful treatment demands
early recognition and removal of the adenoids. The first step in the treat-
ment should be the removal of causative factors. In some cases this will be
sufficient to convert a mouth-breathing child into a nose-breather. In most
cases some operative treatment must be added to this. The disease should
not be thought of as a neoplasm, but as a hypertrophy of normal glandular
tissue, the removal of which is called for when it produces disturbance.
In the soft adenoids of young children, but a simple operation is required.
These friable growths in infants can be removed with the finger. If they
are simply abraded or lacerated, they become absorbed and disappear. No
anesthetic is required. The after-treatment should be the same as that in
the older cases. The ordinary case of adenoids requiring operation is between
two and six years of age; obstructive symptoms are already present; and the
effect of the vegetations upon the child's health is easily seen.
Some surgeons prefer to operate without an anesthetic. The child is wrap-
ped in a sheet which confines its arms and legs. A nurse or assistant sits
facing the operator and holding the child on her lap. The child sits upright
and looks in the same direction as the assistant. The latter holds the child's
legs between her legs, passes the left arm around the front of the child's body
to hold the trunk and arms, and with the right arm against the child's fore-
head presses its head back against her left shoulder. The operator sits facing
the patient. By cultivating a good entente with the child, the surgeon may go
about his work leisurely, giving the patient an opportunity to spit and wash
out the mouth and receive some cheerful word of encouragement. When the
child is intractable to suasion, then the operation may proceed with the same
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
209
expedition as is employed when an anesthetic is used. The operation without
anesthesia has the advantages that there is less bleeding, the surgeon may
work more deliberately, and the hazards of narcosis are obviated; the dis-
advantages are that the child is slightly hurt and often much scared, and the
operator must have greater tact and dexterity. Operation without anesthetic
is to be practised only when there is some good reason for withholding
anesthesia.
Most operations are best done with the patient under the influence of an
anesthetic. Local analgesia should be thought of only in the cases of adults.
For children the best anesthetic is ether and oxygen or nitrous oxid and
oxygen. Ethyl chlorid, somnoform, and chloroform have their advocates.
FIG. 872. — CUTTING CURET FOR THE REMOVAL OF ADENOIDS FROM THE NASOPHARYNX.
More important than the agent employed is the employer. None but a skilled
anesthetist, should be intrusted with this responsibility, as these children are
usually of depleted vitality, with deranged respiratory organs, and the
anesthetic has to be discontinued and resumed at the convenience of the
operator. The child should be anesthetized in the recumbent position.
The best position for operating is with the head low in order that blood
shall not run into the larynx and esophagus. This position is secured by
placing a small sand pillow behind the shoulders or better still by an exag-
gerated lowered head position. If the head becomes congested and the
veins dilated, the head may be elevated for a few minutes until the circula-
tion becomes balanced.
FIG. 873. — ADENOTOME.
This instrument has a flexible cutting blade which slides at the floor of the instrument
and closes it. The amputated tissues find themselves enclosed in a box.
Some surgeons prefer to operate with the patient in the sitting position.
My friend Thomas R. French, brought this method to a high state of
perfection. He invented a chair in which the patient is strapped as soon as
the anesthesia is established. The chair is so arranged that it may be tilted
backward at any moment and the recumbent position secured. Operating
with the patient erect is accompanied by decidedly less bleeding, less anes-
thetic is required, there is less congestion of the vessels of the head, and the
blood runs forward out of the mouth and nose. The surgeon should use the
method to which he and the patient are best adapted.
Special instruments are required. The adenoid curet (Fig. 872) and the
adenotome (Fig. 873) are used. The mouth gag (Fig. 874) should be so con-
structed and applied as not to injure the teeth. Schultz has invented an
VOL. II— 14
210
SURGICAL TREATMENT
FIG. 874. — HINGED MOUTH GAG.
FIG. 875. — REMOVAL OF NASOPHARYNGEAL ADENOIDS.
Showing proper position of adenoid curet for the removal of the whole mass with one stroke
of the instrument.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 211
adenotome which is an effective instrument. Small pledgets of gauze in
sponge holders are used for sponging away the blood. Instruments for per-
forming tracheotomy should be at hand in case of accident.
The patient having been anesthetized for the operation, he is placed in
position, and the mouth gag inserted on the left side and intrusted to the
anesthetist. If the tonsils require operation, which they usually do, this
should be done before the adenectomy (see Tonsillectomy, page 213). By
drawing the tongue forward and elevating the uvula a fair view of the phar-
ynx is secured. With the modified Gottstein curet, the adenoid mass is cut
away from the posterior wall of the pharynx. The size and shape of the
instrument must depend upon the size of the throat and the location of the
disease. It is not necessary to do a thorough scraping operation. The
skillful surgeon, with one stroke of the curet, usually removes all that is
required (Fig. 875). If the growth is high in the pharynx above the reach
of the curet, a small straight curet may be used. This is passed straight
back through the nose and guided by the finger in the pharynx. When
adenoids are large, or hard, as in adults, the adenoid forceps are useful.
When forceps are employed the soft palate is held forward by the left fore-
finger, and the blades are opened so as to grasp nearly all of the lymphoid
tissue. The curet should then be used.
The operation should not be carried so far laterally as to injure the
mouths of the Eustachian tubes. The index finger should precede the
instrument to determine just what is to be done. After the growth, or its
major part has been removed, the finger should be used to break down the
lateral masses and separate adhesions between the growth and the faucial
pillars and sides of the nose. This latter should be depended upon to clear
the Eustachian orifices.
The wound should be sponged dry. The after-bleeding should be but
slight. If bleeding persists it may be controlled by pressure with a gauze
tampon. The patient should be watched for hemorrhage during the first
twelve hours. Should bleeding recur, packing may be depended upon to
control it. If it is severe, packing through the nostrils may also be used.
Healing usually is rapid. No irrigation is necessary unless a purulent dis-
charge develops. The patient should take soft food for a few days, and then
his regular diet. Freedom from dust aids healing. Fresh air is essential.
Recurrences are not uncommon even when a complete operation has been
done. They are observed usually in children in whom the etiologic factors
have not been eliminated or in whom there exists a predisposition to lym-
phatic hypertrophies.
The treatment of adenoids during the first year of life must often be operative.
No anesthetic is necessary. The child should be wrapped in a sheet which
holds its arms at the sides. It should be held upright by the nurse, with the
back of the child's head against the front of the nurse's left shoulder. One
arm should envelop the body and the other hand should press back against
the forehead. A gag is held by the assistant. The operator holds down the
tongue, then passes in an adenoid curet (Gottstein), and with one stroke
removes the growth. The head is quickly brought forward to let the blood
escape, and a small piece of ice enveloped in a square of gauze is pressed into
the pharynx. When the bleeding has stopped, the child is again held up, the
gag and tongue depressor inserted, and an examination made by passing the
finger into the pharynx to see that the operation has been satisfactorily done.
Such young children, even in the fourth or sixth month of life, with cough,
snuffles, malnutrition, and some temperature, seem to do well after this
operation.
212 SURGICAL TREATMENT
Tonsils. — Acute tonsillitis may be an expression of constitutional disease
or it may be a distinctly local infection or irritation. In any case the cause
should be sought and removed if possible. Acute catarrhal tonsillitis should
be met by first purging the system of toxins. The inflamed tonsil should
be painted with pure guaiacol or a similar drug. The drug should be carried
down into the crypts by means of cotton tightly wound about the end of an
application probe. The guaiacol should not run over the surrounding mu-
cosa. This should be done every four hours; and by the fourth application,
it will usually be found that the disease is controlled. If no good results are
observed by the third application the drug should be discontinued. Inter-
nally the ammoniated tincture of guaiac, i to 1.3 Gm. (15 to 20 minims)
every two hours may be given. Fasting or a fluid diet should be prescribed.
For cleansing the tonsil of discharges a gargle should be used every hour.
Hydrogen peroxid is effective. Hot applications to the side of the neck aid
hyperemia. The local application of 4 per cent, cocain solution relieves pain.
A tonsil which has become greatly enlarged and tense, and is causing diffi-
culty in swallowing may be relieved by multiple punctures and hot-water
gargles.
In follicular tonsillitis, the early stage should receive the treatment de-
scribed for the acute catarrhal variety. The tonsil should be anesthetized
with cocain solution and each crypt opened with a probe, followed by a fine
angular curet, and emptied of its contents. The crypts should then be
treated with pure guaiacol on cotton swabs. Suppurative tonsillitis (periton-
sillar abscess, quinsy) should be treated the same as the above. When
abscess has formed, or even before, incision is called for. This is best done
with a sharp-pointed straight bistoury. The blade should be wrapped with
gauze or adhesive plaster, leaving exposed about 1.5 cm. of the tip. Incision
should be made at the lower part or where the abscess seems to point, and
should be toward the median line in order to avoid the great vessels which
lie just external to the tonsil. Membranous tonsillitis of nondiphtheric
origin should be treated by dissolving the membrane with peroxid of hy-
drogen, applied with a pledget of gauze, several times daily. This should
be followed by the application of an antiseptic solution. None is better than
Loffler's solution, which consists of alcohol, 60 parts; toluol, 36 parts; and
liquor ferri sesquichlorid, 4 parts. If peroxid of hydrogen cannot be had,
the membrane may be digested away by the local application of an animal
or vegetable enzyme.
Chronic tonsillitis may manifest itself as a continuation of any of the
acute forms, and require the same treatment as they. Caseous tonsillitis,
retention of caseous secretions in the tonsillar crypts, should be treated by
freely incising the crypts throughout their whole depth, curetting or sponging
out their contents, and applying tincture of iodin or pure phenol on a pledget
of cotton to the interior of the cavity. If the tonsil contains multiple dis-
tended crypts and is chronically inflamed it had best be removed. Mycosis
of the tonsil is treated by correcting any disease of the mouth, and applying
tincture of iodin to the tonsil.
Chronic hypertrophy of the tonsils should not be confused with enlargement
due to dilatation of the blood-vessels or to the presence of serous exudate.
The tonsils of children are normally comparatively large. An acutely in-
flamed tonsil is enlarged, but will return to its normal state when the inflam-
mation has subsided. Such tonsils may require treatment but not necessarily
extirpation. Extirpation is reserved for tonsils which are so enlarged that
they cause obstruction to the respiratory tract, the throat or to the Eustachian
tubes; which are the seat of chronic inflammation which is intractable to
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 213
treatment; or which contain septic material which is causing auto-intoxication.
When any or all of these conditions exist the tonsils should be removed.
In the case of the soft tonsil, local applications and the correction of
defects of personal hygiene, such as are recommended for acute tonsillitis,
will often be of service. Fresh air is essential in these cases. The relief of
intestinal disorders is important. If the tonsil is not occupied by septic
crypts, the removal of the part of it which projects medianward beyond the
pillars of the fauces may be expected to be followed by a cure. In the case
of the hard, fibrous, or cryptic tonsil, more of the organ should be removed
than just the projecting portion.
Removal of the tonsil (tonsillectomy) or enucleation of the tonsil, has sup-
planted the old operation of partial removal (tonsillotomy). The operation
is indicated (i) in simple hypertrophy which causes interference with respira-
tion, and (2) in infections of the tonsil causing local or constitutional dangers
or disturbances. In the first class, tonsillotomy or incomplete removal may
be done; in the second class, the whole gland should be removed.
Removal of tonsils is not to be regarded lightly. The operation is best
done in the hospital, where the patient should have been sent the day before
the operation. The operation should not be done in the presence of acute
inflammation. Women should not be operated upon during menstruation.
The tonsils should not only have been inspected but palpated also, to detect
arterial pulsation, bony or cartilaginous deposits, or the presence of a dis-
FlG. 876. TONSILLOTOME (GUILLOTINE).
placed styloid process. The danger of hemorrhage may be reduced by giving
calcium lactate for a week before the operation. The index of coagulability
may be taken. A hypodermic injection of atropin will reduce the amount of
secretion during the operation.
General anesthesia should be used in the cases of children and nervous
adults. Ether is the anesthetic of choice. Local anesthesia is useful for
older children and calm adults. By painting the surface of the tonsils,
pillars of the fauces, posterior wall of the pharynx, and lower part of the
velum palati, with 10 per cent, cocain solution, rubbing it also into the
recesses, a satisfactory anesthetization may be secured. Adrenalin solution
(i : 1000) is then applied to the same surface. Then a milder anesthetic
solution, such as i per cent, cocain, novocain, or stovain, etc., containing
adrenalin is injected in the tonsil in four places so that the solution reaches
the periphery. If there has been much inflammation local anesthesia will
be found not altogether satisfactory.
The position of the patient is a matter of choice with the operator. Some
prefer the patient with the head lowered in extreme dorsal extension, others
operate with the patient sitting; and others prefer the patient lying on the
right side. The first position has the most to recommend it.
The incomplete operation, which consists in the removal of a larger or
smaller part of the tonsil, was once the common operation. It is done with a
tonsillotome (Fig. 876). It still has its value. The tongue is depressed, the
214 SURGICAL TREATMENT
tonsillotome is slipped over the tonsil and with a quick cut the organ is
divided. Some surgeons become so dexterous that they are able to operate
on the opposite tonsil before the blood from the first has obscured the view.
Usually it is best to sponge away the first blood and dry the wound between
operations.
It is possible, by drawing the tonsil forward and upward after the ring of
the tonsillotome has been slipped over it, to compress it against the alveolar
eminence of the lower jaw, and thus press it practically through the ring and
remove the whole tonsil (G. Sluder).
In children the preparation and methods of operating are the same as for
adenoids (page 208). Usually hypertrophy of the faucial tonsils and of
the pharyngeal adenoid tissue appear together, and should be operated upon
together. The tonsils should receive first attention. They come better
into view when the child is in the sitting position. A tenaculum may be
passed through the ring of the instrument to draw out the tonsil to be cut in
case the tonsillotome does not reach it well.
In operating upon adults, local anesthesia is best; the tonsillotome is
not necessary; the operation may be done with laterally curved scissors or
an ordinary narrow bistoury, after grasping the tonsil with a tenaculum.
The so-called tonsil punch is a useful instrument for removing parts of a
tonsil or for securing portions which the tonsillotome fails to grasp. It is a
cutting forceps with lateral grasp.
Usually after these operations there is no hemorrhage. Sometimes on
account of the presence of an anomalous vessel, bleeding persists or comes on
as a secondary hemorrhage. This condition should always be anticipated
with watchfulness. Slight oozing may be controlled by pressure made for
a few minutes, or by the application of peroxid of hydrogen, tannic acid
solution, or alum powder. When the bleeding is active, the pillars of the
fauces should be retracted apart and the bleeding point seized with curved
forceps and ligated. If a ligature cannot be applied, it may be possible to
pass a suture around the stump. In the event of failure to secure the vessel,
pressure should be employed. For this purpose the tonsillar hemostat is best.
It is a forceps with two light blades, the end of each being armed with a hard
rubber button, one of which is applied to the wound, the other to the outside
of the neck. A pad of gauze should be placed over each. The instrument
may be left on from six to twelve hours. It should be applied only with
sufficient force to stop the bleeding. When the bleeding is not controlled or
serious anemia threatens, ligation of the external carotid may be depended
upon to check it, provided it does not come from a wound of one of the great
vessels.
The after -treatment is the same as that for adenoids: fluid diet, rest, and
fresh air; and antiseptic applications only in the event of suppuration or
sloughing. Usually no application is needed. When necessary, tincture of
benzoin may be applied, or a douche used. The results of the operation are
gratifying. This is especially so in the obstructive cases in children. The
removal of the tonsils in children does not damage the voice; in most instances
it improves it. In older persons, there may be some change in the quality.
The enudealion or complete removal of the tonsil (tonsillectomy) is
the operation which is now most employed. It is the only operation that
should be done for infected tonsils. The tongue is depressed, the tonsil is
grasped with tenaculum forceps. With a knife the tonsil is cut free above
and at the faucial pillars. Scissors, curved on the flat, may be used for this
purpose (Fig. 877). The tonsil is separated from its attachments by means
of the blunt end of the scissors or a tonsil separator (Fig. 878), which is
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
215
curved and about as sharp as a periosteal elevator. Some surgeons use the
index-finger. By blunt dissection the organ is detached from all its connec-
tions excepting the base externally. As the tonsil is lifted inward out its of
bed, a snare is placed around the remaining pedicle, which is crushed. Bleed-
ing is less than in partial tonsillotomy; more skill is required. It is incorrect
to speak of the operation as complete if some portions of tonsillar tissue
remain (Fig. 879).
Some surgeons, after freeing the tonsil from its bed, place the wire snare
about the pedicle, tighten it, and then proceed with the other tonsil. When
the other tonsil has been liberated, the first tonsil is detached by crushing
off its pedicle with the snare, and then the same thing is done with the second
tonsil after hemorrhage has stopped. Care should be taken to see that the
uvula is not included in the loop of the snare.
FIG. 877. — ENUCLEATION OF
TONSIL (TONSILLECTOMY). FIRST
STAGE.
Incision has been made between
tonsil and the anterior and pos-
terior pillars of the fauces and
above. The tonsil is being liber-
ated by blunt dissection.
FIG. 878. — ENUCLEATION OF TONSIL
(TONSILLECTOMY). SECOND STAGE.
The tonsil is dissected free from its
upper, posterior, and anterior attach-
ments, and drawn inward by the tenac-
ulum forceps.
This operation should remove the whole tonsil. If some portion of
tonsil remains, especially in the upper part of the fossa, it should be removed
with the tonsillar punch or the snare. During the operation, blood should
be removed by gauze sponges on holders. A skillful assistant is valuable
in this work.
The patient should not be sent from the operating room until the cessation
of bleeding is assured. If pressure does not control bleeding, a search should
be made for the bleeding vessel. Hemorrhage will usually be found to come
from the tonsillar artery or the venous plexus near the middle of the wound.
The vessel should be seized with a curved clamp. It may be twisted or tied;
the hemostat may be left on; or a tampon may be pressed into the wound
and the pillars of the fauces sewed over it.
Care should be taken in all operations to remove no tissue except the
216
SURGICAL TREATMENT
tonsil. Careless operators have sacrificed the muscular tissue of the faucial
pillars with the result that adhesions and discomfort have followed.
The removal of tonsils by means of the guillotine has been facilitated by
drawing the tonsil forward and upward and then pressing it outward against
the alveolar process of the lower jaw. In order to do this a guillotine tonsillo-
tome, having a ring through which the tonsil may protrude, is used. The
blade should not be sharp, but dull — not rounded, but simply not sharp.
The distal part of the ring is pressed back of the tonsil so far that the tonsil
may be lifted forward by it. The alveolar process then stops the tonsil
anteriorly, as the blade of the guillotine is pressed home. The ring passes
external to the tonsil, and ultimately around it, lifting it out of its capsule and
detaching it. The tonsil may by this method be quickly enucleated with one
instrument and one hand. The distal ring part of the instrument should be
thin, strong and rounded, so that it may be pressed
well out behind the tonsil.
Imbedded or adherent tonsils sometimes are so
covered by the pillars of the fauces as to be almost
hidden. Usually such tonsils are found high up
and often causing Eustachian trouble. The pillars
must be separated by blunt dissection and the
tonsil brought into view. Such tonsils should be
removed.
Foreign bodies in the tonsils and pharynx, such as
fish bones, often become lodged. Frequently such
objects cannot be seen because of the muscular
spasm. This may be relaxed with cocain. Often
bodies which are supposed to be lodged lower
down are found by careful search behind the tonsil.
In searching for these bodies the localizing sense
of pain is often misleading. The first examina-
tion should be without instruments in order to
have the patient relax the throat as much as
possible. The foreign body may usually be picked
FIG. 879. ENUCLEATION ou^ with forceps. Even after the body has been
OF TONSIL (TONSILLEC- removed the sense of irritation remains, and the
TOMY). THIRD STAGE. patient will often insist that it is still present.
The remaining basilar Tumors of the tonsils should be removed,
attachments of the tonsil Malignant tumors may be approached through
are crushed by the wire ,1 ,, •, .-, . fr ^1 i ^
snare which is passed about Pe mouth, or by the external route. The latter
the pedicle. is that which is described for epithelioma of the
posterior part of the tongue. Temporary division
of the lower jaw facilitates the approach. The general principles of opera-
tion are the same as upon the tongue.
Many of these cases are inoperable, and nonoperative and palliative
treatment are indicated. If there is foul secretion, antiseptic gargles should
be used. Excellent analgesics are cocain or orthoform applied locally.
Equal parts of thymol, chloral, and camphor, rubbed on the skin of the neck
give relief. Dyspnea may require tracheotomy. Dysphagia is overcome by
the use of a tube passed by the obstruction and into the esophagus. Hemor-
rhage may be controlled by local styptics or ligation of the external carotid.
Exposure of the Nasopharynx. — Many operations have been devised
for gaining access to the upper part of the pharynx for the purpose of remov-
ing tumors and performing other operations. Some of these operations
will be found described under operations on the bones of the head. The
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 217
operations used for gaining access to the body of the sphenoid bone, for
entering the sella turcica to remove the pituitary body, may be used. Most
satisfactory exposure of the nasopharynx may be secured by dividing the
lower jaw in the middle line, retracting the two halves laterally, drawing the
tongue down into the cleft, separating the soft palate from the hard palate
by a long transverse incision, and retracting the soft palate downward upon
the tongue. This gives wide access to the nasopharynx. After the operation
the divided parts are all restored to their natural positions by sutures.
LARYNX AND TRACHEA
Anatomy. — The larynx is a cartilaginous box, seated on top of the trachea. It is made
up'of several cartilaginous plates, the most important of which are the thyroid, cricoid, and
the two arytenoid. It is attached above to the hyoid bone by the thyrohyoid membrane
and muscles. The cavity of the larynx is closed above by the epiglottis, a valve which
prevents the entrance of foreign matter (Fig. 869). Two dense elastic bands, the vocal
cords, stretch across the interior of the larynx and divide it into an upper and lower chamber.
Two folds of mucous membrane above the vocal cords constitute the false vocal cords.
Between the two is the laryngeal ventricle. The sensory nerve supply of the mucous
membrane of the larynx is through the internal branch of the superior laryngeal nerve.
This nerve passes through the thyrohyoid membrane with the thyrohyoid artery. The
arytenoid muscle and the cricothyroid muscle are supplied by this nerve. The recurrent
laryngeal nerve supplies the other muscles. Sensory acuteness is present to a very high
degree in the mucous membrane of the larynx above the vocal cords. Traumatism here
is highly capable of producing shock. The lymphatics communicate with the chain along
the internal jugular vein. The larynx lies in front of the bodies of the fourth, fifth and
the upper margin of the sixth cervical vertebrae.
The trachea is a tube composed of cartilages and intervening membrane. It is about 12
cm. (4% inches) long, and in the male its transverse diameter is from 2 to 2.5 cm. (% to i
FIG. 88 1. — LARYNGOSCOPIC MIRROR.
inch). It extends from the larynx to the fourth dorsal vertebra, where it divides into the
right and left bronchi. The cartilages of the trachea number eighteen or twenty, are in
the form of incomplete rings, the gaps being posteriorly. The rings and their interspaces
are connected by elastic fibrous membrane. The orifice of the right bronchus is more in a
line with the long axis of the trachea than the left.
In the neck it has in front of it from above downward the isthmus of the thyroid gland,
the inferior thyroid veins, the sternohyoid and sternothyroid muscles, and anastomosing
branches' between the anterior jugular veins. In the thorax, it has in front of it the manu-
brium, the remains of the thymus gland, the arch of the aorta, the innominate and left
carotid arteries, and the deep cardiac plexus of the sympathetic nerves. Behind is the
esophagus, which deviates to the left at the arch of the aorta. Laterally in the neck are
the common carotid arteries, the lateral lobes of the thyroid gland, the inferior thyroid
arteries, and the recurrent laryngeal nerves. In the thorax the pleurae are on either side
and the pneumogastric nerve lies between the pleura and trachea.
Satisfactory examination and treatment of the interior of the larynx and
trachea can be made only by one who has skill and experience in this special
line of work. The gross external operations fall easily within the realm of the
general surgeon. For securing a view of the interior of these organs a good
light, back of the patient's right shoulder, a reflecting mirror on the surgeon's
forehead and a laryngeal mirror, held in the back of the pharynx, are employed
(Fig. 881). Better than a tongue depressor is to have the patient protrude
the tongue, wrap it with a piece of gauze, and hold it with his own fingers
(Fig. 882). Local anesthesia and hemostasis are secured by the same means
218
SURGICAL TREATMENT
as in the nose (page 181); and the same antiseptic and cleansing solutions
may be employed.
In performing endolaryngeal operations, a spray of 4 per cent, cocain is
used, or, better still the part to be operated upon may be touched with a
stronger solution. Especial skill and practice are required because the
anterior and posterior pictures are reversed by the laryngoscope, and the
operating instrument must be directed in the direction opposite to where the
point of attack seems to be. The lateral reflection is not thus reversed.
Cocain in the larynx, it should be remembered sometimes gives a patient the
sensation of suffocation, which is entirely a sensory disturbance. If pro-
longed treatment is required, such as the removal of an intralaryngeal growth,
it is best to accustom the patient to the manipulations by repeated prelimi-
nary examinations and mechanical irritation of the parts. A patient by
practice may be made able to tolerate such manipulations without their
exciting spasm of the throat muscles.
FIG. 882. — LARYNGOSCOPIC EXAMINATION.
Showing positions and methods of illumination for the ordinary laryngeal treatments.
Malformations of the Larynx and Trachea. — Congenital stenosis usually
is in the form of webs or bands stretching across the glottis, and other abnor-
malities are usually present. Nasal and pharyngeal obstructions to breath-
ing should first be corrected. The surgeon should be ready to perform trache-
otomy at any time. If the stenosing membrane is delicate the introduction
of an intubation tube should suffice to give dilatation. Dilatation may be
secured by means of the angular laryngeal forceps passed through the con-
striction and opened. Sounds are also employed. A cutting dilator is some-
times useful.
Aerocele occurs as a pouch filled with air which pushes out between the
cartilages of the larynx or trachea in the neck. It should be treated the
same as any other hernia. The sac should be exposed, excised, the opening
closed by sutures, and the wound sewed.
Acquired stenosis, due to traumatism, inflammation, ulceration, or caustic
inhalation, should be relieved by tracheotomy whenever required. For the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
219
local disease, inflammation and ulceration should be overcome by appropriate
applications. The rest secured by tracheotomy is often of help. The
method of dilatation of the stenosis must depend upon its character. Intuba-
tion with the O'Dwyer tubes may be indicated. The use of dilating forceps,
sounds, or a cutting instrument must depend upon the case. In extreme
cases an external operation should be done. Thyrotomy or tracheotomy
should expose the lesion, and appropriate treatment may be applied.
In stenosing hypertrophic subglottic laryngitis the surgeon has to deal with
a condition usually following tracheotomy for diphtheria; although it may be
associated with other forms of irritation. When the tracheotomy tube is
removed, it is found that the patient has stenosis above the
tracheal opening. In cases in which the new tissue is soft,
treatment consists in the use of an intubation tube for as
many hours each day as it can comfortably be worn. Or a
smooth rubber tube may be passed through the larynx, the
lower end resting upon the tracheotomy tube and the upper
end just reaching above the stenosis (Fig. 883). The tube
may be secured by engaging its lower end in the tracheot-
omy tube, or a silk suture may pass out through the mouth
and be fixed to the face by adhesive plaster. When the
disease is older and the hypertrophic tissue is firm, laryn-
gotomy gives access, and the stenosing bands may be divided
or removed. A rubber tube may then be put in place, and
left for two or three days. Urethral sounds passed upward
through the tracheal opening are useful dilators.
John Rogers invented an intubation tube which passes
down below the tracheal opening, and receives a second tube
or plug at right angles through the tracheal opening (Amer-
ican Jour, of the Med. Sciences, Nov., 1905). This plug
holds the tube and prevents its displacement (Fig. 884).
Injuries of the Larynx and Trachea. — Burns should be
treated by total rest of the voice, and cold applications to
the outside of the neck. The surgeon should be prepared
to perform tracheotomy and insert a tube in the event of
progressive edema or stenosis.
Contusions may cause submucous hemorrhage which
should take care of itself unless so great as to produce steno-
sis, in which event tracheotomy is called for. Contusions
of the larynx may be serious because of the intimate relation
of its nerves to the blood-pressure regulating mechanism.
Fatal cases of shock have resulted from such contusions with-
out gross lesions. The surgeon should beware of this, and
be ready to treat shock when contusions of the trachea are
threatened or have occurred.
Fractures of the larynx and trachea are rare and serious conditions. Frac-
tures of the laryngeal cartilages often result fatally from the entrance of
blood into the trachea or from laryngeal edema. Tracheotomy and the
insertion of a tube should be done as soon as possible, before serious symp-
toms appear. Blood should be aspirated from the trachea. Then any
displacement which needs attention may be remedied. In fractures of the
trachea, tracheotomy below the injury should be done. Unless tracheotomy
is done early in these cases, a rapidly developing emphysema may make the
operation difficult. If the operation cannot be performed at a place lower
than the injury, then the lower end of the tube should reach below the level
FIG. 883 —
SOFT RUBBER
TUBE FOR MAIN-
TENCY OF TRA-
CHEA AFTER
OPERATION
STENOSIS.
FOR
220
SURGICAL TREATMENT
of the injury. If the ordinary trachea tube is not long enough a rubber tube
should be used. Any wounds of larynx or trachea which are accessible may
be sutured.
Dislocations of laryngeal cartilages are easily reduced by manipulation,
aided by swallowing movements or flexion and extension of the head.
Wounds of the larynx and trachea require first that a free respiratory
channel shall be secured. If the wound has not caused bleeding into the
lumen, its treatment as an ordinary wound is all that is necessary. If suffi-
ciently large, it should be sewed. Sutures should involve all of the layers
except the mucosa. Usually bleeding into the trachea is present. This
calls for a free exposure of the injury and ligation of the bleeding vessels.
Tracheotomy below the wound is commonly an advisable expedient. This
allows of free exposure of the wound and treatment while respiration goes
on unhampered. Wounds of the larynx call for tracheotomy because of the
danger of fatal edema of the glottis which may develop at any minute. In
FIG. 884. — LARYNGEAL INTUBATION TUBE, COMBINING A TRACHEOTOMY TUBE, DEVISED
BY ROGERS.
The intubation tube with the bulb is inserted through the mouth into the larynx. The
straight tube is passed through the tracheotomy or laryngotomy wound and screwed into
the former at a right angle. The pin prevents unscrewing.
the event of much loss of substance or great laceration, it often becomes
advisable to place a good-sized rubber tube in the lumen of the larynx and
trachea, above the tracheotomy tube, in order to obviate stenosing contrac-
tures during healing. Such a tube may be removed by a silk thread passed
through its upper end, brought out through the mouth, and fastened to the
ear and face by adhesive plaster. After its removal, an intubation tube
should be introduced at frequent intervals (see Cut Throat, Vol. II, page 360).
A wound of the extreme lower end of the trachea or of a bronchus may
be sealed by including the apex of the lung in the suture to cover the wound.
Wounds of the trachea or larynx with loss of substance may be covered by
a bone-and-skin flap, including a layer of the anterior plate of the upper end
of the sternum. The skin is turned in to take the place of absent mucous
membrane. The clavicle may be used for the same purpose. The opening
may be covered by soft tissue and a cartilage graft from the rib inserted to
give stiffness.
Inflammations. — Acute catarrhal laryngitis is treated largely internally
by medical means. Inhalation of the compound tincture of benzoin by
pouring two teaspoonfuls upon half a pint of boiling water is of help. A
tablespoonful of paregoric added to the above may be inhaled for extreme
irritability. The same effect is secured by the use of a spray or nebulizer
carrying a bland oily antiseptic. The following is useful for this purpose:
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 221
liquid petrolatum, 30 c.c. (i ounce); oil of sandalwood, 0.3 c.c. (5 drops);
oil of tar, 0.2 c.c. (3 drops). Hot applications to the skin of the neck are of
service. Rest of the voice is called for.
Laryngeal spasm occurs both in adults and children. Laryngismus
stridulus usually yields to medical treatment. The application of hot wet
cloths to the front of the throat, as hot as can be borne, may be expected to
relieve alarming acute attacks. If the patient is made to vomit, the spasm
will relax. Even when these measures are not employed, relaxation of the
spasm usually takes place as a result of carbon dioxid intoxication before
death occurs. Traction on the tongue by grasping it with the fingers and
pulling it forward at intervals corresponding with the frequency of respira-
tion tends to relieve spasm of the glottis. If the jaws are tightly closed, the
same effect can be produced by pushing the lower jaw forward by means of
the fingers behind the angles. Sometimes the condition becomes so alarm-
ing and intractable that tracheotomy or intubation is called for.
Other methods for relieving spasm of the glottis are cold applications to
the front of the neck, hot foot baths, and the exhibition of relaxing drugs.
A few inhalations of chloroform or amyl nitrite are effective. The general
health of the patient should be improved. In adults the correction of nasal
disease, such as adenoids, polyps, turbinate hypertrophies, or other causes
of obstruction or irritation, is required. If there is acute inflammation, it
may be treated as acute catarrhal laryngitis.
In children stridulous laryngitis is most quickly relieved by immersing
the child in a hot bath up to its chin. After fifteen or twenty minutes, or
the relief of the spasm, the child should be rubbed until the skin is dry and
warm. Any of the methods described above for the relief of laryngeal spasm
may be used.
Edema of the glottis, whether due to laryngitis, traumatism, cellulitis,
circulatory derangement, or infective inflammation in adjacent structures
such as the thyroid gland, tonsils, or cellular tissues of the neck, is an ex-
tremely dangerous condition, and demands active treatment, careful watch-
ing, and preparation for immediate tracheotomy or intubation. Attention
should be addressed to the relief of the causative condition. Free drainage
of any adjacent infection is imperative. The edema may be relieved by
multiple punctures of the mucous membrane of the glottis, to allow the escape
of serum from the submucous connective tissue spaces. The punctures may
be followed by the application of a mild astringent, such as silver nitrate,
i per cent.; or liquor ferri subsulphatis, 0.6 c.c. in 30 c.c. of water (10 drops
to the ounce). In these cases the edema may rapidly become worse at any
moment, dyspnea and cyanosis becoming distressing. The surgeon should
be ready to perform tracheotomy or intubation at any moment. It is true
that adrenalin will cause a temporary contraction of the swollen mucous
membrane, but when its effect wears off the edema is apt to be made worse.
The drug may be used in emergency, preliminary to the introduction of a
tube.
Membranous laryngitis should receive the appropriate treatment which
is indicated by its cause. But, whether fibrinoplastic, croupous, or diph-
theritic, the respiratory canal should be kept clear of obstruction. Peroxid
of hydrogen is an effective mechanical solvent. It may be used in the form
of a spray. Equal parts of hydrogen peroxid, fluid extract of hamamelis,
and cinnamon water are useful. Lime water is also of value. The inhalation
of the steam rising from slacking lime is of decided help. The air which the
child breathes should be kept warm and moist. It may also be medicated.
This is done by making a tent over the bed, providing openings for ventila-
222 SURGICAL TREATMENT
tion, and conducting into it steam from boiling water. This may be done
with a simple tea kettle, the nozzle of which has been lengthened by a tin
pipe. Some soothing and antiseptic action may be secured by adding to the
boiling water oil of eucalyptus, oil of pine needles, or oil of tar — i c.c. in i
liter (15 drops to the quart) of water. Hot applications to the skin of the
throat, or other measures to produce hyperemia, are of decided value.
These measures failing to relieve dyspnea, if the child is becoming cyanotic
and suffering with air hunger, intubation or tracheotomy should be done.
The first of these is to be preferred.
Chronic laryngitis is benefited by the local application of silver nitrate
solution (i or 2 per cent.). The cure requires the removal of the cause.
Dry laryngitis is relieved by inhaling the steam of boiling water containing
4 c.c. (i dram) of compound tincture of benzoin, in 500 c.c. (i pint) of water.
Spraying with antiseptic oil, as in acute laryngitis, is of service.
Singers' nodules, usually located on the margin of the vocal cord, single
or multiple, are to be treated first by rest. The voice should not be used
even for ordinary speaking. This treatment should continue so long as the
nodules are growing smaller. When the nodules cease to diminish in size, it
means that fibrous tissue is present, and the further reduction of the growth
cannot be expected without operation. It is possible to remove the growth,
but the operation may leave a permanent damage to the voice tone. Some
laryngologists have crushed the nodules by means of laryngeal forceps.
Others have reported good results from the application of 3 per cent, solution
of zinc chlorid, or 12 per cent, solution of ferric chlorid.
Tuberculosis of the larynx is to be treated by the same means as are
described for tuberculosis in general. Ulceration is usually present, and
should be treated by local cleansing. A spray of hydrogen peroxid is most
effective. This may be followed with a mild alkaline antiseptic spray
(page 183). The laryngeal spray apparatus should be used. Dilute
hydrochloric or dilute nitric acid should be applied directly to the ulcer after
cleansing and drying. Lactic acid, phenol, guaiacol and tincture of iodin
have been applied with satisfaction. The laryngeal applicator is used for
this purpose. Curetting the ulcers has been practised with success. Some
surgeons have preferred to do this operation through a free external laryn-
gotomy opening.
Nervous patients are often made worse by operation; and other methods
of treatment are better. In properly selected cases curetting the ulcer
is often curative. The actual cautery is of service. Distressing pain may
be relieved by a spray of orthoform, 10 per cent., in ether. Cocain may be
depended upon to give temporary relief.
Laryngectomy has been resorted to in extensive disease. Tracheotomy
is of value in cases of stenosis. Cures sometimes follow this operation. The
complete rest of the larynx, secured by tracheotomy, is most beneficial.
None of these measures is apt to be successful if the disease is complicated
by pulmonary tuberculosis. The injection of alcohol to block the superior
laryngeal nerve arrests the pain and makes swallowing easier in advanced
cases. By making pressure externally over the course of the nerve a painful
point can be located. The needle is introduced perpendicular to the skin
at this point to a depth of i or 1.5 cm. (% or % inch). The point of the
needle is then moved about till it touches the nerve. This is evidenced by a
sharp pain which radiates to the ear. From i to 4 c.c. of a warmed 75 or
85 per cent, alcohol solution are injected. The injection is continued till
the pain in the ear stops. The nerve will usually be found at the upper
edge of the thyroid cartilage, about one-third of the distance from its outer
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 223
edge. The anesthesia, following each injection, lasts from one to forty
days.
The tender point will usually be found where the internal branch of the
superior laryngeal nerve penetrates the thyrohyoid membrane. This point
is about midway between the upper border of the thyroid cartilage and the
hyoid bone and about i cm. anterior to the superior cornu of the thyroid
cartilage.
In some cases of laryngeal tuberculosis swallowing becomes so painful
that the patient suffers also from inanition. If injections of alcohol do not
give sufficient relief, resection of the superior laryngeal nerve may be done.
Syphilis of the larynx requires first the application of constitutional
treatment (Vol. I, page 283). Locally the ulcers should be cleansed the same
as in tuberculosis and then touched with phenol, tincture of iodin or silver
nitrate solution (5 per cent.). The local treatment is of little momene
compared with the great importance of vigorous constitutional treatment.
Stenosing contractures must be prevented by constitutional antisyphilitic
treatment (see Operations for Laryngeal Stenosis, page 226).
Perichondritis and chondritis, due to tuberculosis or syphilis, require
the specific treatment appropriate for these diseases. Typhoid perichon-
dritis is prone to suppuration and necrosis of cartilage. When abscess
forms, except in tuberculosis, it should not be temporized with. The pus
should be evacuated externally, and not be permitted to rupture spon-
taneously through the mucous membrane. It will commonly be found that
necrosis of a cartilage, once begun in the presence of suppuration does not
stop until the whole cartilage is destroyed. By free drainage and careful
removal of the necrotic cartilage, edema of the glottis may be averted.
Laryngeal Hemorrhage. — When not due to an open wound, bleeding
under the mucous membrane, should be treated by incision and liberation
of the clot. A capillary oozing is controlled by the local use of adrenalin.
The voice should not be used. Sedatives should be employed to control
irritation.
Tumors of the Larynx. — Benign tumors constitute the great majority of
laryngeal growths. They should be removed. Temporizing with sprays,
etc., while followed in a few cases by amelioration or even disappearance of
the growth, can not be relied upon. Endolaryngeal growths are best re-
moved by means of cutting forceps, the snare, or curet, in the hands of the
experienced laryngologist. In the case of nervous persons, children, and
when dealing with extensive or subglottic growths, better success is secured
by doing a low tracheotomy and laying open the larynx from the outside
(see Laryngotomy, page 230). This exposes the interior of the larynx.
The growth may be removed with scissors or knife, and if an open wound
remains it may be touched with an antiseptic such as silver nitrate or phenol.
Tumors above the vocal cords may be approached externally by subhyoid
pharyngotomy (page 229). Laryngotomy is apt to cause changes in the
voice and disturbances of phonation; subhyoid pharyngotomy is free from
this objection.
Malignant growths are represented chiefly by carcinoma. The intrinsic
growths are confined wholly within the larynx. Extrinsic growths occur at
the superior aperture and are not confined by the laryngeal cartilages. The
former usually develop more slowly, and infect the lymphatics later. Car-
cinoma occurs most frequently on the vocal cords. Diagnosis has been made
possible by laryngoscopic examinations and the removal of tissue for micro-
scopic examination. The treatment of malignant growths of the interior of
the larynx by operation through the mouth is difficult and unsatisfactory.
224 SURGICAL TREATMENT
The same may be said of subhyoid pharyngotomy. Laryngotomy, done
by a median incision through the thyroid and cricoid cartilages, is to be
preferred in all cases of lateral growths, and tumors not requiring laryngec-
tomy. The interior of the larynx being exposed, the growth should be re-
moved with a safe zone of healthy tissue on all sides. If it is found that the
cartilage has been invaded or is dangerously close to the disease, a partial
laryngectomy may be done. Total laryngectomy is indicated in cases of
bilateral disease with involvement of the cartilage. It may be done in cases
with lymphatic involvement. Inoperable cases may require tracheotomy,
and nonoperative treatment (see Carcinoma and Sarcoma, Vol. I, page 331).
The results which are being secured in malignant growths of the larynx
have steadily improved until now it has become one of the hopeful fields of
treatment. No cures were reported before the discovery of the laryngoscope.
Gliick, in a series of 24 consecutive cases of laryngectomy has had no opera-
tive deaths; and in a series of 27 cases of partial excision of the larynx, he
had i operative death. In 22 cases of laryngectomy for cancer, he had i
operative death. Pneumonia is the danger to be apprehended in these
operations. There are reports of permanent cures not only following simple
laryngotomy and laryngectomy, but also following operations in which there
have been involvement of the tongue, pharynx, esophagus, and lymphatics
of the neck. Cases of intrinsic cancer of the larynx, in which the disease is
discovered early, may permanently be cured by median laryngotomy or
laryngectomy. It should be remembered that the curable stage gives no
symptom but hoarseness, which may come and go. To wait until cough,
difficult phonation, pain, odor, swelling, glandular involvement and cachexia
are present is to defer until hope has passed. In late cases, operation may
prolong life — or shorten it — but if the patient is able to endure an operation,
and desires the chance, he should not be denied it (see Laryngotomy and
Laryngectomy, page 231).
Tumors of the Trachea. — The treatment of tumors of the trachea is in
general the same as that of tumors of the larynx. The benign internal
tumors are best exposed by tracheotomy, and removed with knife or scissors.
It is possible to remove pedunculated growths by means of the tracheoscope,
but the external operation is simpler. In malignant growths, the trachea
should be opened, and an operation, sufficient to remove all of the disease,
performed. In early cases removal of the mucous membrane may be suffi-
cient. If the tumor fixes the mucous membrane to the surrounding struc-
tures, a segment of the whole thickness of the trachea should be removed.
The opening may be closed by a plastic operation, or a permanent trachea
tube may be used. Before excision of the trachea, a temporary low trache-
otomy should be done, if possible (see Resection of the Trachea, page 237).
Foreign Bodies in the Larynx, Trachea and Bronchi. — Usually foreign
bodies which enter the respiratory passages cause so great reflex coughing
that they are expelled. The lower down they pass, the more difficult is
their expulsion. When not forced out by expiratory effort, they become a
serious menace to life. It is estimated that the mortality in all cases is about
33 per cent. If the body is not removed, pneumonia, infection and suppura-
tion, or edema may be expected to lead to a fatal termination. In some
cases the body passes downward and becomes encysted in a bronchial tube
and ceases to be a serious factor. Foreign bodies remaining in the trachea
or larynx cannot easily become encysted unless lodged under the mucous
membrane; and the sooner they are removed, the better the prognosis.
If the coughing, which the body excites, does not cause its expulsion,
the patient should be placed on his back with the head and neck lower than
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 225
the thorax, or completely inverted. A child may be held up-side-down and
given a few sharp slaps upon the back of the chest at the end of inspiration.
If these measures do not cause the extrusion of the body, they should at least
prevent it passing deeper toward the lungs. The use of emetics is to be
deprecated. If dyspnea is severe or if life is threatened by choking, trache-
otomy should be done at once. The offending substance will often be expelled
through the wound. If it is above the tracheal opening, the patient has air,
and the body may be sought deliberately. It if is below the opening, it
may be reached with tracheal forceps.
If there is not sufficient urgency to call for immediate tracheotomy, the
next 'step to be taken is the determination of the character of the body and its
location. The modern use of the laryngeal mirror, the x-ra,y, the
tracheoscope, palpation, auscultation and percussion may be depended upon
to give a pretty accurate location of the foreign body.
A body located between the vocal cords or above them may be extracted
with the aid of the laryngeal mirror and forceps (Fig. 885). In some cases
it has been possible to dislodge it with the finger. When the finger is used,
care should be taken not to force the body downward. When the foreign
body is in the larynx below the vocal
cords, or in the trachea, it is most easily
reached by tracheotomy.
In using the laryngeal mirror and
in intralaryngeal manipulations, a pre-
liminary cocainization of the mucous
membrane by a cocain spray renders
the operation more facile. If tracheot-
omy is done general anesthesia is not
advisable because it destroys or dimin- ^ 88s._LARYNGEAL FoRCEPS.
ishes the respiratory and coughing re-
flexes, and these must often be depended upon to throw out the offending
substance. Local anesthesia is entirely satisfactory for the opening of the
trachea.
A low tracheotomy is to be preferred. In some cases the body, if in the
larynx, can be pushed upward into the pharynx. If it is anywhere between
the vocal cords and the bronchi it can be reached with tracheal forceps
through the tracheal opening. Bodies impacted low in the trachea or in the
bronchi are best removed by the aid of sight, through the tubular tracheo-
bronchoscope. Iron objects may be secured by means of the electromagnet.
The great progress made by tracheoscopy and bronchoscopy in recent
years, as a result of the pioneer work notably of Killian and Jackson, has
quite revolutionized the surgery of foreign bodies in the respiratory tract.
The tubes which have been perfected for this purpose, now make it possible
to remove foreign bodies from the trachea and bronchi through the mouth.
Pieces of bone, buttons, pins, nails, and other objects have thus been removed.
A nail has been removed from a third bronchial division by bronchoscopy
through a tracheal opening. It is the opinion that, in these tube operations,
general anesthesia should be used in children; in late cases, with irritation
and infection, bronchoscopy should be done through a tracheal opening;
and bronchoscopy through the mouth should be confined to early cases or
cases in which there is but little infection and irritation.
Formerly, bodies in the bronchi were reached only by operation through
the chest wall. These operations are still called for when bronchoscopy fails.
If, after the study of one of these cases, the location of the body cannot
be determined, but that it exists is quite certain, tracheotomy is called
VOL. II— 15
226
SURGICAL TREATMENT
for as an explorative measure (see Tracheotomy, Tracheoscopy, Bronchos-
copy, and Operations on the Chest).
OPERATIONS
Tracheotomy. — This is one of the oldest and most important operations
in surgery. It is indicated, (i) for the relief of obstructions in the larynx and
upper trachea in order that the respiratory air may be admitted below the
obstruction, (2) for the direct removal of foreign bodies from the larynx and
trachea, (3) for the passage of the bronchoscope, (4) for the direct access
to diseases of the trachea, (5) as a preliminary step in operations about the
nose, mouth, pharynx, and larynx, in order that the trachea may be occluded
above the tube to prevent the inspiration of blood or other matter into the
bronchi, (6) for the purpose of pre-
venting the inspiration of infectious
matter in certain diseases of the upper
respiratory tract, (7) in order to give
rest to the trachea in certain diseases,
(8) as a preliminary in operations about
the head and mouth in order to place
the apparatus for anesthesia away
from the field of operation, and (9) as
a preliminary to certain operations
upon the chest wall in order to pro-
vide for apparatus for artificial respi-
ration and anesthetization. The
operation is done in the median line
where there are no important struc-
tures except some transverse veins and
the isthmus of the thyroid gland. The
division of these is not a matter of
moment (Fig. 886).
The special instrument required is
the tracheal canula. This instrument,
commonly called tracheotomy tube, is
made of aluminum, hard rubber, or
silver, and is constructed with an inner
and outer tube, the latter of which is
FIG. 886.— INCISIONS FOR OPERATIONS ON provided with a broad flange for the
THE LARYNX AND TRACHEA. i r . • • r j
attachment of a retaining bandage
Snowing transverse incision through hyo- /TT oo \ TJ. • n i -L i
thyroid membrane, median bisection of (F'g- 887)« Jt IS well to have several
thyroid cartilages, transverse thyrocricoid S1ZCS at hand. The largest Size that
incision, and median tracheotomy. will easily fit the trachea without un-
due pressure should be used. In emer-
gency "a tracheal canula may be made of rubber tubing (Fig. 888). Other
instruments needed are a narrow scalpel, four small retractors, mouse-tooth
forceps, hemostats, needles, thread, and the special instruments to meet the
special conditions present.
Either general or local anesthesia may be used ; and in desperate, cyanotic
cases, no anesthetic is required. The patient should be in the lowered-head
position with the head extended by dropping the head-rest part of the table
(Fig. 508) or with a sand pillow behind the shoulders, to bring into strong
relief the structures in the front of the neck. If there is great engorgement of
the veins of the neck the sand pillow without the lowered-head position
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 227
should be used. Either high or low tracheotomy is performed. The two
may be combined, and the isthmus of the thyroid divided. If the cricoid
cartilage is divided in the operation of tracheotomy, it is a laryngotracheoiomy.
If the operation is done above the isthmus of the thyroid gland it is called
high tracheotomy. This is the easiest and most
commonly performed operation. The promi-
nent thyroid cartilage of the larynx is the land-
mark. Below it the cricoid cartilage can be
felt. An incision in the median line is made
through the skin from above the level of the
cricoid downward for 4 or 5 cm. (1^2 or 2
inches). The veins lying in the superficial
fascia are usually transverse branches of the
jugular which may be retracted or divided and
tied. The superficial and deep fascias are di-
vided in the same line, and the small communicating veins retracted or divided.
The space between the bellies of the sternohyoid muscles and sternothyroid
muscles is located and the muscles retracted to either side. Retraction and the
position of the patient's head should all be geometrically correct, so that the
FIG. 887. — TRACHEOTOMY TUBE
OF ALUMINUM OR SILVER.
FIG. 888. — TRACHEOTOMY TUBE OF SOFT RUUBKR.
surgeon shall have no trouble in keeping exactly in the median line. The deep
layer of the deep fascia lies across the floor of this space and splits to enclose the
isthmus of the thyroid between its layers. The isthums is recognized as a
bulge of soft glandular tissue lying in front of the trachea. Usually one ring
of tracheal cartilage lies above the level of the isthmus. The isthmus should
228 SURGICAL TREATMENT
be retracted downward. If it fills too much of the wounds, as is often the case,
an incision of the fascia on either side will liberate it, and permit its downward
displacement. If necessary the isthmus may be ligated in mass on either
side and divided in the middle line. In some cases it is most convenient
to retract upward the isthmus, or to divide part of it. The trachea should
be cleared of the loose connective tissue lying in front of it, and freely exposed
by retraction. The larynx should then be steadied and drawn upward by the
fingers or by a small tenaculum, hooked in the cricoid cartilage, and the upper
two or three rings of the trachea divided in the middle line. This should be
done with a fine knife which divides also the mucous membrane. It is best
that the incision be made upward. L. S. Pilcher practised removing a small
piece of the tracheal rings to make a free opening.
When it is desired to make a permanent tracheal opening or to reach
low-lying foreign bodies, low tracheotomy is done. The preparation is the
same as for the high operation. The skin incision is made in the middle
line from just below the cricoid cartilage nearly to the sternum. The veins
and small arteries are retracted or tied and cut. The same fascial layers
are encountered. The thyroid isthmus is retracted upward, or it may be best
to divide all of it or part of it. The surgeon should remember that a middle
thyroid artery is sometimes given off from the innominate artery, and passes
up in front of the trachea; the innominate sometimes is found as high as the
seventh ring of the trachea; and the thymus gland, in the young especially,
may completely overlie the trachea below the thyroid gland. Two or three
rings of the trachea should be divided in the middle line sufficiently far above
the sternum so that at inspiration the lower end of the opening does not sink
below the upper border of the manubrium.
The cartilages and mucous membrane having been incised, the necessary
thing should be done. If the operation is for diphtheria, false membrane
should be removed. This is accomplished with forceps and swab. Often
long strings of membrane may be pulled out. But even though much of the
obstruction is removed, a trachea tube should be inserted. If done for
obstruction which is not to be removed at once, a tube is inserted. When
disease, such as ulcer is treated, it is well to insert a tube in order to continue
the treatment. If done for a foreign body, which is removed, the wound may
be closed at once. After operations upon the head, the bleeding having been
checked, the tube may be removed and the wound closed. The same course
is to be followed when the higher disease for which the operation was done
no longer threatens complications.
The insertion of the tube is accomplished by retracting laterally the di-
vided rings with the small retractors. The tube should be provided with
tape for fastening it. It should be slipped gently through the wound and down-
ward until the flange engages against the skin. Force should not be used.
The tube should just nicely fit the trachea. It should be held by a tape
passed around the neck. One suture should be put in the wound above the
tube and preferably none below. A small strip of gauze should be packed
into the lower and upper parts of the wound, and a layer of gauze placed
between the skin and the collar of the tube. A few layers of gauze, moistened
with water, should be kept over the mouth of the tube. This gauze should
be moistened frequently. It is to filter out dust and give some moisture to
the inspired air. The comfort of the patient will be contributed to by keeping
the air in the room moistened with steam.
There are certain operative complications which may occur. These are not
so much to be expected when the operation can be done deliberately; but
when a hurried emergency tracheotomy must be performed, damage may be
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 229
done to the adjacent structures. It sometimes becomes necessary, without
preliminary preparation, or assistance to open the trachea with the knife
that comes quickest to hand. In such emergency operations the bleeding
from the distended veins may be profuse, and as the trachea is opened much
blood may be aspirated. The bleeding may be checked by grasping each
edge of the wound between the fingers, or, if a free hand is needed, by making
pressure on either lip of the wound with the index-finger on one side and the
middle finger on the other. As the patient gets air and the cyanosis subsides,
the venous engorgement abates. Aspirated blood itself may become a serious
menace and add to the dyspnea. When it is not promptly coughed out, it
may be removed by passing a soft rubber catheter down to the bifurcation
and sucking it out or forcing air in. The lowering of the patient's head and
elevation of the lower part of the trunk is of service. In incising the trachea
false membrane may not be incised but left clogging the opening, this should
quickly be removed.
The postoperative complications most to be guarded against are in the
nature of infections. Pneumonia should be guarded against, by cleanliness
of the wound; by keeping the patient's skin healthy; by maintaining the
vital resistance; by protecting the skin from chill; and by providing fresh,
clean, moist, filtered air.
Complications may be avoided by postoperative care. The inner tube
should be removed and cleaned in warm water several times daily. Mucus
appearing in the tube can be caught with a swab during expiration. In
order that the inner tube shall not have to remain out too long, it is well to
have two, one being ready to insert as soon as the other is taken out. The
outer tube should be taken out by the third day to be cleansed, and in order
to inspect the trachea. The interior of the trachea may then be cleaned
of mucus. Any pressure-ulceration calls for another tube. Granulations
line the opening by this time, and replacing the tube is not difficult. Retrac-
tors may be required. The filtering gauze over the tube should be changed
as often as it becomes soiled by mucus coughed into it. Mucus should be
kept wiped away from the skin, and if the skin becomes red a mild antiseptic
powder should be applied. Granulations may require to be suppressed
with silver nitrate. When the tube has served its purpose and is no longer
required it should be removed and the wound allowed to close by granulation
under an aseptic dressing.
Suprahyoid Pharyngotomy. — This operation is, perhaps, less hazardous
than the operation below the hyoid. A transverse incision is carried along
the upper border of the hyoid bone from sternomastoid muscle to sterno-
mastoid (Fig. 504). This divides the platysma, mylohyoid, geniohyoid,
and part of the digastric and hyoglossus muscles. After hemostasis is se-
cured the mucous membrane is opened transversely. A good approach
to the lower pharynx, back of the tongue, and upper larynx is secured. The
wound should be closed by layer sutures, with provision for drainage anterior
to the posterior layer of fascia. Healing is best secured if a preliminary
tracheotomy has been done and the canula retained for a few days.
Subhyoid Pharyngotomy.- — This operation is rarely performed. The
operation is sometimes indicated to reach the structures in the region of
the upper aperture of the larynx. The same preparation as for trache-
otomy is required. A transverse incision is made just below the hyoid bone
(Fig. 504). This divides skin, superficial fascia and platysma. Hemostasis
is secured, and the wound deepened by transverse incision of the sternohyoid
and thyrohyoid muscles. This exposes the thyrohyoid membrane, which is
incised horizontally together with the mucous membrane. By keeping close
230 SURGICAL TREATMENT
to the hyoid bone, the superior laryngeal vessels and nerves which pierce
the membrane close to the thyroid cartilage on either side are avoided. This
operation gives a good exposure of the epiglottis and upper laryngeal aper-
ture. At the conclusion, the wound is sutured in layers with provision for
drainage of the tissues anterior to the thyrohyoid membrane. The opera-
tion cannot be aseptic. Edema of the glottis, infection and pneumonia
make the mortality high. A tracheotomy should give rest to the wound in
healing and reduce the hazard.
Transverse Laryngotomy. — This operation is done through the crico-
thyroid membrane in persons over thirteen years of age (Fig. 504). In
younger persons the cricothyroid space is too small to make it worth while.
The operation is a valuable emergency expedient when the disease or ob-
struction is high. It is the easiest of the operations for external opening of
the air passages. The space between the thyroid and cricoid cartilages is
located, and a median incision made. The fascia is dissected away from
and the space exposed by retracting laterally the sternohyoid and sterno-
thyroid muscles. The cricothyroid artery comes off from the superior thy-
roid and passes transversely across the membrane to meet its fellow from
the opposite side. This should be looked for and avoided. A transverse
incision is made through the membrane and mucosa. The necessary thing
may be done, and the wound left to heal by granulation, or a short canula
inserted as in tracheotomy.
Median Laryngotomy (Thyrotomy). — This operation consists in laying
open the larynx for the purpose of removing foreign bodies or tumors, or
for the treatment of disease (Fig. 504). The preparation is the same as for
tracheotomy. Local or general anesthesia may be used. A preliminary low
tracheotomy should be done and a canula inserted. In some cases it is
best to do this tracheotomy a week or two before, in order that the patient
may become accustomed to breathing through a tube and the trachea made
tolerant. To prevent blood flowing down to the bronchi, the operation
should be performed with the patient in the lowered-head position, or the
trachea above the canula should be packed with gauze, or the sponge-
covered canula should be used. The thyroid cartilage of the larynx should
be exposed by a median incision. The soft tissues are retracted laterally,
and hemostasis secured. The thyroid cartilage is then divided exactly in
the median line, the incision involving the mucous membrane. Retractors
are applied and the interior of the larynx is exposed. To minimize shock
and bleeding, all of the exposed mucous membrane should be touched with a
4 per cent, solution of cocain in adrenalin solution. The conditions for
which the operation is done should then be given attention.
In most cases it will be best to carry the opening still lower by dividing
the cricothyroid membrane and the cricoid cartilage in order to secure good
retraction. In other cases the operation is required to be continued down-
ward into the trachea (laryngotracheotomy).
If the operation has left a defect of tissue, a tracheal canula should be
retained in place. If no considerable traumatism has been inflicted upon the
mucous membrane the canula may be removed. The laryngotomy wound
should be closed by sutures of chromicized catgut through the cartilage but
not involving the mucous membrane. The soft structures should be sutured
over this or the wound may be allowed to drop together without sutures.
Some advantage in healing may be secured even in uncomplicated cases
by leaving in the canula. If it is well borne, it should by all means be re-
tained for a few days. If no canula is used, one ready sterilized should be
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 231
at hand for the first few days, ready to be introduced in the event of edema of
the glottis developing.
By means of this operation, exploration is most successfully made, foreign
bodies removed, cicatrices divided or excised, ulcers or other disease treated,
and tumors extirpated. If it is found that the operation must be converted
into a partial or complete laryngectomy, it may easily be continued as such.
Before closing the wound the presence of packing should not be forgotten.
Partial Laryngectomy.- — This operation is a continuation of median laryn-
gotomy. When it is found that a portion of the larynx should be sacrificed
for carcinoma, an incision should be made from 0.5 to i cm. (%g to % inch)
from the outer margin of the disease; and the adjacent cartilage may be cut
away with scissors or knife. A similar operation is done for necrosis of
cartilage. In tuberculosis and. benign tumors it is usually necessary to
sacrifice only the mucous membrane. When a large defect of mucous mem-
brane is left after removing the disease, if the scar contraction which must
follow its healing is going to narrow seriously the lumen of the larynx, the
defect may be covered with epithelium by turning in a flap of skin, and
suturing it to the mucous membrane. After several days, when it has united,
the pedicle is divided, and the remaining mucous membrane and skin edges
sutured together. After the success of the transplantation has been assured,
the tracheal wound, which has had to be left open, should be sutured. In
the course of ten days more, the low tracheotomy canula may be removed.
In cases in which so much of the wall of the larynx has been sacrificed
that inspiration causes a serious collapse of the soft coverings, it should be
practicable to turn up an osteoplastic flap containing the anterior table of
the manubrium, as in the trachea (page 237), or a piece of costal car-
tilage may be transplanted.
Total Laryngectomy. — The complete removal of the larynx is done for
bilateral intrinsic cancer, in hopeful cases of extrinsic cancer involving both
sides of the larynx, and in extensive tuberculous laryngitis. In cases of
marked stenotic contractures and in extensive necrosis of the cartilages, the
operation is not called for if the mucous membrane is not ulcerated. Under
the best conditions, the operation is not free from shock, and should not be
done upon feeble patients. Gliick's consecutive series of 24 cases, with no
deaths due to the operation, and Crile's 27 laryngectomies with 2 operative
fatalities, by no means represent the average mortality in the hands of the
average surgeon, for most surgeons know of pneumonia, reflex inhibition of
the heart and respiration through irritation of the superior laryngeal nerves,
mediastinal abscess, neuritis of the vagus, sepsis and shock as frequent
complications if the patients who are entitled to laryngectomy are operated
upon as they come.
For intrinsic cancer, this operation offers the greatest hope; and recent
results show a low degree of mortality. The disease is recognized early;
it does not tend to invade the cartilages; it does not produce early metastases;
and for these reasons can be wholly eradicated, and is, perhaps, the most
curable of any internal cancer.
Laryngectomy in one stage is a much more hazardous operation than the
two-stage procedure. For all cases local anesthesia is best. The general
anesthetic of choice is nitrous oxid and ether. If a tracheotomy has been
done, the anesthetic may be given through the tube. Even though general
anesthesia is used, the lines of incision should first be infiltrated with
novocain.
The lowered head position is used, with the knees flexed and the legs
fastened to keep the patient from sliding. The head should be extended
232
SURGICAL TREATMENT
upon the trunk to bring the front of the neck into prominence. The lowering
of the head should not be so great as to cause a swelling of the veins of the
neck, but simply sufficient to give the aid of gravity in preventing blood from
running into the bronchi. Better than a sand-pillow behind the shoulders
is a table with a head-rest which can be dropped.
An incision is made in the median line from the hyoid bone nearly to the
sternum. If necessary, a transverse incision may cross the upper end of the
median incision. The skin, superficial fascia and platysma should be dis-
sected free, exposing the larynx and the overlying muscles from the hyoid
bone to the second ring of the trachea. The sternohyoid, the anterior belly
of the omohyoid, sternothyroid and thyrohyoid muscles are divided on either
side at both the upper and lower limits of the larynx, and retracted laterally.
The superior thyroid arteries should be ligated (see Vol. I, page 411). This
vessel passes downward from the cornu of the hyoid bone, under the above-
mentioned muscles, and is easily identified, as it gives off its branches at the
Buccinator
Orbicularis oris
Pterygomaxillary ligament
Mylohyoideus
Hyoid bone
. Thyrohyoid ligament
Thyroid cartilage
Cricoid cartilage
Trachea
Inferior laryngeal artery
Glossopharyngeal nerve
Stylopharyngeus
Middle constrictor
Superior laryngeal artery and nerve
Inferior constrictor
External laryngeal nerve
Cricothyroideus
Inferior laryngeal nerve
Esophagus
FIG. 889. — MUSCLES OF PHARYNX AND EXTERNAL RELATIONS OF LARYNX. (After Luther
Holden.)
thyrohyoid membrane. The larynx is then freed partly by blunt dissection
just as though it were a tumor. The dissection should be carried back to the
esophagus, from which it should partly be separated. Novocain solution
should be injected under the mucous membrane at the level of the incision and
the trachea divided at the first ring. The division may be made below or
above the cricoid cartilage, depending upon the location of the disease. The
trachea is then brought forward through the lower end of the wound, the
isthmus of the thyroid having been tied in two places and divided between.
The stump of the trachea is fastened to the skin on either side by a suture.
The anesthetic is then continued through a tube in the trachea.
The larynx should be lifted forward and dissected free from the esopha-
gus. Novocain solution should be injected about the mucous membrane, and
the thyrohyoid membrane divided close to the hyoid bone. A packing of
gauze is inserted in the pharyngeal wound, the larynx is drawn forward and
removed.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
233
The mucous membrane of the trachea should be treated with a 10 per cent,
solution of cocain, applied with a pledget of gauze before inserting the tube.
After the trachea has been sewed to the skin, a good-sized tracheal can-
ula should be introduced. The sutures are tied about the canula to hold
it in place. This tube should fit so snugly that blood can not enter the trachea.
The anesthetic is continued through the canula if general anesthesia is
employed.
In dividing the inferior constrictor of the pharynx, as much as possible
of the muscle should be left for the later closure of the wound (Fig. 889). As
much of the pharyngeal mucous membrane as possible should be left for the
same reason. The place of amputation, below and above, should be well
beyond the disease, the location of which should have been predetermined by
FIG. 890. — LARYXGECTOMY.
The larynx has been freed and permitted to fall forward. The pharyngo-esophagearopen-
ing is in process of being sutured.
laryngoscopic examination. Usually the division will be made above the
third ring of the trachea.
The opening into the pharynx should be closed by two rows of sutures,
and the sternohyoid and sternothyroid muscles sutured across in front. The
wound should be dried and packed with gauze saturated with i per cent.
iodin solution. The skin wound should then be closed, leaving an opening
for the gauze drain. A moistened gauze covering should be placed over the
canula opening.
The operation of Gliick makes the division of the thyrohyoid membrane
first. A tracheotomy tube is then inserted into the upper opening of [the
larynx and the dissection continued downward. The amputation at the
first ring of the trachea is then done (Fig. 890) .
234
SURGICAL TREATMENT
Exceptional Conditions. — In this operation should the esophagus be opened
by accident, or a part of it removed by design, the wound should at once be
sewed by a suture passing down to but not through the mucous lining. In
more extensive disease, involving esophagus and pharynx, the structures
invaded should be removed. Such an operation may require removal of the
base of the tongue, part of the pharyngeal wall, esophagus and lateral struc-
tures of the neck. It is possible to remove in such an operation part of the
common carotid artery, internal jugular vein, and pneumogastric nerve of one
side, together with the adjacent structures. If so much of the pharynx or
esophagus is removed that it cannot be united over the feeding tube, a perma-
nent pharyngeal or esophageal fistula in the neck must be made by sewing the
skin to the mucous membrane.
A rubber deglutition tube is used. It has a funnel at the upper end.
Artificial feeding is avoided by passing this tube through the mouth, into the
esophagus well beyond the fistula, the funnel at the upper end resting upon
FIG. 891. — WOUND CLOSED AFTER LARYNGECTOMY WITH RECTANGULAR
FLAP.
Note tracheal tube and drainage gauze.
the base of the tongue and pharynx and preventing its slipping downward.
With this tube the patient is able to swallow fluids which are placed in the
mouth. The removal of the epiglottis should depend upon its involvement
in the disease. If possible it should be saved.
Other Operations.— Gliick made a rectangular skin-platysma flap, having
its base at one side, the two sides of the flap representing the upper and lower
limits of the larynx. This flap is turned aside. A straight median incision
passes down in front of the trachea from the middle of the lower transverse
incision. Before closing the wound he introduces a rubber feeding tube
through the nose and pharynx into the esophagus. At the close of the
operation the stump of the trachea is sutured in the vertical wound and the
rectangular flap is sutured back with provision for drainage. The free side
of the flap should be directed to the side upon which the patient prefers to
lie, preferably the right side (Fig. 891). Most surgeons now use only the
median incision, and remove the epiglottis whether it is diseased or not.
Perier's method begins with a T-incision ; the trachea is divided early at the
first ring; the great cornua of the hyoid bone are divided; and the anterior
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
235
wall of the esophagus is sewed to the thyrohyoid membrane. In some cases
it may seem best to perform a preliminary tracheotomy.
Laryngectomy in two stages has recently come to be most highly prized.
It is the operation of choice. At the first operation the larynx is isolated
from its surrounding connections, but not cut loose from the trachea or
pharynx. It is left in place, and packed about with gauze. This packing
with gauze in the presence of a clean wound results in the formation of
granulations; there is no danger of infection; and when the larynx is taken
out later, the remaining cavity is found lined with granulation tissue. This
is most important because the danger of mediastinal infection is obviated.
In the one-stage operation the cavity left after removal of the larynx pre-
sents a great wound-surface with feshly opened cellular tissues; in the two-
stage operation the myriads of cellular mouths are closed by granulations.
The second operation may be done five or ten days after the first operation.
Crile performed a preliminary tracheotomy and packed the larynx and
trachea about with gauze as a first operation (Fig. 892). This two-stage
(Zoro ticta.
FIG. 892. — LARNYGECTOMY.
Diagram showing method of packing gauze about larynx as a preliminary operation.
operation, combined with preliminary tracheotomy, is the ideal procedure,
and should give the lowest mortality.
In the one-stage operation, the deep packing with iodin gauze is intended
to serve this same purpose — exciting the throwing out of a protective barrier
of connective tissue and exudate to prevent infection of the mediastinum.
Conclusions. — Whatever operation is done a happy outcome should not be
expected unless the patient's mouth was clean and free from infected teeth
and the anesthetic administered by skilled hands. The lowered-head posi-
tion and the coughing reflexes should be depended upon to keep the bronchi
free of blood. If the lowered-head position is not used, the inspiration of
blood may be prevented by tracheotomy and a gauze tampon above the
tracheal canula as the first steps in the invasion of the respiratory tract.
The cocainization of the mucous membrane of the larynx before introducing
a canula is an important step for the prevention of shock.
Sebileau (Bull, et Mem. Soc. de Chir., Paris, Feb. 15, 1910) practised
first a preliminary tracheotomy which was done twenty days before the final
operation. Second, the stump of the trachea was carefully sewed to the
skin just above the sternum, the sutures including the edge of the tendon of
the sternomastoid muscle. Third, the pharyngeal wound was closed and
the hyoid muscles sewed in front of the line of suture. Fourth, the cavity
was obliterated by sewing the divided hyoid muscles and the subcutaneous
236 SURGICAL TREATMENT
fatty tissue in front of the esophagus, and applying a firm compression dress-
ing. Fifth, a drain was placed in the upper angle of the wound to provide
for the escape of pharyngeal secretions. Sixth, the patient was fed by a
nasal tube for a week on ten days.
After-treatment. — The after-treatment of these cases requires as much
skill and more zeal than the operation. All the rules for the after-treatment
in tracheotomy (page 229) apply here. Besides these, especial care is
needed to see that no regurgitated gastric contents or discharge enter the
trachea. Every precaution should have been taken to prevent postopera-
tive vomiting. The anesthetic should have been discontinued as soon as
possible, and the patient should have regained consciousness before the end
of the operation. The patient should be propped up in bed on the day after
operation, and if his strength will permit he should be sitting up in a reclining
chair on the second day after operation. If he feels like it, he should be
encouraged to walk about on the third day. Care should be taken that the
strength of a weak patient is not overtaxed. Feeding should be by nutrient
enemata for the first five days. The mouth and teeth should be swabbed
every hour with a mild antiseptic, such as mentholated boracic acid solution.
As soon as stomach feeding is begun, only sterile foods, served in sterile re-
ceptacles, should be used for the first ten days. If the patient requires more
nourishment than can be supplied by the enemata, a sterilized rubber tube
should be passed by the mouth or nose into the esophagus, and the food
administered through that. If nutrient enemata have been used for five
days, feeding by the esophageal tube may be begun on the sixth day and
continued till the tenth day. Then food may be swallowed from the mouth,
unless a fistula has appeared in the neck, in which event the esophageal
tube should be continued. The patient should be watched every minute
day and night by a competent nurse for the first two days. Morphin or
drugs which inhibit the bronchial reflexes should not be given.
The gauze drain should be removed on the second day. If there is dis-
charge and evidence of leakage from the mouth, it should be changed sooner.
If the wound is clean, only a small bit of drain should be inserted. The
entrance to the trachea should be kept scrupulously clean. The gauze
around the tracheal canula should be changed as often as it is soiled. It is
best to use gauze moistened with weak bichlorid solution. The whole
canula should be removed and replaced by a sterile one every four hours.
The inner tube should be cleaned or changed for a sterile one every hour or
two. For keeping the throat clear, the suction apparatus employed by
dentists may be used with advantage, during the first few days.
A soft rubber tube may be introduced through the nostril and pharynx
into the esophagus before the wound is closed. This tube may be left in
place, and the patient fed through it as soon as the stomach is ready for food.
Vomiting and deglutition can prevent healing by dragging upon the
suture line. Some surgeons prefer to avoid feeding-tubes because of the
muscular action of the throat caused by their presence.
Phonation. — After laryngectomy, without apparatus, patients may de-
velop the power of pharyngeal articulation by which they are able to make
themselves understood by persons near by. The artificial larynx has not
been perfected to the degree to make it satisfactory. Its chief objection is
that it requires an opening of the pharynx. Gliick has devised an apparatus
which can be used after closure of the pharynx. The apparatus consists of
a metal cap which is connected with the tracheal canula. A valve permits
inspiration but not expiration. Between the valve and the canula a tube
goes off which contains a small reed. This is connected with a tube which
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 237
passes through the nose to the pharynx. Expiration takes place through
this, and causes the reed to vibrate. The sound is conveyed to the pharynx,
where, by the muscles of phonation, it is transformed into articulate speech.
Resection of the Trachea. — This operation sometimes is required in con-
nection with laryngectomy. When the disease for which the larynx is
removed involves also the trachea, the latter is resected at the same time.
It may require independent resection for malignant disease, tuberculosis,
cicatricial contracture, necrosis of cartilages, or destructive wounds. The
preparation, and position for operation are similar to that for tracheotomy
or laryngectomy. A median incision is made, the isthmus of the thyroid
ligated in two places and divided between, and the trachea dissected free
from its lateral attachments. The recurrent laryngeal nerve lies in the angle
on either side between the trachea and esophagus, and should be spared if
possible. The trachea having been isolated, it should be divided below the
disease, a canula inserted, and the anesthetic continued here. The diseased
part should be separated from the esophagus and the trachea divided above
the disease. If the gap in the trachea is not more than 3 cm. (i^ inches) it
can be united with chromic catgut sutures, and normal breathing restored.
If the gap is too great to be sutured, a special tracheal canula may be fitted
to conduct the respired air across the gap. I believe in such cases it would
be feasible to turn up an osteoplastic flap containing the anterior table of
the manubrium, to give stiffness to the tracheal wall and to furnish an
epithelial lining, this to be covered by a second flap with the epithelial side
externally. Costal cartilage may be transplanted to give stiffness to the
reconstructed tube.
Intubation of the Larynx. — This operation, perfected by Joseph
O'Dwyer, consists in placing in the larynx a tube of metal or hard rubber for
the relief of dyspnea due to certain forms of laryngeal obstruction.
The indications for intubation are found in obstructive conditions not
due to spasms which cause dangerous dyspnea, and which are dilatable or
capable of being passed by an instrument. The operation has found its
greatest field in diphtheria in which the membrane has grown into the larynx.
It is applicable also in edema of the glottis. It has- no place in the case of
tumor, or in conditions in which it is desired to give rest to the larynx.
If the obstruction is below the reach of the intubation tube it is of no use.
If force is required to introduce the tube through the glottis, it should not be
used. In other conditions, producing cicatricial contraction which is steadily
encroaching upon the lumen of the larynx, the tubes are used to maintain the
patency of the laryngeal tube. The operation is well suited to children
because in these tracheotomy produces more shock and takes more time.
The operation has the disadvantage that special instruments and special
experience are required.
The instruments for intubation are essentially those devised originally
by O'Dwyer. They consist of a set of tubes, made in various sizes, each
provided with a flange at the upper end which rests upon the false vocal
cords, and prevents the tube slipping downward (Fig. 893). With these are
used an instrument for inserting and extracting the tubes, also a mouth gag
and other accessory instruments. A tracheal canula and the instruments
for tracheotomy should always be at hand, in readiness for employment, in
case the false membrane is pushed ahead of the tube, and occludes the
trachea, or in case the tube is too small, and slips through the larynx.
Many modifications and a few improvements of the O'Dwyer instruments
have been made. Perhaps the best of these are those of Max Thorner.
These instruments are more simple than those of O'Dwyer. The tubes have
238
SURGICAL TREATMENT
the upper opening funnel-shaped and the lower end oblique. The inserter
and extractor are combined in one simple instrument.
The technic of intubation is simple. No anesthetic is required. If the
danger of shock is great the laryngeal mucous membrane may be cocainized
or a hypodermic injection of atropin may be given. In children these are
rarely required. Most operators have the patient in the sitting position
facing the surgeon. The child is held on the lap of an assistant just as in
the operation for adenoids without an anesthetic (see page 208). Another
assistant extends the head upon the neck and holds the mouth gag. With
the arms and legs pinned in a swathing sheet all of this can be done by one
FIG. 893. — INTUBATION INSTRUMENTS.
assistant. The mouth is held widely open; a tube of correct size, fixed upon
the introducing instrument, and having a loop of thread passed through a
hole in its upper end, is taken in the right hand; the surgeon introduces the
index-finger of his left hand into the mouth of the patient, hooks its tip later-
ally back to the epiglottis, and draws the epiglottis and base of the tongue
forward thus widely opening the larynx; the tube is then introduced, passing
along the left forefinger as a guide, until its tip enters the larynx, and passes
down between the vocal cords; the tube, being well engaged in the larynx,
is steadied by the finger, and the introducer is removed; the tube is then
pushed gently into place, being steadied by the loop of thread which is used
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 239
to withdraw it in case it slips too far downward; if the tube fits nicely and the
patient breathes satisfactorily, the loop of thread is cut and removed, and the
tube left in place. If the surgeon is not quite sure of the fit of the tube, the
thread may be fastened around a tooth or an ear and left.
Some laryngologists prefer to place the patient swathed in a sheet in the
dorsal position on a table with the head hanging over the end, or in the
position described for laryngectomy. An assistant leans over the patient
with his elbows on either side of the trunk, and grasps the head laterally
with his hands. The surgeon sits or stands on one side facing the patient's
face, and introduces the tube as above described. This position has the
advantage that the patient may be held more steadily, there is less shock, the
light comes from above, there is less danger of the tube slipping down, and
in the event of necessity the patient is ready in position for tracheotomy.
This position is coming more and more into use.
The manipulations in the operation should be gentle. The instruments
should not press upon sensitive parts. The tube and introducer should be
kept accurately in the middle line. The passage of the tube into the larynx
should be easy.
The description of this operation is easy, the execution is fraught with
difficulties. The patient struggles and gags. In diphtheria he coughs bits
of membrane into the surgeon's .face. A sudden motion may displace the
mouth gag, and the surgeon may be bitten badly. The tube may be lost
from the holder, and pass into the esophagus. It may force false membrane
ahead of it and occlude the trachea, demanding immediate tracheotomy to
save the child's life. Spasm of the glottis may be so severe as to make intu-
bation impossible. Some of these conditions are present in most cases, and
success is secured only through experience, patience, and gentleness.
The postoperative care requires constant watching of the patient as long
as the tube is in place. Unless the loop of thread is left in the tube so that
the nurse may withdraw it, the patient should not be left without some one
present who can take out the tube. Its withdrawal is necessary in case it
should become clogged. If difficulty is found in removing the tube the
patient should be inverted and given a smart slap on the back while gentle
traction is made on the thread. If the tube is coughed out, as is often the
case, it will be found usually that it is no longer necessary. If it is still
needed, it should at once be replaced.
The feeding of the patient is usually not difficult. Fluids may be taken
without trouble. In some cases deglutition is much interfered with, and the
patient can take only very small amounts at a time or must be nourished from
a nursing bottle. Some cases require that the head shall be lower than the
thorax in order to swallow. When these difficulties are insurmountable,
nutrient enemata must be resorted to. Rather than that the patient should
suffer from lack of nourishment, tracheotomy should be performed and the
laryngeal tube removed.
When the need for the tube has passed it is best removed by the extract-
ing instrument. The operation should be conducted the same as the intro-
duction. The paralysis of the vocal cords which follows the wearing of the
tube is temporary.
Tracheoscopy and Bronchoscopy. — The principles applied in these opera-
tions are the same as employed in direct laryngoscopy, esophagoscopy, and
gastroscopy. It consists in passing a straight tube into the organs designated,
through which examination and treatment may be conducted. The instru-
ments which are most effective are those perfected by Killian, of Freiburg, and
by Jackson, of Pittsburg. They consist of straight tubes of various lengths
240
SURGICAL TREATMENT
and sizes, with and without electric lamps at their lower or upper extremities
(Fig. 894). For the larynx, the laryngoscopic speculum (Fig. 895) is useful.
This instrument is employed as a guide also for the passage of the deeper
instruments. Forceps (Fig. 896) and other appliances, which may be
FIG. 894. — INSTRUMENTS FOR TRACHEOSCOPY, BRONCHOSCOPY, AND ESOPHAGOSCOPY.
Esophagoscope with aspirator.
passed through the long tubes are used. The successful handling of these
instruments is only acquired by practice. In order to avoid the shock
arising from manipulation or pressure upon the laryngeal mucous membrane,
it should be cocainized, whether general anesthesia is used or not. The
amount of secretion may be lessened
by a preliminary dose of atropin.
The position of the patient best
for these operations is lying on the
back with the head hanging over the
end of the table and resting upon a
movable extension. In this position,
with the mouth widely opened, and
the epiglottis and tongue drawn for-
ward, a good view below the vocal
cords may be had without any tube.
These operations are best performed
under general anesthesia, although
Killian succeeded wonderfully with
a local anesthetic. The mouth
should be well cleansed and the instruments made aseptic.
For direct laryngoscopy, Jackson uses the separable illuminated slide
speculum alone. This instrument may be used with the patient under
general anesthesia or with local anesthesia. For local anesthesia, the pharynx
is cocainized with 4 per cent, cocain on a swab; and the larynx is cocainized
with a 20 per cent, solution applied with laryngeal forceps guided by the
FIG. 895. — LARYNGEAL SPECULUM THROUGH
WHICH ESOPHAGOSCOPE is PASSED.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 241
FlG. 896. ESOPHACOSGOPIC AND TRACHEOSCOPIC FORCEPS.
FIG. 897.- — BRONCHOSCOPY.
Showing use of head-lamp and reflector.
VOL. II—i6
242
SURGICAL TREATMENT
laryngoscopic mirror. The instrument is used as in superior bronchoscopy
and constitutes the speculum through which the bronchoscope is passed.
With this short speculum in position, the larynx and the region of£the
pharyngo-esophageal orifice are brought in full view. Foreign bodies may
be removed, new growths excised, edematous swellings incised and punctured,
or applications made. When these instruments are used without an internal
lamp the head lamp and reflector of Kirstein are useful (Fig. 897).
For superior bronchoscopy, according to the method of Jackson, the
patient is fully anesthetized and placed in the dorsal position with the head
FIG. 898. — TRACHEOBRONCHOSCOPY.
Tracheal speculum in position.
FIG. 899. — TRACHEOBRONCHOSCOPY.
Bronchoscope passed through speculum.
extended at the occipito-atloid and atlo-axoid joints. The extension of the
neck should not make a curve distributed along the whole cervical spine.
The head while resting on the head-extension of the table should still be con-
trolled and rest in the hands of an assistant.
The illuminated slide speculum is passed into the mouth directly in the
median line close to the dorsum of the tongue until its tip has just passed the
epiglottis. The tip is then tilted strongly forward by lifting the handle.
FIG. 900. — TRACHEOBRONCHOSCOPY.
Speculum removed, leaving bronchoscope in position.
This presses forward the epiglottis and the base of the tongue and exposes
the glottic aperture (Fig. 898). The bronchoscope is lighted and passed
through the speculum into the trachea (Fig. 899). The speculum is then
removed, and the bronchoscope passed to the desired point (Fig. 900).
Care should be taken in first introducing the instrument that it is not passed
too far beyond the epiglottis. The closure of the upper esophageal orifice
by the pharyngeal constrictors may be mistaken for the glottic orifice, and the
instrument passed into the esophagus.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 243
The instrument can be made to enter either bronchus by swinging it to
one side. Secretion which is in the way may be sponged out, or if excessive
it may be aspirated through a rubber tube. The lamp, becoming covered
with blood or dimmed by some other means, may be removed and cleaned
without withdrawing the bronchoscope. The bronchoscope is provided with
side openings so that it shall not occlude the bronchus which it does not enter.
Forceps of various forms and probes are employed to remove foreign bodies.
By observing from which orifice the most secretion pours or which shows a
reddened and swollen mucosa, a hidden foreign body may be located.
The operation of lower bronchoscopy is practised through an opening made
in the trachea (Tracheotomy, page 226). This greatly facilitates access to
the bronchi. A shorter tube may be used, the view is better, the mouth and
larynx are avoided, an aseptic operation may be done — and in many respects
the operation has advantages over the high bronchoscopy. Its disad-
vantage is that a tracheotomy is added. It is by this operation that the
second and third divisions of the bronchi are made accessible.
The operation of esophagoscopy is performed with the patient in the same
position as for upper bronchoscopy f or in the lateral position. The same
FIG. 901. — ESOPHAGOSCOPE.
The direct illumination instrument of Green.
instruments may be used as for bronchoscopy, or the esophagoscope of Von
Mikulicz. The slide speculum may be used, and the esophagoscope passed
through it. Experience enables the operator to pass the esophagoscope
without a speculum. Some prefer to use the finger as a guide, starting the
instrument at the right side of the mouth, guiding it to the right side of
pharynx, and thence into the esophagus. The entrance to the esophagus is
opened by lifting forward the base of the tongue and hyoid bone. The
method now much in favor is by the use of a flexible guide, which is first
passed and then followed by the esophagoscope.
The direct illumination instrument of N. W. Green (Annals of Surgery,
vol. 59, 1914) is highly satisfactory (Fig. 901). R. Lewisohn (Annals of
Surgery, vol. 57, 1913), devised a very effective telescoping esophagoscope.
He showed the dangers and disadvantages of the straight, rigid, and flexible
instruments; and perfected an instrument which can be introduced with the
patient sitting, and cause no serious discomfort (Fig. 902).
For the operation of esophagoscopy, a general anesthesia is not so neces-
sary as in bronchoscopy. A tractable patient, with an empty stomach, and
the esophageal orifice anesthetized with 10 per cent, cocain solution, can
cooperate in the operation, if conscious. The lateral position is preferred
for the rigid-tube instrument, the head being supported by an assistant.
The patient is instructed to breathe quietly, to let the saliva flow, and to raise
244
SURGICAL TREATMENT
his hand if he experiences severe pain. The instrument should glide into the
esophagus without force. The pain in the larynx, following the operation,
can be relieved by cold applications to the throat.
The location of the disease should be known beforehand in order that the
shortest tube may be employed. Through the esophagoscope, foreign bodies
may be removed, tumors excised, strictures incised or dilated, ulcers treated,
fissures cauterized, and diverticula treated.
A longer instrument is used for gastroscopy. Jackson and others have
even passed the pylorus with these instruments and entered the duodenum
(see Esophagus and Stomach).
The removal of foreign bodies from the larynx, trachea, bronchi, esopha-
gus, or stomach is accomplished through the tubes used in the above opera-
tions. Forceps for use in these instruments are helpful. Many forms
are made. The wire snare may be of service in some cases. It is possible
FIG. 902. — ESOPHAGOSCOPE.
The telescoping instrument of
Lewisohn.
FIG. 903. — ESOPHAGOSCOPE.
Telescoping instrument released and tube
extended to stomach.
to slip a snare over an open safety pin and close it before attempting its
removal. This has been successfully done. A magnet on the end of a rod
may be used to remove iron bodies.
THE MOUTH
Two peculiarities of the oral cavity are of moment in the treatment of its
injuries and diseases: asepsis can not be attained; and all of its structures are
extremely vascular. The high degree of vascularity usually insures healing
notwithstanding the infection which naturally is present.
Cleansing the Mouth. — While an aseptic state of the buccal mucous
membrane cannot be attained, still a high degree of cleanliness is possible.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 245
Before undertaking important operations in the mouth, such as excision of
the tongue or for cleft palate, the state of the teeth should be looked to, and
any decayed or septic teeth should receive appropriate attention; the teeth
should be kept well cleaned; spongy gums should be treated with a mild
astringent; nasopharyngeal disease should be cured; and infected tonsillar
follicles should be treated. A i per cent, hot solution of sodium oleate is
an effective mouth disinfectant. The soapy taste may be removed with a
5 per cent, solution of potassium chlorate. For several days before opera-
tion the nose should be sprayed with a mild alkaline antiseptic solution (page
183), and the mouth should be washed several times daily with the above
solutions, or with equal parts of alcohol and water.
The hygiene of the mouth must not be neglected by the surgeon. To
remove particles of food from between the teeth, the teeth should be brushed
after each meal with a brush of bristles. Seriously sick patients should
have their mouths cleansed several times during the day. This is one of the
important functions of nursing. The mouth should be rinsed with warm
water, containing sodium chlorid, boric acid, tincture of myrrh, cologne
water, or alcohol. Sore places should be treated with boric acid. If the
tongue is dry, it should be moistened with 25 per cent, glycerin solution.
A useful mouth wash consists of glycerin (i part), alcohol (3 parts)
and boiled water (6 parts).
Examination of the Mouth. — In examining the mouth preliminary to
treatment the patient should either sit facing the light or lie recumbent.
With a good light, a laryngeal mirror, and a tongue depressor, all parts of
the mouth may be brought into view for treatment. In the case of children
a gag may be necessary. Before such examination and treatment the surgeon
should wash his hands in the presence of the patient.
For prolonged exposure of the mouth cavity the mouth-gag must be used.
There are many forms of this instrument (Fig. 524 a, b, c). Care should be
taken that pressure is made on the teeth, and not on the soft tissues. During
operation, an aspirating apparatus, on the principle of the air pump, such as
used by dentists, may be employed to remove saliva and other fluids.
Position for Operation. — In bloody operations in the mouth, the best
position for operation is with the head lowered. To prevent blood running
into the larynx it is the practice of some surgeons to perform tracheotomy,
insert a tracheal canula, and pack the lower pharynx with gauze. This
operation has the advantage that it removes the anesthetic apparatus from
the field of operation. The entrance of blood into the larynx and esophagus
can be nearly as well prevented by the lowered-head position. The dis-
advantage is that the blood runs from the nose and mouth instead, and re-
quires to be sponged away.
Hemostasis. — In most wounds of the mouth bleeding stops when the
wound is sutured. As a preliminary to small operations, to prevent excessive
bleeding from small vessels, adrenalin, locally applied, is of value. In opera-
tions involving large vessels, to prevent serious loss of blood, temporary or
permanent ligation of the contributing artery may be practised. In cavities
or wounds, which are not to be sutured, packing with gauze is an effective
hemostatic.
Anesthesia. — For operating under general anesthesia, the ordinary
mask may be used, and operation and anesthetization made to alternate.
Pressure hemostasis may be made while the mask is on the patient's face.
The operation is continued until the patient begins to show reflexes, and then
it is interrupted and the anesthetic resumed. The use of the nasal tube,
through which the patient may breathe and at the end of which the anesthetic
246 SURGICAL TREATMENT
mask may be applied, takes the latter away from the field of operation.
Local anesthesia is effective for a large proportion of operations in the mouth.
Cocain may be applied directly to the mucous membrane, or the anesthetic
may be injected through a previously benumbed mucosa. A mouth gag
having tubes attached for carrying anesthetic vapors into the mouth is
often useful (see Anesthesia, Vol. I, page 124).
Wounds of the Lips. — Contusions and wounds of the lips may result in
much swelling. Often an extensive wound may be found through the mucous
membrane as the result of crushing the lip against the teeth. If such a
wound of the mucous membrane is seen at once, the mouth should be cleansed
with boric acid solution, the teeth should be cleaned, and if the wound is large
and gaping, the lip should be everted and the wound sewed with fine silk.
Whether the wound is sewed or not, the mouth should be washed frequently
with boric acid solution.
Wounds involving the exposed mucous membrane or skin should be
sutured with fine silk, pains being taken to secure niceness of apposition.
Inflammations of the Lips and Mouth.— Cellulitis of the lips is always diffi-
cult to treat. The causative factor should be discovered and eliminated,
if possible. Often an infected hair follicle or mucous gland can be discovered.
This should be incised with a sharp-pointed knife. Causative eczema or
herpes should be treated. For the cellulitis itself hot applications are
effective. They should not be applied to the mucosa. As soon as suppura-
tion is focalized an incision should be made. In the female, the incision
should be through the posterior surface of the lip even though the pus is
nearer the skin surface. With local anesthesia, a horizontal incision should
be made. In a man the hair should be shaved from the lip, and a horizontal
incision made at the place nearest to the pus. An opening sufficiently large
for free drainage is demanded.
Chapped lips may be prevented by anointing the mucous membrane of
the lips with oil, fat, glycerin, or ointment before exposure to the cold, wind,
or other causative conditions. The treatment consists in the use of appli-
cations. If & fissure of the lip has developed, and, because of induration
about its base, refuses to heal, it may be touched with silver nitrate. If this
does not effect a cure the best treatment consists in excising a small wedge
containing the fissure and sewing the wound. This operation may be done
with local anesthesia. It has the advantage that it cures the disease and
diminishes the possibility of the development of epithelioma at the site of
the fissure.
Herpes of the lips should be treated first by removal of the cause. Often
this is an infection of the nasal or buccal mucous membrane. In adults,
when due to auto-intoxications, the patient should be given a laxative, put
on a reduced diet, and the lip touched with spirits of camphor or alum.
If scabs or ulcers have formed, an ointment should be used (see Herpes,
Vol. I, page 829).
Ulcers of the lips should not be permitted to become chronic. If they
do not heal under the treatment recommended for ulcers (Vol. I, page 308),
after the constitutional cause has been removed, the ulcer should be curetted,
or removed by a wedge-shaped excision and the wound sewed.
Stomatitis is an inflammation of the lining of the mouth, which may repre-
sent any of the many varieties of mucous membrane infection. The treatment
is similar to that which is given for inflammations of the nose, throat, or
other mucous membranes. In most cases a wash of saturated solution of
boric acid will effect a cure. The teeth should be kept clean. The wash
should be used every hour at least. Thrush should be prevented by cleanli-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 247
ness in the feeding of infants. When, as a result of ignorance or carelessness,
it occurs, the swabbing of the infected areas with boric acid solution should
be sufficient. If this does not check the disease, stronger antiseptics should
be used. Unless the progress of thrush is stopped, infection and even per-
foration of the intestine, as shown by H. P. deForest (Am. Jour. Obstet.,
Jan., 1910), may occur. Gonorrheal stomatitis should be treated the same as
gonorrhea! infection elsewhere. The local application of silver nitrate
solution to the infected area is most effective. Membranous stomatitis
is treated by hydrogen peroxid and the same applications as recommended
for membranous tonsillitis.
Gangrenous stomatitis (cancrum oris), due to the inoculation of virulent
organisms into the tissues of the lips and cheeks of feeble persons, usually
children, requires vigorous treatment. The nourishment of the patient
should be improved. This is best done by feeding with top milk and eggs,
and keeping the child in the open air. Sloughs should be cut away. Bur-
rowing pus should be freely evacuated. Pure phenol followed by alcohol,
or other strong antiseptics, should be applied. The infected external parts
should be kept covered with a large, hot, wet, antiseptic compress. The
mouth should be washed with boric acid solution.
Bites of insects upon the mouth may cause edema or cellulitis. If it is
known that the insect has come from putrid material, tincture of iodin should
be applied (see Stings and Bites of Insects, Vol. I, page 275).
Epithelioma of the Lower Lip. — This slow-growing disease is most sus-
ceptible of radical cure if operated upon early. The presence of enlarged
lymph nodes in the neck should not militate against operation. The
enlarged lymphatics may be due to bacterial infection; and even though
due to secondary deposits of epithelioma, there is always hope that the last-
involved gland may be removed. When no enlargement of the lymphatics
is palpable, it should be assumed that the lymph-nodes of the neck are in-
volved, and they should be removed, except in the very early cases; and many
surgeons operate on the neck even in the early cases. The proportion of
surgeons in this last class is steadily increasing. When a surgeon says that
he does not open the neck in early cases and has only 20 per cent, of recur-
rences, we should ask him, why not try to prevent some of the 20 per cent,
recurrences? It should always be borne in mind that the glands are in-
volved before they become enlarged, and that they become enlarged before
they can be felt. The question is, why take any chances with a curable
disease which is fatal if not cured?
If the disease is on both sides of the median line an incision should be made
below the lower border of the lower jaw from one facial artery to the other.
The facial arteries and veins should be ligated and cut. The superficial skin
flap should be dissected down as far as the middle of the larynx, or farther
if necessary. The subcutaneous fat should not be included in the flap (Fig.
904). Having turned down the flap, the superficial fat, lymphatics, and
connective tissue should be dissected up in a mass extending back to the
great vessels and especially in the spaces below the jaw. The tissues should
be dissected away from the muscles connecting the jaw and the larynx so
that the outer surfaces of these muscles is exposed. The mass of tissue that
is dissected up should include the submaxillary salivary glands, because the
first lymphatics to become involved lie in the embrace of these glands. This
mass should not be disintegrated but should be in one body (Fig. 905).
The tumor, growing in the lip, should then be removed by incisions on
either side of it far enough away to escape the disease. These incisions
should preferably be vertical and involve the whole thickness of the lip.
248
SURGICAL TREATMENT
When the lower limit of the disease is reached, the incisions should be con-
nected by a transverse incision. If the diseased area is not small the two
FIG. 904. — OPERATION FOR EPITHELIOMA OF LIP. FIRST STAGE.
Superficial flap turned down, exposing lymphatics and connective tissue.
vertical incisions should pass from the lip down to the submaxillary incision
(Fig. 906). The tumor with the attached skin and the mass of connective
tissue andfglands from the neck should all be removed as one mass.
FIG. 905. — OPERATION FOR EPITHELIOMA OF LIP. SECOND STAGE.
Lymphatic and connective tissue dissected up in a mass.
If the segment of the lip removed is too large to permit easy closure of
the wound, lateral incisions should be carried outward through the cheeks
from the angles of the mouth. This permits sliding flaps inward, and the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
249
turning out of mucous membrane to cover the new-formed lip (Fig. 907).
The mucous membrane inside of the mouth should be sewed to close the
FIG. 906. — OPERATION FOR EPITHELIOMA OF LIP. THIRD STAGE.
Alter the neck dissection, the lip is incised on either side of the disease, and the isolated
segment of lip removed with the tissues of the neck. The lymphatics and connective tissue
which have been dissected from the neck are placed on a piece of gauze which covers the
wound.
FIG. 907. — OPERATION FOR EPITHELIOMA OF LIP. FOURTH STAGE.
Result after closure of incisions.
wound from mouth secretions. A drain should be placed in either side of the
neck.
In cases of more extensive growth, involving the whole lip, the primary
250 SURGICAL TREATMENT
incisions may be wider (Fig. 908) (see Plastic Operations, Vol. Ill, and
Surgery of the Neck, Vol. II, page 360).
In early cases of disease of one side only the neck operation may be con-
fined to one side; in older cases both sides should be operated upon. In
recurrent cases, following the old-fashioned V operation, a wide dissection
FIG. 908. — OPERATION FOR MORE EXTENSIVE EPITHELIOMA OF THE LIP.
Lines of incision.
may be made and life saved. Apparently hopeless cases may be cured by
boldness of dissection. The amount of tissue that may be removed from the
neck is very great. One carotid artery one deep jugular vein, one pneumo-
gastric nerve, the larynx, trachea, lower jaw, tongue, esophagus, muscles,
lymphatics and skin may be removed if necessary to save life.
FIG. 909. — EPITHELIOMA OF LIP. THE V-!NCISION.
Although progressive surgeons now operate on the lymphatics in all
cases, still the old incomplete operation made many cures. Twenty years
ago I removed by V-shaped section an epithelioma of the lip of four months'
standing. Eighteen months later, an enlarged nodule appeared in the neck,
and was removed under local anesthesia; one year later I removed a second
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
251
enlarged nodule from the neck; and though microscopic examination showed
epithelioma in all three operations, still no further recurrence took place, and
the man remains well today. Had the lymphatics been operated upon at
FIG. 910. — RESECTION OF LOWER Lip
WITH PROVISION FOR SLIDING FLAP.
FIG. 911. — RESECTION OF LOWER LIP.
Sliding flap sutured in place.
the first operation, the hazard of recurrence in this case would have been
avoided.
The surgeon should not be encouraged by the cures in the old methods
to neglect the neck. The following technic may be followed, but in all of
FIG. 912. — EXCISION OF LOWER
LIP WITH PROVISION FOR PLASTIC
SLIDING FLAPS TO CLOSE WOUND.
FIG. 913. — WOUND CLOSED AFTER
EXCISION OF LOWER LIP.
these methods there should be added the dissection of the neck. From the
incisions of excision, in all of these cases, there should be carried downward
an incision connecting the lip wound with the submaxillary incision.
FIG. 914. — RESECTION OF LOWER LIP BY
V-INCISION WITH ADDITIONAL LATERAL IN-
CISIONS.
FIG. 915. — WOUND CLOSED AFTER
V-RESECTION OF LOWER LIP.
The technic in the cases of very small tumors consists in making a V-
shaped incision through the whole thickness of the lip. The incision should
be so placed as to remove i to 2 cm. of apparently sound tissue on either side
252
SURGICAL TREATMENT
of the growth (Fig. 909). If as much as a half of the lip is removed, or so
much that a disfiguring tightness of the lower lip or redundancy of the upper
lip results, a transverse incision should be carried outward from the corner
of the mouth and from the bottom of the wound to permit a flap to slide
inward (Figs. 910 and 911). In making the horizontal incision from the
FIG. 916. — EXCISION OF LOWER LIP WITH PROVISION FOR PLASTIC FLAPS TO COVER THE
DEFECT.
angle of the mouth, the mucous membrane lining the cheek should be divided
on a level about i cm. higher than the division of the skin on the outer side of
the cheek in order to provide mucous membrane to be turned out to form a
covering for the newly constructed part of the lip (Figs. 912 and 913).
FIG. 917. — LIP RESTORED BY PLASTIC FLAPS.
In cases in which the whole or nearly the whole of the lower lip is removed,
the V should have a wide angle (Figs. 914 and 915) or the excision
should be in the form of a U. As much of the chin as possible should be
preserved. Horizontal incision should be carried outward from the corners
of the mouth as described above. These incisions should be made higher
in the mucous membrane than in the skin. Two lower incisions should curve
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 253
FIG. 918. — EXCISION OF LIP WITH PROVISION
FOR LATERAL FLAPS.
FIG. 919. — LATERAL FLAPS USED TO
RESTORE LOWER LIP.
FIG. 920. FIG. 921.
FIG. 920. — RESECTION OF LOWER LIP WITH FLAP FROM ABOVE TO FILL DEFECT.
FIG. 921. — RESECTION OF LOWER LIP.
Defect filled by flap from above
FIG. 922. — REMOVAL OF WHOLE LOWER LIP.
Defect to be corrected by flaps from cheeks.
FIG. 923. — LIP RESTORED BY FLAPS
FROM CHEEK.
254
SURGICAL TREATMENT
downward and backward from the bottom of the wound, passing upon the
cheeks or the neck below the jaw (Figs. 916 and 917). These two lower
incisions serve for the loosening of the sliding flaps and also for the dissection
of the submaxillary lymphatics (Figs. 918 and 919). Other incisions are
required to meet special conditions. A flap from the upper lip may be turned
FIG. 924. — EXCISION OF LOWER LIP WITH PROVISION FOR SLIDING CHIN FLAP.
down to fill the defect in the lower lip if the mouth is not small (Figs. 920
and 921). Flaps may be turned down from the cheeks to reconstruct a whole
lower lip (Figs. 922 and 923). A new lower lip may be reconstructed by slid-
ing up the tissues of the chin (Figs. 924 and 925).
FIG. 925. — LIP RESTORED BY SLIDING CHIN FLAP.
Benign Tumors of the Lip. — -Angioma of the lip may be treated by the
methods already given for that disease (Vol. I, pages 325 and 842). If it
involve much of the thickness of the lip the tumor may be excised. The free
mobility of the tissues here renders excision of the growth and plastic clos-
ure of the wound very satisfactory. Cystomata, horny elevations and other
benign tumors should be removed as elsewhere.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 255
Macrocheilia. — Permanent enlargement of the lip or lips, whether con-
genital or due to lymphangiectasia, may amount to a disfigurement. A very
satisfactory improvement in the appearance may be made by removing a
broad wedge from the whole width of the lip and sewing the wound. The
base of the wedge should represent the junction of the buccal and orificial
surfaces of the lip. It should be planned so that enough tissue is removed
to bring the lip down to the desired thickness (Fig. 926). A thin sharp knife
is essential. The wound should be closed with deep and superficial sutures
of horsehair or celluloid thread (see Plastic and Cosmetic Sur-
gery, Vol. III).
Diseases of the Soft Palate and Uvula. — Acute infections of
the soft palate should at first be treated by a boracic acid
spray and the relief of adjacent infections. If the edema be-
comes marked, multiple punctures should be made. This may
be done by passing a retractor behind the palate to support it,
and then making ten or twenty punctures into its substance
with a sharp-pointed bistoury. The punctures should be
about 3 mm. deep, and should be made especially in the uvula
and lower part of the palate. Abscess of the palate should be
incised. For Mycosis, see Vol. I, page 838.
Ulcers of the uvula and soft palate, when of syphilitic or
tuberculous origin should receive their appropriate treatment
(see Syphilis and Tuberculosis, Vol. I, pages 283 and 276).
Simple ulcers are best treated by being touched with silver
nitrate. Fluid diet should be used.
Bifid uvula may be treated by grasping the tip of each part
and denuding its inner surface of mucous membrane with knife
or scissors, and then suturing the cleft.
Elongation of the uvula may be said to exist when it im-
pinges upon the tongue or epiglottis during inspiration. If it
gives rise to symptoms of irritation, it should receive treat-
ment. The cause of the relaxation should be sought. Anemia, constitu-
tional weakness, or chronic nasopharyngeal disease should be corrected.
Often there is nothing to be found but a relaxed condition of the tissues of
the pharynx. Astringents such as nitrate of silver (5 or 10 per cent.) or
chromic acid (10 or 20 per cent.) may be applied to the relaxed structures by
means of a cotton-covered applicator two or three times each week. Relaxa-
tion due to diphtheria or other paralyses should receive general treatment.
If these measures fail uvulotomy should be done. The whole uvula should
never be removed except for malignant disease. The uvula is anesthetized
by applying strong cocain solution at its anterior surface and then making
infiltration injections of mild anesthetic. For elongated uvula, only enough
of the tip should be cut off to make it normal in length. If the section is
made transversely and not sutured an open wound is left at the tip. The
irritation of food may cause hyperplasia and a consequent enlargement of
the stump. This may be obviated by grasping the tip with forceps, removing
a wedge with the apex upward, and closing the wound with a fine catgut
suture (Figs. 927 and 928). In some cases three sutures may be required.
Distressing cough, nausea and vomiting may be relieved by this operation.
Uvulotomy should not be done at the same time that adenoids are removed
lest adhesions take place.
Tumors of the palate should be removed by wide excision if malignant.
Benign tumors should be removed if they produce any disturbance of func-
tion or distress. Certain hypertrophies of the soft tissues under the hard
FIG. 926. —
MACROCHELIA.
Ope rative
removal of a
wedge of tissue
to reduce the
size of the
lower lip.
256
SURGICAL TREATMENT
palate and osteomata of the hard palate cause a swelling in the middle of the
roof of the mouth which develops up to a certain point and remains station-
ary. These tumors require no treatment.
Adhesions of the soft palate to the pharyngeal wall, commonly due to
syphilis, have been referred to under adhesions of the pharynx (page 205).
Many operations have been devised for this condition. None will be success-
FIG. 927. — CUNEIFORM UVULOTOMY.
INCISION.
FIG. 9270. — CUNEIFORM UVULOTOMY.
WOUND CLOSED.
ful unless after their separation the parts are kept apart. Whether this is
accomplished by an obturator, by repeated retraction, or by continuous
retraction, it all comes to the same thing — separation of the parts until the
wounds made by the incision have become covered with epithelium. A
method which has been ineffective in some cases may be effective in others.
In all cases a horizontal curved incision should pass across the back of the
FIG. 928. — ADHESION OF PALATE TO PHARYNX.
Showing incisions for making mucous membrane flaps.
palate dividing it from the pharyngeal wall. This should be sufficiently wide
to make a free opening from the buccal pharynx to the nasal pharynx, turn-
ing down the soft palate as a flap. A method of maintaining the separation
until healing of the surfaces is complete, which may be tried, consists in
holding the flap of soft palate forward by suturing it temporarily to the
under surface of the hard palate. A leaded weight may be sewed to the flap
to keep it down.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
257
After cutting free the palate from the pharyngeal wall the raw surface on
the palate may be covered by flaps of mucous membrane. A flap may be
taken from the side of the palate and inside of the cheek. This may be
placed so that it folds under the free edge of the soft palate. Its free end
may be held by sutures passing through the palate. Laterally it may be
sewed to the mucous membrane of the under surface of the palate. This
operation is done on either side (Figs. 928 and 929).
Cleft-palate. — The satisfactory treatment of this condition requires an
understanding of its causation.
In early fetal life the nose and mouth make one cavity. At the eighth week the palate
begins to grow in from either side in the form of two horizontal processes. These processes
meet and coalesce in the middle line. When their development is arrested a median cleft
of the palate results. This may be complete or the processes may unite in some of their
FIG. 929. — ADHESION OF PALATE TO PHARYNX.
Adherent palate has been separated, mucous membrane flaps cut and sutured over the raw
surface produced by dissecting free the palate from the pharynx.
parts in front or behind. The roof of the mouth is not wholly formed by these two proc-
esses. In the middle line and anterior to them a median process of mesoblastic tissue
comes down from above, and goes to make up the front part of the hard palate} the anterior
part of the nasal septum, and the middle portion of the upper lip. The intermaxillary bone
is represented in this tissue. When this intermaxillary process fails to unite with the rest
of the maxilla a lateral cleft results. Such a cleft may be on one or both sides and is found
running through the base of the nostril. Thus the cleft in cleft-palate which is required
to be repaired may be represented by a Y or any of its parts. The anterior intermaxillary
process may be dislocated forward if both arms of the Y fail to unite, so that a median
portion of the lip and palate, together with alveolar process, bearing the middle incisor
teeth, may project forward. For this reason cleft-palate is apt to be associated with hare-
lip (Fig. 930).
Unless these clefts are closed, sucking is impossible or difficult, food passes
into the nose from the mouth, speech is imperfect, and the individual suffers
the moral harm arising from the deformity.
VOL. II— 17
258
SURGICAL TREATMENT
The infant with cleft-palate must be fed in the vertical position so that
the food will flow easily into the esophagus.
If operation cannot be done at once, the mother should press the bones
of the upper jaw together several times daily. This treatment tends to
reduce the width of the fissure. As soon as operation can be done it should
be proceeded with. The surgeon should not be ambitious to complete the
work at one operation. It is much better to do what can be done easily and
satisfactorily, and finish the operation later. Several operations may be
required. The harelip should be operated upon after the palate has been
made entirely satisfactory.
Operation by all means should be undertaken before the child is over
three months of age. The mortality among infants not operated upon is very
high. Although the modern tendency is to operate early, many surgeons
still prefer to wait until the child is stronger. Some surgeons prefer to
operate for cleft-palate when the child is five or
six years old, and for harelip at the age of six
months.
The most favorable time for operating is as
soon as possible after the'child is one day old. It
seems that the undeveloped state of the nervous
system at this age makes shock less of a factor.
The parts are pliable, and vocalization is not
developed. If the child is poorly nourished, or
weak, or possessed of incurable defects, operation
had best not be undertaken until it is gotten into
a better state of resistance. An operation which
is done after vocalization is established, may cor-
rect the anatomic defect, but the defect of speech
will remain.
The best position for operation is the lowered-
head position so that blood may escape by the
nose and mouth. The child should be swathed to
confine its arms and legs; and fixed with its head lowered on the operating
table.
If the intermaxillary segment is free, it should be sutured back in place
after freshening the edges. Fine silver wire is best for this purpose. If it is
held away by a short septum a wedge may be removed from the front of the
latter. Usually it is easily pressed into place. A later plastic operation
may be done, if necessary, to elevate the front of the flattened nose. In
young infants this segment requires no attention, as the pressure of the lip
will hold it back after the cleft has been operated upon. The repair of the
harelip should be deferred until the operation on the palate has proved itself
successful.
The later operation, which must be performed upon children whose jaws
have become firm, must deal especially with the soft tissues. The mouth
should be gotten into as healthy a condition as possible. Diseased teeth and
tonsils should receive attention. Adenoids should be removed. The child
should be made accustomed to the antiseptic spray. It should not be oper-
ated upon unless its health is good.
The instruments required are mouth gag, tongue depressor, palate knives
(narrow scalpels), elevators for separating the soft tissues from the hard
palate, small swabs for sponging, needles, needle-holders, silk and fine wire
sutures. The anesthetic should be begun with an ordinary mask, and
FIG. 930. — DIAGRAM OF
ANATOMY OF CLEFT PALATE
AND PREMAXILLARY PROC-
ESS.
259
continued with a nasal inhaler or tube. Operation cannot be done well
without a good light and good assistants.
The simple operation for closing a narrow cleft is done as follows: A silk
suture is passed through the tip of the tongue to draw it forward. Care
should be taken that the tongue is not pulled so far forward that the glottis
is opened for the entrance of mucus and blood. With the child in the
lowered-head position, the edges of the cleft are freshened by removing a thin
strip of mucous membrane from either side, or by incising each edge longi-
tudinally and spreading the wounds wide apart. This latter is better than
sacrificing tissue, although more difficult. An incision is then made along
the inner aspect of the alveolar process (Fig. 931) on either side. The
closer these incisions are made to the teeth, the broader will be the flap for
suturing and the less will be the tendency to slough. Bleeding should be
FIG. 931. — OPERATION FOR CLOSURE OF NARROW CLEFT IN CLEFT PALATE.
Edges freshened and lateral incision made along alveolar margin. This incision and the
subsequent loosening of the mucous membrane should not injure the descending palatine
artery.
checked by pressure. If necessary a little adrenalin may be used in the
wounds. The elevator is introduced in these incisions, and the mucous mem-
brane with the periosteum separated from the bone as far inward as the
cleft. The extent of this separation and the length of the lateral incisions
must depend upon the facility with which the flaps can be made to close
the cleft. Surgical judgment is demanded. Thus two flaps are formed,
each being attached anteriorly and posteriorly, which are capable of being
displaced inward until their edges come together, and are sutured.
If the tension upon the sutures is too great, union will not take place.
If the tissues are separated too much from their blood supply sloughing will
occur. The descending palatine vessels should be spared. If they must be
divided to complete the closure posteriorly, that should be done at a later
operation.
One reason why the tissues are tense in the middle line is because of the
resistance offered by the aponeurosis and muscles of the velum palati which
260
SURGICAL TREATMENT
connect it to the hard palate. Attached to the posterior border of the hard
palate are the fascia of the velum, the tensor palati and the levator palati
muscles. These must be detached before the soft structures can be moved
inward. The lateral incisions having been carried back to the posterior
margin of the hard palate, a knife or scissors curved on the flat to nearly a
right angle, is passed into the lateral wound, and by a transverse cut the
velum palati is divided from its bony attachment (Fig. 932). The extent
FIG. 932. — SHOWING METHOD OF DIVIDING THE INELASTIC APONEUROSIS WHICH HOLDS
THE SOFT PALATE TO THE HARD PALATE.
The mucous membrane has been separated from the lower surface of the hard palate and the
knife (K) cuts the aponeurosis.
of this cut must depend upon the amount of relaxation required. It is best
to use the knife, and cut upward only through the aponeurosis, without
penetrating the superior layer of mucous membrane. This requires skill.
Usually the mucous membrane on the nasal side is cut. Some surgeons
use scissors and make a through-and-through cut. This is unnecessary
mutilation.
FIG. 933. — CLEFT PALATE OPERATION COMPLETED.
Central wound closed with sutures. Lateral wounds packed with gauze.
The cleft is closed by interrupted sutures of silver wire or silk. In
twisting the wire a uniform method should be followed, always from left to
right. As these sutures are tightened, if it is observed that undue tension
is being made, the lateral incisions must be lengthened or the separation of
tissue extended, until union without tension is secured. The lateral spaces
should be packed with antiseptic gauze (nosophen, formidin, or iodoform)
flush with the surface (Fig. 933).
261
Sliding-flap operations are most effective. They are done with flaps of
mucous membrane and periosteum. In doing these operations failure is
invited if the main blood supply of the flaps is destroyed, and no one factor
will contribute more to the success of the operation than preserving the blood
supply. The descending palatine artery is the important vessel. It passes
down from the sphenomaxillary fossa, emerges from the posterior palatine
foramen, and runs forward in a groove on the hard palate close to the alveolar
process. A short lateral incision close to the alveolar process avoids this
vessel. The ascending palatine artery is less important (Fig. 934).
In the operation of W. A. Lane the descending palatine artery is divided
on one side only. The child is operated on preferably when it is one day old,
FIG. 934. — INCISIONS FOR CLEFT PALATE.
This incision shown by dotted line divides both branches of the descending palatine
artery and destroys the main blood supply to the flap. The incision should be external to
the artery as shown by the solid black line. The vessels should be lifted away from the bone
and preserved in the flap.
or as soon as possible thereafter. After placing the mouth-gag and drawing
forward the tongue with a ligature, a mucoperiosteal flap is cut. If the soft
parts underlying the edges of the cleft are vascular and thick the flap is
made in such a way that its base is at the free margin of the cleft. The
incision is made external to the alveolar process, where the mucous membrane
is reflected upon the cheek. This flap is turned inward (Fig. 935).
In cutting this reflected flap, the incision (BC) passes from the anterior
limit of the cleft forward and outward to the cheek; thence it passes along the
cheek external to the alveolar margin (CD) and then inward along the free
posterior border of the palate to the uvula (DE).
262
SURGICAL TREATMENT
The palatine blood supply is divided and nourishment must come from
the small vessels at the free margin. The descending palatine artery is
divided and clamped as the flap is reflected inward, and its mucous mem-
brane turned upward.
To make the raised flap, an incision is then made along the free margin of
the other side of the cleft (BH). This is carried along the edge of the cleft
about half way back where it is continued obliquely outward and backward
on the upper surface of the soft palate (HG). This is met by a transverse
incision (GF) along the posterior margin of the soft palate to the uvula. If
necessary an oblique anterior incision (AB) is also made. This flap (BUG} is
then lifted up with the elevator. The soft palate is freed from the posterior
margin of the hard palate. The palatine vessels are not injured on this side.
FIG. 935. — OPERATION FOR MEDIAN CLEFT PALATE IN INFANCY.
Lines of incision. Below is shown a cross-section of the bone and flaps, after the flaps
have been placed.
The reflected flap which is first turned down, with its scant blood supply
is then placed between the raised flap and the bone, and fixed in place by two
rows of sutures. The blood supply of the raised flap is ample, as the palatine
vessels are not destroyed. The poorly nourished flap is thus attached
to a surface which is well supplied with blood (Fig. 936).
If the septum of the nose has a free lower margin, this margin should be
incised longitudinally (Fig. 935 //), and the two ends of this incision crossed
by short transverse incisions (/ and /). Two small flaps should be turned up,
and these sutured to the upper surface of the reflected palatine flap.
In the case of wide clefts in the newborn, an incision is made around the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
263
entire alveolar process (Fig. 937). Two incisions (C and D] are carried from
the front of the cleft outward to join this first incision. From the posterior
ends of these two incisions an incision is carried along the margin of the cleft
on either side asilfar back as the tip of the uvuia (EE and FF). The two
flaps (ACER and BDFF) are elevated from the bone, care being taken not
FIG. 936. — OPERATION FOR CLEFT PALATE.
Result after flaps have been sutured. The large raw surface is left to granulate.
to injure the descending palatine vessels. The anterior central flap (G) is
elevated from before backward, left attached at the front of the cleft where
it receives the anterior palatine vessels, and turned back to provide mucous
membrane for the floor of the nose (Fig. 938).
FIG. 937. — OPERATION FOR WIDE
CLEFT IN THE NEWBORN.
Lines of incision.
FIG. 938. — OPERATION FOR WIDE
CLEFT.
Showing flaps sutured in place.
The two lateral flaps are swung inward and sutured together in the middle
line as far back as can be done without tension. The closure of the extreme
posterior part should usually be done as a later operation (Fig. 938).
These same principles of operating may be applied to older children or
adults. In older cases in which the cleft is wide and the sides ascend ob-
liquely into the nose, similarly, a reflected flap and a raised flap may be used.
Two flaps are created of mucous membrane, submucous tissue, and perios-
264
SURGICAL TREATMENT
teum. One, the reflected flap, is made by an incision close to the teeth on
the alveolar border. The other, the raised flap, is made by an incision as
high in the nose as possible along the edge of the cleft (Fig. 939). In the
FIG. 939. — OPERATION FOR CLEFT PALATE BY DOUBLE FLAP.
Showing incisions. The heavy black line represents the incision through which the
flap is dissected free from the bone. The dotted line represents the posterior part of the
incision which passes as high in the nose as possible and through which the opposite flap is
dissected free from the bone.
FIG. 940. — COMPLETED OPERATION FOR CLEFT PALATE BY DOUBLE FLAP.
The flap from one side has been turned inward and interposed above the flap which has
been dissected free from the other side.
first the superior palatine vessels are divided; on the other side, they are
spared. The reflected flap is hinged at the edge of the cleft, inverted with
its mucous membrane upward, and drawn above the raised flap on the other
side. Each is fastened by a row of sutures (Fig. 940).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 265
The jaw-compressing operation aims to press together the separated bony
structures. In the early operation for cleft-palate, T. W. Brophy forced the
two maxillary bones together to close the defect. He contended that there
is an actual separation of the bones about equal to the width of the cleft.
He, therefore, freshened the edges of the cleft, forcibly brought the two supe-
rior maxillae together, and held them in this position until union was secured.
By this operation union of the soft palate with restoration of its function,
and union of the harelip are facilitated. The operation may be done
without anesthesia. The technic is as follows : A strong needle on a handle, or
a straight drill provided with an eye, is entered within the mouth, and
thrust horizontally through the upper jaw just behind the malar process
and above the level of the horizontal process of the palate bone. The needle
carries at its point a strong silk thread, the loop of which is pulled down into
the mouth through the cleft. The same operation is repeated on the opposite
side. The first thread is passed through the loop of the other side and pulled
through both sides, crossing the nasal fossa. A thick silver wire, sharply
bent at the end, is hooked into the loop, and pulled. A second wire, parallel
to the first, is passed through the anterior part of the jaws. These two wires
may be seen through the cleft as they pass across the lower nasal fossa. A
small oblong lead plate having a hole near either end is laid against the outer
side of the right maxilla, inside of the mouth, above the alveolar process.
The posterior wire is passed through the posterior hole and the anterior wire
through the anterior hole. These ends of the wire are twisted together from
left to right as the plate is tightly pressed inward and the left ends are held
taut. The twisted ends are then flattened down against the lead plate.
The left ends of the wire are similarly treated under the left cheek. As the
wire is being twisted the maxillae should be pressed together by the strong
hands of an assistant. If the bones have become too firm to allow closure of
the cleft, they should be divided with a scalpel or chisel applied above the
lead plates. The freshened border of the entire cleft is then sutured. Fine
silver wire or silk sutures are used for the soft palate and other soft parts.
The lead plates and wires should be left for three weeks. The mouth should
be kept clean. Only sterile food should be used. Some ulceration will take
place under the plates, but it quickly heals after their removal.
This operation was once very popular. Now most in favor with surgeons
doing much of this work are the sliding-flap operations.
The after-treatment, following operations for cleft-palate, should be scru-
pulously carried out. The success of the operation depends much upon it.
The child should be placed on its side with the face rotated downward so
that saliva may flow easily from the mouth upon a towel.
The child should not be fed until the stomach surely will retain food.
Small amounts of sterile water should first be given. No solid food should
be taken for five days or a week. Milk, orange juice, meat juice, soft egg,
custard, beef jelly, strained gruels, legume soups, and such should be used.
Sterile water should be given after each feeding. Sutures will often slough
out. Those which remain at the end of a week should be removed.
The head should be held so that fluid will run out of the mouth and the
palate sprayed with mild antiseptic solution 3 times daily. If the child
resists and fights against this cleansing, it should be omitted unless the
wounds look infected.
Infection, too great tension, or too little blood supply may cause failure
of union. Usually when this occurs, it does not involve all of the wound.
As granulations cover the ununited edges, secondary sutures may be applied.
A small hole remaining after operation may close itself. Spontaneous healing
266
SURGICAL TREATMENT
may be expected in openings not larger than 2 or 3 mm. in diameter. If they
do not heal the application of the actual cautery will produce granulations
which should fill the opening and cause its closure. If the opening persists,
it may be closed by means of a simple plastic operation. Such operations
should be deferred until the palate is plump and succulent, and not done
while it is still thin, tense and pale (see Plastic Operations, Vol. III). Unless
the operation for cleft-palate is done during the early weeks of life disturbed
phonation will be persistent.
When an older child has been cured of cleft-palate the training of the voice becomes an
important matter. These children should be given systematic training in voice culture.
Every sound and word in which they are defective should be practised persistently until
it can be pronounced correctly. A great help is in watching the teacher's lips, tongue and
expression while making the sound. Patience and persistence bring success. Learning to
speak in another language is useful for children which have matured a bad pronounciation
of their mother tongue. It is as great a sin to neglect the voice culture of these children
as it is to deny them the benefit of operation.
Perforations of the Palate. — Perforations whether congenital, or due to
disease, or following an operation for cleft-palate, should be closed according
to the general principles of plastic surgery (see Vol. III).
Harelip. — This condition is easily amenable to cure. The operation is
one of the oldest and most satisfactory in surgery. When cleft-palate is
FIG. 941. — SIMPLE HARELIP
OPERATION.
Perfect-looking result immedi-
ately after operation.
FIG. 942. — RESULT OF SIMPLE
HARELIP OPERATION.
The perfect-looking result immedi-
ately after operation becomes an imper-
fect-looking result five years later be-
cause of contraction of the scar.
associated with harelip, the former should be cured first as the smaller
mouth resulting from the operation for harelip greatly diminishes the acces-
sibility to the palate. If there is no cleft-palate, the harelip should be
operated upon during the first days of life, provided the child is healthy.
Operation is best done on the day after the child is born. The lowered-head
position is best. Every bit of blood possible should be saved, as these little
people do not bear hemorrhage well. The coronary arteries should be
caught as soon as cut. Tissue should preferably not be removed. The edges
should be freshened by incision and dissection in preference to resection.
The first step in the operation consists in freeing the lip from the alveolar
margin so that easy apposition can be made. This should be done by an
incision through the labio-alveolar fold and a similar incision in the cleft
on either side. The incisions for making the edges raw for suturing should
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
267
be made with a small, thin, sharp knife. Allowance should be made for the
contracture of the scar tissue which will invariably take place. If the
operation ends with a symmetrical-looking mouth, the result will not be
good, because a dimple will occur later as the result of scar contraction. At
the close of the operation, there should be a slight redundancy or fulness of
FIG. 943. — IDEAL HARELIP
OPERATION.
Note slight projection at
lower end of wound which in
the course of time will become
even.
FIG. 944. — LATER RESULT OF
IDEAL HARELIP OPERATION.
The operation that was so planned
that a projection marked the lower end of
the scar shows a perfect result five years
later.
tissue at the edge of the lip in the line of the cleft (Figs. 941 and 942). The
simple operation is undesirable because of the difficulty of this calculation.
A plastic flap obviates to a degree the objection of the old operation, although
scar contraction should still be considered (Figs. 943 and 944). Another
FIG. 945. — OPERATION FOR HARELIP.
The mucous membrane has been sewed'
the skin sutures are ready to be tied, and the
lateral incisions have been made.
FIG. 946. — OPERATION FOR
HARELIP.
Result after closure of wound.
objection to the old operation is that it sacrifices tissue in paring away the
margins of the cleft; and the preservation of tissue is a decided advantage.
The operation devised by Christian Fenger is most effective. It is a
split-flap operation, similar to that done for restoration of the lacerated
perineum. After the lip has been freed from the alveolar margin, an incision
268
SURGICAL TREATMENT
is made at the skin-mucosa border of the cleft. The mucous membrane
flap is dissected back from either side and united by sutures which are
tied posteriorly (Fig. 945). This dissection leaves the surfaces of the cleft
lip widely denuded. To produce a slight elongation of the line of suture to
FIG. 947. — SPRING FOR HOLDING THE
CHEEKS AFTER OPERATION FOR HARE-
LIP.
FIG. 948. — SIMPLE OPERATION
FOR HARELIP.
Showing lines of incision.
compensate for later contraction of the scar, short transverse incisions should
be made on either side. Deep stay sutures are then inserted. Finally the
skin sutures are introduced (Fig. 946). Silk, thoroughly impregnated with
paraffin, is used. The wound should not be covered with a dressing.
FIG.
949. — SIMPLE OP
FOR HARELIP.
Flaps adjusted and wound
sutured.
FIG. 950. — HARELIP OPERA-
TION TO REMEDY A SIMPLE
NOTCH IN THE LIP.
Transverse incision made
above notch through whole thick-
ness of the lip.
A child should be prevented from opening its mouth widely after the
operation. By taking a piece of zinc oxid adhesive plaster, 2.5 cm. (i
inch) wide and about 30 cm. (12 inches) long, placing the middle under the
chin, drawing it tightly up across each cheek, and crossing the two ends at
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
269
the root of the nose, the jaw and face may be held so that the child can do no
harm by opening its mouth. The strip may be rolled into a cord as it passes
in front of the eyes (A. H. Ferguson). H. L. Smith (Surg. Gyn. and Obst.,
Nov., 1916) devised a simple wire spring for holding the cheeks (Fig. 947).
The operation best adapted to the average case of lateral harelip is the
following: The outer side of the cleft is freshened by peeling away the mucous
FIG. 951. — NOTCH DEFORMITY
CORRECTED BY CONVERTING
TRANSVERSE INCISION INTO VER-
TICAL WOUND.
FIG. 952. — WOUND SUTURED.
The scar contracture a few
months after the operation will re-
move the downward projection at
the site of the wound.
membrane. This denudation should extend also outward upon the margin of
the lip for a short distance. The inner side of the cleft is then seized at the
lip margin with fine mouse-tooth forceps, and a flap cut by transfixing the
whole thickness of the lip. This flap should not be a thin paring but
should have bulk. Its apex should be swung downward to the outer part
of the denuded lip surface. Thus a part of the vermilion border of the
FIG. 953. — HARELIP OPERATION
WITH TRANSVERSE INCISIONS.
FIRST STAGE.
FIG. 954 . — FLAPS DRAWN
DOWN INTO POSITION. SECOND
STAGE.
cleft conies to form a part of the border of the reconstructed lip. Each case
is peculiar and requires judgment in calculating the size and shape of the
flap and the area of denudation. The wound should be sutured with horse-
hair or celluloid-treated thread. A deep suture close to the coronary artery
will control it. A row of sutures should be used on both the facial and dental
sides of the lip. Every other suture should be passed deeply, the skin sutures
just to the mucous membrane, and the mucous membrane sutures just to the
270
SURGICAL TREATMENT
skin. Every other suture should be for superficial approximation. The
deep sutures hold the muscle and prevent bleeding (Figs. 948 and 949).
Care should be taken that no epithelium is left upon the surface to be
covered. The tissue removed should come just to the skin. The preser-
vation of the lines representing skin-mucous-membrane juncture should be
exact. The vertical wound will ultimately contract, and to secure a final
perfect result, there should be a slight fulness of the lip directly below it.
Harelip pins have no advantage over sutures, and many disadvantages.
FIG. 955. — WOUND SUTURED
VERTICALLY. THIRD STAGE.
FIG. 956. — HARELIP OPERA-
TION WITH LONG OBLIQUE IN-
CISIONS. FIRST STAGE.
Many other operations suggest themselves, according to the principles of
plastic surgery, to meet special conditions. A simple harelip of slight degree,
constituting a notch in the lip, is remedied by making a transverse incision
passing through the whole thickness of the lip (Fig. 950), drawing its two
ends together (Fig. 951) and sewing it as a vertical wound (Fig. 952). In
more aggravated cases transverse incisions to form a flap are useful (Fig.
953). Such flaps are drawn downward (Fig. 954) and the wound sutured
FIG. 957. — WOUND READY FOR
SUTURE. SECOND STAGE.
FIG. 958. — WOUND CLOSED.
THIRD STAGE.
vertically (Fig. 955). More pronounced cases require oblique incisions
(Fig. 956) to secure longer flaps (Fig. 957). These may be sewed and
adapted in both vertical and horizontal lines (Fig. 958).
Still more aggravated cases require larger flaps such as may be secreud by
incisions passing upon the cheeks (Fig. 959). These flaps are swung down
and adjusted to give a slight projection at the lip margin (Fig. 960). They
may be sewed with interrupted and continuous sutures (Fig. 961).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 271
In double harelip, the prolabium should be utilized. An operation
combining on either side the principles used in the single operation is applic-
able. The median bud may be so hypertrophied that a wedge of its tissue
"
FIG. 959. — HARELIP OPERATION WITH
CHEEK FLAPS. FIRST STAGE.
FIG. 960. — HARELIP OPERATION WITH
CHEEK FLAPS. FLAPS DRAWN DOWN.
FIG. 961. — HARELIP OPERATION WITH
CHEEK FLAPS. WOUNDS SUTURED.
FIG. 962. — OPERATION FOR
DOUBLE HARELIP.
First stage. Lines of incision.
FIG. 963. — OPERATION FOR
DOUBLE HARELIP.
Second stage. Flaps turned down.
tf/^J
^
FIG. 964. — OPERATION FOR
DOUBLE HARELIP.
Third stage. Wounds sutured.
should be removed. When necessary it may be lengthened by making a
transverse puncture through it, and closing it by a transverse suture. Each
case offers a different problem.
272
SURGICAL TREATMENT
4
m
FIG. 965. — OPERATION FOR
DOUBLE HARELIP WITH TRANS-
VERSE INCISIONS. FIRST STAGE.
FIG. 966. — OPERATION FOR
DOUBLE HARELIP WITH TRANS-
VERSE INCISIONS. FLAPS TURNED
DOWN. SECOND STAGE.
FIG. 967. — OPERATION FOR
DOUBLE HARELIP WITH TRANS-
VERSE INCISIONS. WOUNDS
SUTURED. THIRD STAGE.
FIG. 968. — OPERATION FOR
DOUBLE HARELIP WITH CHEEK FLAPS.
LINES OF INCISION. FIRST STAGE.
FIG. 969. — OPERATION FOR
DOUBLE HARELIP WITH CHEEK FLAPS.
FLAPS SUTURED. SECOND STAGE.
The raw surfaces may be covered
with grafts or by sliding flaps from the
cheek.
FIG. 970. — DOUBLE-FLAP
OPERATION FOR DOUBLE HARE-
LIP. LINES OF INCISION.
The flaps ABF and BCD are
turned down; the point C is su-
tured at A ; the point B is sutured
at E.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 273
The operation is similar to two operations for single harelip (Fig. 962).
Usually lateral flaps must be turned down below the central bud (Fig. 963).
The suturing should adapt the flaps to their new position (Fig. 964). In
some aggravated cases two lateral incisions are well adapted to secure the
flaps (Fig. 965). After bringing down the flaps (Fig. 966), it may then be
determined just how the sutures must be applied (Fig. 967). By providing
for flaps from the cheeks (Fig. 968), the most aggravated cases may be
remedied (Fig. 969). The defect left in the cheek may be closed by further
plastic or it may be covered by a skin-graft. Incisions providing for over-
lapping flaps are applicable to most of these cases (Fig. 970). In such cases
the possibilities of scar contraction must always be considered in closing the
wounds (Figs. 971 and 972).
The notched-lip, following operation for harelip or of congenital origin,
is easily cured by making a transverse incision through the lip above the
notch and closing it by transverse sutures as a vertical wound (Figs. 973 and
974).
FIG. 971. — DOUBLE-FLAP OPERA- FIG. 972. — EXCEPTIONAL DOUBLE-FLAP
TION FOR DOUBLE HARELIP. OPERATION FOR DOUBLE HARELIP.
Wound closed. If the prolabium is large, the wound
may be closed thus.
The deformed nostril, associated with harelip or following operation for
harelip, may be treated at the time of operation or later. In some cases
the nostril is wide and flat. It may require that the nose shall be made
higher by a septum operation (page 190). Usually it is also well to detach
the outer implantation of the alar cartilage and move it inward. In some
cases it is well to cut out a part of the cartilage to reduce the size of the
nostril (see Plastic Operations, Vol. III).
The ajter-treatmeni of harelip cases should be carried out with scrupulous
care. After suturing the wound, the skin should be dried and a strip of
adhesive plaster placed under the chin to hold the mouth closed (page 268).
Dressing on the wound is rarely necessary. The child's hands should be
watched or restrained so that it shall not touch its mouth. Its food should
be sterile fluids administered from sterile containers. Only sterile water
should be given the first day. Several times daily a little boracic solution
should be sprayed between the lips. On the third day all but one of the deep
sutures through the skin may be removed to prevent scars. On the fourth
day the remaining deep skin suture may be removed. The sutures to be
taken out are first the deep ones and those which seem to be cutting or
which threaten ulceration. The deep posterior mucosa sutures and the
superficial skin sutures may be left for seven to ten days.
VOL. II—iS
274 SURGICAL TREATMENT
Secondary operations may be required to improve the symmetry of the
lip or nose. If the upper lip is thin and tight, it may be relaxed by sliding in
tissue from the check. If the lower lip is out of proportion and larger than
the upper lip, a V-shaped piece may be removed from it. After operation,
dyspnea may require attention. This is because of the narrowing of the
respiratory orifices. The lower lip should be depressed at each inspiration
until the child becomes accustomed to the new conditions. The nose should
be kept cleaned of blood and discharges. Some surgeons pass a suture
through the back of the lower lip and fasten it under the chin with adhesive
plaster, thus holding the lip down to prevent dyspnea.
If failure of union is present as a result of infection or defective nourish-
ment, infected sutures should be removed and the wound frequently dressed.
After the surfaces have become covered with clean granulations, secondary
sutures should be put in after trimming the edges. Victory may thus be
snatched from defeat.
FIG. 973. — OPERATION FOR FIG. 974. — RESULT AFTER
NOTCHED LIP. VERTICAL CLOSURE OF A HORI-
A transverse incision is closed ZONTAL INCISION.
vertically. Overcorrection is made The result with downward pro-
because the later scar-contraction jection of dimple is here somewhat
will restore the normal contour. exaggerated.
THE TEETH AND GUMS
The cleansing of the mouth and teeth has already been discussed in
connection with oral asepsis (page 244), and as a preliminary essential to
success in all operations upon the mouth, respiratory passages and esophagus.
The good condition of the teeth is necessary for two reasons: (i) an essential
part of digestion is good mastication; and (2) the presence of carious teeth
constitutes a constant menace to health by furnishing infection to the
alimentary canal, to the lymphatics and blood, and to the adjacent tissues.
Teeth capable of physiologic mastication and uninfected teeth are an essential
prerequisite for good health.
To prevent the decay of teeth, the child must first be born with a good
organism to start with. Good general health helps to preserve the teeth.
Exercise of the teeth is essential for their health. It is important that,
especially in childhood and adolescence, food requiring mastication shall be
fed and masticated. Children should be taught to masticate thoroughly.
But they cannot be taught this if they are fed on gruels and mush. Healthy
children as soon as they have teeth enough should have foods which give
some resistance to the jaws. Dates, nuts, dry bread, fruits, a meat bone — •
these are some of the things which should constitute a part of the daily ration.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 275
Children should early begin to work for their living with their teeth. The
profession of dentistry is an outgrowth of the tendency to pamper the mouths
of infants with soft and fermentable foods which the dear little things may
take easily.
Caries of the teeth begins in openings in the enamel in which bacteria
penetrate and establish foci of disintegration. Such openings are usually
the result of the breaking down of the enamel by the products of fermentation
in the mouth; but they may be congenital. They may be caused by trau-
matism, by strongly acid foods, or cracks may be caused by taking into the
mouth extremely hot or extremely cold materials. Once having begun, the
infection slowly spreads, breaking down and destroying the tooth substance
as it advances. As soon as the advancing process of infection approaches
the pulp chamber and the interior nerve-supplied parts of the tooth, the
irritating products of infection cause pain, just as in inflammation elsewhere.
Asepsis of the mouth reduces the bacteria and prevents the chemical erosion
of the enamel. The deposit, precipitated upon the teeth from the oral secre-
tion which increases in a ratio with ill health, is a culture bed of micro-
organisms. The acid products of fermentation in this substance have the
power of dissolving the enamel of the teeth. It is, therefore, important that
it should be kept removed. Good hygiene diminishes it; but few people are
free from it. Particles of food, lodged at the bases of the teeth also act as
culture beds for microorganisms whose acid products erode enamel.
The removal of these destructive substances from the mouth is best ac-
complished by mechanical means. The tooth brush should be used at least
twice daily, and as much of the surfaces of the teeth as are accessible should
be brushed. Particles of food should not be allowed to remain lodged be-
tween the teeth. They may be removed by means of a silk thread engaged
between the teeth. Once daily or every other day, some cleansing substance
should be used with the tooth brush. For this purpose tooth powder is to be
recommended.
The following formulae are used for tooth powder:
Calcium carbonate (pure, fine, precipitated) 100, powdered "castile soap
25, sodium bicarbonate 25, orris root 100, myrrh 100, oil of wintergreen 10.
Calcium carbonate (pure, fine, precipitated) 95, castile soap 4, saccharin
%, oil of peppermint %, oil of birch %.
Calcium carbonate (pure, fine, precipitated) 35, magnesium carbonate 12,
orris root 18, oil of peppermint %.
The destructive power of the buccal precipitate may be reduced by
neutralizing its acids by rinsing the mouth once daily with milk of magnesia.
When once caries has begun, it will continue until the tooth is destroyed,
unless the disease is stopped. This demands that all of the carious part of
the tooth shall be removed down to healthy structure, that the cavity shall be
rendered sterile and free from culture material, and that the further access
of bacteria shall be prevented by filling the cavity with some resisting material
which can be made to penetrate every crevice. Scientific dentistry has
solved these problems. The most effective filling is the inlay held by
cement. Teeth which do not lend themselves to being filled are protected
by covering with a cap of gold. Teeth which can neither be filled or capped
are made capable of mastication by fixing a new crown to the root by means
of pins and other mechanical devices. Irreparably decayed teeth should be
extracted.
Besides the diseases entering through the enamel of the crown, infections
often begin at the root of the tooth. Such root infections may, perhaps, be
conveyed by the blood or lymph-channels but they most probably enter by
276 SURGICAL TREATMENT
way of the canal or at the side of the root. The infection in such cases destroys
the nerve and circulatory channels entering the root, and the tooth becomes
dead. If suppuration is present at the root, drainage should be provided
either by opening the root through the crown, by making an incision through
the gum, or by extracting the tooth. If none of these things is done, spon-
taneous opening may take place through the gum, pus may escape at the
side of the tooth, infection of the alveolar process may occur, the antrum of
the upper jaw may become infected, or the natural resistance of the tissues
may overcome the infection. Such infection is prone to cause recurring
attacks of inflammation and suppuration, although the intervals between
such attacks may be long. There is always danger that the infection will
penetrate to the alveolar process of the jaw, and cause periostitis or necrosis.
One of the modern dental sins is the filling or crowning of "dead" teeth
without cleaning out the root canal, removing all animal matter from it, and
filling it with rubber or some other non-decomposable substance. The com-
plete cleaning out of root canals, down to and through the apical foramina,
and the complete filling of the canals, is one of the triumphs of modern dentis-
try. If a tooth with a dead root is filled or capped, and the animal material
in the root canal (nerve, lymph and blood-channels) is left, this unnourished
material is apt to become infected; drainage is prevented by the filling or
cap which seals the outlet of the canal; and the patient is a candidate for
general systemic infection from the confined products at the apex of the tooth.
Patients would be much better off to leave their dead teeth uncrowned and
unfilled rather than to have the uncleaned canal sealed up. It is from such
bad therapy as this that streptococcic infections of the teeth develop and pro-
duce the secondary manifestations — "rheumatism," arthritis, neuritis, infec-
tive valvular disease of the heart, arteriosclerosis, necrosis of the jaw, etc.
It is possible that by preventing streptococcic infection of the teeth a causa-
tive factor in gastric and duodenal ulcer may be eliminated.
The common streptococcus infection which occurs at the apices of unfilled
roots should be treated by removing all animal matter from the root canals.
In this work the #-ray is indispensable. This simple drainage usually suffices
to effect a cure of the infection. Electrolysis and antiseptic medication
forced through the canal also are used. After all inflammatory reaction has
subsided, the thoroughly dried canal is then filled with rubber and rubber in
chloroform solution, which should be pressed in until it just passes through
the apical foramina and enters whatever extradental cavity may be present.
If a cavity of considerable size has developed at the apex because of rare-
faction and absorption of bone and tooth, it is usually best to trephine
through the alveolar process, pack the cavity with gauze and secure its heal-
ing by granulation. Often the apex of the tooth, projecting into such a
cavity, may be cut off. The tooth can often be saved. Its sacrifice should
not be considered necessary in most cases.
Teeth should be examined every three months, or every six months at the
most, by a dentist, in order that beginning disease may be discovered and
its advancement checked. Prophylaxis in the care of the teeth repays well
for every inconvenience which it may entail. Dentistry, besides preventing
and curing infections, with all the constitutional harm arising from them, is
able by the application of prosthetic surgery to preserve the function of masti-
cation. In the treatment of many diseases of the alimentary tract and many
constitutional ailments, it will be found that defective mastication is the
chief causative factor, and that when the teeth have been made efficient the
disease has been cured. For proper mastication there should be at least
two efficient molar teeth in each jaw on each side. In the absence of such
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 277
teeth, they may be supplied by some of the above-mentioned methods, by
bridges, or by the use of false teeth supported on plates. Plates bearing
false teeth are best made of gold, or some other substance which is a good
conductor of heat, in order that the warmth of the covered mucous membrane
may be radiated. Hard rubber does not serve well for this purpose.
Alveolar abscess, resulting from root infection, should be freely evacuated.
If an effort is to be made to save the tooth, the mucous membrane should be
incised at the place of swelling. The mouth should be washed out frequently.
As the opening becomes a sinus, the dentist can determine what may be done
to preserve the tooth or whether it is best to preserve it. Sometimes these
abscesses in the lower jaw become large and are surrounded by much celluli-
tis, the pus appearing under the skin below the jaw. In such cases, incision
should be made in the submaxillary region where the pus indicates, and the
tooth whose root is involved in the disease removed. Denudation of bone
will usually be found, but unless necrosis is clearly evident the removal of the
bone need not be undertaken as the power of recovery in this region is very
great. Later, if necrosis demands operation, the diseased bone may be
removed (see Caries and Necrosis, Vol. I, page 692; and Osteomyelitis of the
Jaw, Vol. II, page 283). If a sinus persists after operating on alveolar
abscess, its opening in the mouth should be closed by denuding the surfaces
and suturing it. As soon as it is reduced to a simple external sinus it will
heal unless there is dead bone.
Pyorrhea alveolaris (Riggs' disease) caused by the Endameba buccalis
and, perhaps, other species which destroy the peridental membrane, charac-
terized by alveolar suppuration and loss of teeth, should be treated by the
general surgical principles laid down for suppuration. The mouth should
be cleansed; the teeth should be cleared of tartar; hopelessly decayed teeth
should be removed and remediable teeth should be treated; suppurating foci
should be sought and drained by incision or by the removal of teeth; carious
bone should be removed; and suppurating sinuses should be opened. Wash-
ing and cleansing of diseased foci should be practised. Sound teeth should be
preserved. This treatment is recommended because the pyorrhea is due
largely to secondary bacterial infections.
The specific treatment, aimed to destroy the ameba, consists in the hypo-
dermic injection of 0.03 Gm. (^ grain) of emetin hydrochlorid on from
three to six successive days. The same result is secured by the internal
administration of two or three tablets of Alcresta ipecac, each containing 0.6
Gm. (10 grains); these should be taken by mouth 3 times daily for from
four to six successive days. This treatment must be repeated in bad cases.
Rinsing the mouth with fluidextract of ipecac is of value in early cases.
If the secondary infection persists the organisms which are causing the
trouble should be identified, and a vaccine made (see Vaccines and Bacterins,
Vol. I, page 255).
Gingivitis. — Inflammation of the gums, whether a part of a general
stomatitis, whether due to pyorrhea alveolaris, or whether a local manifes-
tation of rickets, scurvy, lead poisoning, mercurial poisoning, or phosphorus
poisoning, should be treated by first treating the causative factor. The
teeth should be cleaned, carious foci should be removed, cavities should
be filled, and an antiseptic mouth wash should be used. If the gums
are soft and spongy, permanganate of potash solution is an effective mouth
wash.
Exuberant swelling calls for removal of hyper trophied tissue or its incision
to permit the escape of blood. Massage of the gums with a stiff brush is
helpful.
278
SURGICAL TREATMENT
The following mixture, painted on the gums every day, is useful: 3 Gm.
zinc iodid, 3 Gm. iodin, 10 c.c. glycerin, 10 c.c. water.
Extraction of Teeth.- — The removal of teeth is called for in cases of irrep-
arably decayed teeth, teeth in malposition, to gain access to diseased
alveoli, for feeding in cases of tightly closed jaws, and as a preliminary to
certain operations such as excision of the jaw and draining the antrum. The
instruments used are forceps and elevators. Forceps are made in many
shapes to fit teeth of various forms and positions, but the handy surgeon
does not require a great variety.
Extraction may be done without any anesthetic, with local anesthesia,
or with general anesthesia, according to the rules already given (Vol. I,
page 92). If the tooth is loose or if there are contraindications, no anesthetic
need be used. For local anesthesia, the mucous membrane may be numbed
on either side by touching a spot with phenol solution. Through
this area the hollow needle may be introduced, and all of the soft tissues
about the fang and neck of the tooth infiltrated with analgesic solution.
FIG. 975. — EXTRACTION
OF TEETH.
The wrong way.
FIG. 976. — EXTRACTION OF
TEETH.
The right way.
This permits extraction without pain. Fairly good analgesia may be secured
by spraying the gum with ethyl chlorid after covering the surrounding
parts with cotton for protection. The inferior dental nerve may be anesthe-
tized as it enters the canal in the lower jaw. For anesthetizing the nerve
supply of the jaws, see Local Anesthesia and Neuralgia of the Trigeminal
Nerve, Vol. I. For general anesthesia nitrous oxid is to be preferred.
Before using, the forceps should be sterilized. The technic requires that
the tooth shall be grasped, not by the crown (Fig. 975) but well down upon
the neck (Figs. 735 and 736). In order to do this properly the gum must be
pressed away from the tooth by the jaws of the forceps or as a preliminary
step by means of an elevator. This should not be done in a half-hearted
way, but the forceps should grasp the tooth well down on the root (Fig.
976). This separation of the soft tissues from the tooth gives rise to some
bleeding. The tooth should be firmly grasped by the forceps, loosened by a
lateral rocking motion, and pulled out. This lateral leverage motion is
the important movement in extraction. It should be carried far enough
to free the tooth from its attachments, but not so far as to break the fang or
alveolar process. The wrong way is to attempt the loosening of a tooth by
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 279
traction in the direction of its long axis. The tooth having been loosened
by lateral leverage is then easily removed by traction in the direction of its
long axis combined with rotation. The tooth to be removed should have
been identified beyond question before the operation.
Extraction by means of the elevator is practised in the absence of forceps,
and in cases in which the mouth cannot be opened. The elevator is used
as a lever, passed down into the socket, and made to pry out the tooth.
The bleeding after extraction usually stops after a few minutes. The mouth
should be rinsed with clean water. If the bleeding does not stop promptly,
a gauze packing in the socket may be expected to be sufficient. Some adren-
alin chloride may be added to this. Styptics which are irritating or corrosive
should not be used because of the danger of sloughing. If an antiseptic
styptic is required, one of the mild powders, such as zinc oxid, diluted
subgallate of bismuth, aristol, or formidin may be employed. The pressure
of a clean gauze packing should be the main reliance in all cases of hemor-
rhage. Bad cases may require that the pressure shall be maintained by
holding the jaws firmly together by means of a chin-and-head bandage;
or a clamp, screwing the gauze into the socket, may be required; or con-
tinuous digital pressure, in the absence of mechanical apparatus, may be
necessary. Ligation of the external carotid is the last expedient (see Hemor-
rhage, Vol. I, page 409). Death from hemorrhage following tooth extraction
is not uncommon. It does not occur in the presence of competent surgery
and modern surgical facilities.
Tooth Grafting.— After the removal of a sound tooth by accident or as
a temporary expedient, it is possible to press it back into its socket and have
it become reattached. It is essential that the fang and neck of the tooth shall
be free from decay and that the alveolus shall not be infected. In the pres-
ence of infective disease grafting is impossible. If the tooth is to be replaced
immediately, as may be the case in the accidental or purposeful removal
of a sound tooth, the fang and neck should not come into contact with any
thing which is infective, the socket should be washed out with warm sterile
salt solution until it is free from blood, the tooth should be pressed back into
its normal position, and held there immobilized until it becomes united to
the soft tissues.
In the case of a tooth which has become soiled, or in which some time has
elapsed since its removal, or in which the socket has required treatment,
replacement should be deferred until the best possible asepsis can be insured.
A tooth, for example, has been knocked out and fallen upon the ground; it
is brought to the surgeon for replacement after some hours or days; here the
problem is more difficult. The tooth should be cleaned and immersed in
warm antiseptic solution which should be kept at body temperature. Boro-
salicylic solution is suggested. The socket should be syringed out several
times daily with warm saline solution until the traumatic reaction has sub-
sided. The other teeth and the rest of the mouth should be brought into
the best state of cleanliness possible. If the removed tooth presents any
caries which should demand filling, it should be filled, being handled with the
utmost aseptic care. The aseptic tooth is then pressed firmly back into the
cleansed socket, and held by fixation apparatus, which exerts some constant
pressure upon its crown.
The immobilization of teeth after grafting is an important step in the
operation. This is best accomplished by making an impression of the teeth
of the affected jaw, and preparing a gold plate from this, which shall fit
over the adjacent teeth, protecting and immobilizing the grafted tooth. This
immobilization should be maintained for three months.
280 SURGICAL TREATMENT
The mouth should be kept clean. Particularly is it important that no
particles of food shall become lodged about the grafted tooth. Careful
syringing of the mouth must be relied upon to prevent this. To insure
immobilization, mastication should not be practised for the first month; and
for the next two months, no masticatory pressure should be made on the
grafted tooth. Success is secured by vigilance; a fatalistic policy means
failure.
Not only may the natural tooth be thus replaced, but it is possible to
graft teeth from another jaw. The same principles as already set down apply
to the heteroplastic operation.
Tumors of the Gums and Teeth. — Odontoma is an abnormal growth of
dental tissue which should be removed to prevent interference with normal
teeth and because of its irritation. Odontoma of the fang requires removal if
it give rise to trouble. Cysts arising in connection with the teeth are treated
by removal of their walls. Odontomata may give rise to cysts which require
eradication of the cyst wall. Excision of the jaw is not called for in these
cases. Angioma of the gum is to be treated the same as angioma elsewhere.
Myeloid sarcoma is the least malignant of the sarcomata; it should be eradi-
cated by extraction of the adjacent teeth, excision of the growth, and, if it
lay close to the bone, the adjacent bone should be removed with the rongeur.
All other forms of sarcoma should be treated by wide, systematic excision of
soft tissue and bone. Epilhelioma of the gum should be treated by wide
excision.
One of the most common tumors of the gum is called epulis. This may
mean any one of several forms of growth, but the treatment applied should
be that for fibrosarcoma. The adjacent teeth should be extracted so that a
margin of about 5 mm. of sound tissue may be removed with the growth.
The adjacent bone should be removed. For this purpose the rongeur
forceps may be employed or a quadrilateral section of alveolar process may
be cut out with the saw and chisel (Vol. I, page 717). Artificial teeth may
later be adjusted to the defect (see Tumors of the Jaws, Vol. II, page 286).
THE JAWS
Deformities of the jaws, resulting from thumb sucking in infancy, from
adenoids, and from scar contractures, are all to be treated by prophylaxis.
Thumb sucking may be prevented by simply lengthening the child's sleeves
by the addition of some stout, washable material, and closing the ends of
the sleeves beyond the finger tips with a shirr string. Such an addendum
should be worn at that part of the day when finger sucking is practised.
Unless this bad habit is cured, the alveolar process will be pressed forward
in the upper jaw and backward in the lower jaw, and overlapping teeth result.
An apparatus to correct the deformity may be called for. The plastic,
growing jaw is easily moulded to a desired shape by any pressure long con-
tinued. The dentists, by what is called orthodentistry, apply apparatus to
correct the shape of the jaw as the child grows.
Underdeveloped lower jaw, following ankylosis of the temporomaxillary
joint or disease which fixes the jaw, may be greatly improved by osteo-
plastic operation and liberating the joint. The deformed and small jaw
(Fig. 977) may be improved by moving forward the chin by means of trans-
verse section of the rami and forward displacement of the lower segment
(Fig. 978). The operation on the bone should be a plastic with the insertion
of a graft of bone on either side. If this does not give enough forward
projection of the chin, a piece of costal fibrocartilage may be transplanted
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 281
(Fig, 979). At a later operation, if necessary, a joint plastic operation may
be done (see Operations on Bones and Joints, Ankylosis, Vol. I).
FIG. 977. — MALOCCLUSION OF LOWER JAW.
Operation for lengthening body of jaw. The bone is exposed by an incision below the
jaw. The soft tissues are dissected up, and the bone is divided on either side by a Z-shaped
incision.
In other cases, a plastic operation may be done for changing the contour
of the body of the jaw. Tilting forward of the jaw may be secured by divid-
ing the rami and inserting a wedge of bone (Fig. 980).
FIG. 978. — RESULT AFTER OPERATION FOR MALOCCLUSION OF LOWER JAW.
The median segment of the body of the jaw has been moved forward, and separation main-
tained by inserting bone-grafts taken from the tibia.
Defective occlusion is treated by wedge-shaped resection and horizontal
division of the mandible (Fig. 981). The wedges of bone are removed and
inserted as grafts in the horizontal gap (Fig. 982). Prognathism is cured
282
SURGICAL TREATMENT
by resection of a wedge of bone on either side of the body of the lower jaw
(Fig. 983)-
FIG. 979. — PERFECTED RESULT AFTER OPERATION FOR MALOCCLUSION OF LOWER JAW.
A TRANSPLANT OF COSTAL FIBROCARTILAGE HAS BEEN ADDED LATER TO IMPROVE THE
SYMMETRY OF THE CHIN.
This transplant is simply slid under the soft tissues of the chin through the smallest possible
wound.
In treating malocclusion in the adult the lines of division of the bone must
be adapted to the peculiar conditions of each case (Fig. 984). The result
differs with vertical division through the ramus (Fig. 985), division at the
FIG. 980. — CHANGING CONTOUR OF JAW.
Wedge of bone-graft inserted in divided ramus for the purpose of tilting the body
forward.
base of the neck, of the condyle (Fig. 986), or vertical division between the
ramus and the body of the jaw (Fig. 987).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
283
Deformities of the lower jaw with defective occlusion in adults are treated by
osteoplastic operations. Forward displacement of the lower alveolar
process is remedied by removing a V-shaped segment and making a trans-
verse cut below (Fig. 981). The segment is tilted upward and held by a
transplanted wedge (Fig. 982).
FIG. 981. FIG. 982.
FIG. 981. — DEFECTIVE OCCLUSION TREATED BY WEDGE-SHAPED RESECTION AND
HORIZONTAL DIVISION OF MANDIBLE.
FIG. 982. — RESULT AFTER OPERATION FOR DEFECTIVE OCCLUSION.
The wedges of bone have been removed and inserted in the horizontal gap.
The treatment of prognathism with malocdusion is by the same principle.
Osteotomy may be done alone or combined with the grafting of a piece of
bone from the tibia or rib (see Operations on Bones; Bone Grafting, Vol. I,
page 772).
FIG. 983. — PROGNATHISM TREATED BY RESECTION OF A WEDGE OF BONE ON EITHER SIDE.
Periostitis and osteomyelitis of the jaw have been discussed under
Alveolar Abscess (page 277). Osteomyelitis demands immediate and
active treatment (Vol. I, page 692). As soon as possible, the bone should be
drilled or trephined. This can be done through a small incision in the skin
below the lower border of the jaw. Even though the operation has been
284
SURGICAL TREATMENT
done before pus has collected, it will abort the disease. An early opening
of the inferior dental canal is the one important step in acute osteomyelitis.
If the disease has progressed to necrosis and exfoliation of bone every
effort should be made to save the teeth. Even though the alveolar process
FIG. 984. — OPERATIONS FOR MALOCCLUSION.
Showing lines of division which may be used to tilt body of jaw upward.
with the tooth sockets is gone, if the teeth are attached only by alveolar
mucous membrane they may be saved. Granulations grow about the roots
and they again become attached.
FIG. 985. — SHOWING OCCLUSION SECURED BY VERTICAL DIVISION OF RAMUS.
Hopelessly decayed teeth should be removed. Because of difficulty in
opening the mouth it is often impossible to identify the diseased tooth. If
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
285
forceps cannot be introduced the tooth should be removed with the elevator.
It is poor surgery in acute cases to "wait until things have quieted down."
If pus is present free drainage should be secured either through the skin below
FIG. 986. — SHOWING OCCLUSION SECURED BY DIVISION OF THE NECK FROM THE RAMUS
OF THE LOWER JAW.
the jaw or through the mucous membrane of the mouth. Osteomyelitis
calls for trephining of the jaw or cutting away enough bone to freely drain
the cancellous interior. The diseased tooth can usually be identified through
PIG. 987. — SHOWING OCCLUSION SECURED BY VERTICAL DIVISION OF RAMUS FROM BODY
OF LOWER JAW
the external wound by following up the abscess cavity to its alveolus. The
injection of hydrogen peroxid may help as a guide.
286 SURGICAL TREATMENT
Necrosis of the jaw whether from local infection or constitutional poison-
ing requires removal of the sequestrum. This should be carried out accord-
ing to the principles already laid down (Vol. I, page 688). Acute septic
conditions should be relieved, but it is generally best not to remove a seques-
trum until its detachment is complete. In some cases the operation for
removal of the sequestrum may be done through the mouth and an external
scar avoided. The best drainage is always secured by an external opening.
In some cases a resection of much of the jaw may be necessary (Resection of
Jaw, Vol. I, page 717).
Tumors of the jaws, benign or malignant, should as a rule be removed.
Benign tumors should be removed if they are steadily growing, if they inter-
fere or are about to interfere with function, if they cause pain, or if they are
unsightly. Malignant tumors should be removed, if removable. If the
benign central fibromata of the upper jaw or odontomala are removed while
small, the operation is easy; but to defer operation until the tumor has be-
come enormous is to invite a serious condition only to be remedied by a
serious operation. Cysts are cured by laying them freely open, and removing
the lining membrane with the curet. This is sufficient in the cysts of odon-
tomatous origin. Cystic degeneration of sarcoma demands wide excision.
In odontomata the rudimentary tooth which is the focus of the disease should
be sought and removed. Osieomata and enchondromata may be removed
with the gouge.
Of the malignant tumors of the jaws, sarcoma is the most to be feared.
It starts from the marrow or from the periosteum. The former, myeloid
sarcoma, is more encapsulated and produces metastases but slowly: it is,
therefore, more easily cured. Curetting out the growth from the interior of
the bone, and then with a sharp gouge removing a thin layer of the surround-
ing bone suffices to cure the disease. Strong curettage alone down to healthy
bone, and the destruction of the peripheral cells with pure phenol usually
cure the disease. Wide resections in this form of sarcoma is not necessary.
Every effort should be made to preserve the lower jaw in one piece. Periph-
eral sarcoma, usually of the spindle-cell or small round-cell type, starting
from the periosteum, is an extremely malignant disease, and demands early
and wide excision.
Carcinoma of the jaw is usually by extension from the adjacent mucous
membrane, but inasmuch as epithelium is found lining many cavities and
alveoli and lying close to the bone, the disease may from the beginning closely
involve the osseous structures. Early and wide eradication of the growth is
imperative, together with removal of the draining lymphatics (see Lymphatics
of the Neck, page 363). In advanced cases of carcinoma, operation has
something to offer. The lymphatics of the neck should be removed. Then
after a week or two, the extirpation of the primary disease should be
attempted. If a wide operation involving the mouth is to be done, prelimi-
nary tracheotomy is advisable. Temporary ligation of the external carotid
may be relied upon to save blood. Hemorrhage, shock, and pneumonia are
the dangers inherent in operation (see Resection of Jaws, Vol. I, page 717;
Tumors, Vol. I, page 323). The starvation treatment of ineradicable tumors,
by ligation, injection, and removal of the blood-vessels, is sometimes
applicable in this region (Vol. I, page 333).
THE TONGUE
Congenital Defects. — Bifid tongue, if pronounced, is cured by removing
the mucous membrane from the inner surfaces of the cleft and suturing the
wound with interrupted non-absorbable sutures. The sutures may be
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 287
removed on the fifth day, except the anterior suture which should be left
a day or two longer. Soft food only should be taken during the first three
days.
Tongue-tie, in which the tongue is held to the floor of the mouth by a
short frenum, usually remedies itself as the child grows. The division of
many normal frena is demanded by many anxious mothers; and many
unnecessary operations are performed upon this organ. If the tongue can
not be lifted by the fingers away from the floor of the mouth on account of a
short frenum, the frenum should be divided. This is accomplished by
raising the tip of the tongue with the fingers, putting the frenum on the
stretch, and cutting it with scissors close to the jaw. The cut should involve
the mucous membrane, but not the underlying muscles.
Swallowing the Tongue.— This accident should be guarded against in
operations upon persons with mental diseases, in cases of division of the
frenum, operations on the genioglossi muscles, and in cases of congenitally
relaxed tongue. In such cases during and after operation the tongue should
be held forward or watched lest its tip enter the pharynx or even the
esophagus, and cause suffocation by closure of the glottis.
Injuries. — Foreign bodies in the tongue, if not removed, are prone to cause
induration, or a sinus, which persists until the body is removed.
Wounds of the tongue should be treated by the methods already given (see
Wounds, Vol. I, page 186). Even small wounds should be sutured. The
best material is black silk, because it is most easily seen for removal. If
there is a loss of substance, the wound should be closed by suturing the ad-
jacent mucous membrane over it. In cases in which the tissue is almost
separated, it should be sutured back in place with the hope that the naturally
vigorous circulation of the parts will cause its union. The sutures should
not be tied tightly because the parts will swell. Bleeding from small vessels
is controlled by the sutures. Bleeding from larger vessels should be checked
by the ligature before suturing the wound. Foreign matter should be
removed and blood clots should be sponged from the mouth. Before apply-
ing the sutures, it is a wise precaution to irrigate the wound and to sponge off
the mucous membrane around the wound with the view of removing gross
infective material.
After suturing a wound the mouth should be kept as clean as possible.
The teeth should be cleansed, and a mild aseptic mouth wash frequently used
(see Cleansing the Mouth, page 244). A fluid diet has the advantage that it
is least apt to irritate the wound. The mouth should be washed out after
food is taken. Open wounds sometimes become persistent ulcers. In
such cases decayed teeth should be treated and all sources of infection
minimized.
Wounds in the posterior part of the tongue may be reached by passing a
silk suture through the tip of the tongue to draw it forward and steady it.
Digital pressure may be required to control bleeding. In some cases it has
been found necessary to expose and ligate the lingual artery in the neck.
A local anesthetic suffices for suturing wounds of the anterior part of the
tongue, but for operations on the posterior part a general anesthetic is best.
If there is much bleeding from wounds of the back part of the tongue a
tracheotomy with packing should be done.
In suturing these wounds, it is well to leave one end of the wound open
for drainage. If much swelling occurs, sutures which cut should be re-
moved. The friability of the tissues about old infected wounds renders
suturing inadvisable until the cellulitis has been controlled by drainage and
cleansing.
288 SURGICAL TREATMENT
Gunshot wounds of the tongue are prone to carry infection and a careful
watch should be kept. If a bullet is lodged in the base of the tongue, per-
sistent bleeding calls for tracheotomy and packing of the back of the throat.
This having been done, under general anesthesia, the surgeon may proceed
to deal with the foreign body. Even though the ball is not lodged in the
tongue, the dangers from hemorrhage and edema are so great that trache-
otomy is always advisable. Secondary hemorrhage is to be expected in these
cases, which is another advantage of having done a tracheotomy.
Burns of the tongue may be due to heat or to caustic substances. A slight
burn requires that the mouth shall be kept clean and washed with a mild
antiseptic solution (see page 244). Extensive burns, producing much
edema of the tongue, may require, in addition to the above, incisions to
liberate serum. If the back of the tongue is involved, the danger of edema
of the glottis renders tracheotomy advisable. Ulcers are discussed below
(page 289).
Inflammations of the Tongue. — Acute superficial glossitis is usually as-
sociated with some other disease against which treatment should be aimed.
Beside removing the cause, an aseptic astringent mouth wash should be used
(see Mouth Cleansing, page 244; Mucous Membrane Medications, page
183).
Acute parenchymalous glossitis should be met by removing the cause when
it is known. As the disease usually occurs in debilitated adults and often
gives rise to profound sepsis, constitutional treatment is important. Whether
the infection is caused by streptococci or staphylococci, treatment by bacterial
vaccine or serum is of value. The acute symptoms may be expected to
abate in three or four days although a chronic induration may persist.
If the swelling is great, it is best relieved, drainage secured, and hyperemic
reaction brought about by free incisions. Such incisions should be made on
the dorsum on either side, 0.5 to i cm. (%6 to % inch) from the middle line.
The incisions should go into the musculature and be about i cm. (% inch)
deep. A packing with nosophen, iodoform, or formidin gauze may be
inserted. Other incisions may be required if the swelling is great. Abscess
should be watched for and opened. Gangrene should be met by cutting
away the slough as fast as it forms; and so long as a sloughing base is present,
it should be treated frequently with phenol, followed by alcohol, and covered
with antiseptic powder.
Edema of the glottis should be expected; and facilities for momentary
tracheotomy should be at hand. The neck should be kept clean and covered
with antiseptic dressing. Especially in the streptococcic infections is the
disease apt to spread to the deep structures of the neck. Streptococcic
angina should receive radical treatment as soon as it is recognized. The
same with cellulitis or abscess of the neck (see Neck, page 360). Septic
pneumonia must be guarded against.
The patient should breathe fresh, clean air. The mouth and nose should
be kept cleansed with antiseptic solution (pages 183 and 244). Milk, eggs,
and fruit juices are the best food. The mouth should be washed after each
ingestion, and ulcers should be covered with antiseptic.
The glossitis due to mercurial poisoning rarely requires incision; it is more
of an edema than cellulitis. When the tissues of the mouth are soft and
boggy and the discharges foul, permanganate of potash solution is indicated
for washing the mouth.
Chronic superficial glossitis represents a number of conditions. The
conditions described under diseases of the skin may appear here and require
the same treatment as when occurring in the skin. Such a disease is herpes.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 289
Exfolialive glossitis requires antiseptic mouth washes (pages 183 and 244)
and improvement of the general health. Painful exfoliative glossitis may be
relieved by means of applications of silver nitrate or the actual cautery.
The application of orthoform and the compound tincture of benzoin are of
service. The dyspeptic tongue is to be treated by correcting the gastro-in-
testinal and general disorders. A permanganate of potash wash is useful.
The tongue may be painted daily with silver nitrate solution (i per cent.)
or with chromic acid solution (2 per cent.). Furrows and cracks in the
tongue should be treated by the correction of bad habits. Alcohol and
tobacco should be inhibited. Constitutional disorders should receive atten-
tion. The mouth should be kept clean. Carious teeth should be treated.
Cleansing of the cracks is best secured by the application of peroxid of
hydrogen after each meal. Every second day the cracks should be opened
and a weak solution of silver nitrate applied. Unless healing of these furrows
is secured they are prone to become the seat of epithelioma. If persistent
induration appears, it should be treated as epithelioma.
Leukoplakia (called also psoriasis of the tongue, although it may involve
also the lining of the cheeks and lips) requires first that constitutional dis-
orders, especially syphilis, shall be corrected. Inasmuch as the disease is
incurable when once well-established, prevention is most important. Syph-
ilis is a strong etiologic factor. Mercurialization and low states of resistance
conduce to the disease. Locally the irritations of smoking and taking into
the mouth such irritants as alcohol and spices are to be guarded against. A
syphilitic who smokes is inviting the disease.
The active treatment demands that the causes shall be corrected. The
hygiene of the mouth should be looked to. Decayed teeth should be reme-
died. The mouth should be cleansed, at least after each meal, with diluted
peroxid of hydrogen or other mouth wash. The discomfort of dryness may
be relieved by rubbing the patches at night with ointment of balsam-of-Peru.
Painting the patches daily with glycerite of tannic acid is recommended.
Tincture of iodin, chromic acid (2 per cent, solution), and silver nitrate (2
per cent.) are used. Possibly the actual cautery has helped some cases. It
seems that the more the parts are irritated with applications the greater is
the danger of epithelioma.
At the best the disease is quite intractable. Excision of the diseased area
in the early stage has been done with the result that the disease has recurred
and spread from the scar. When a persistent chronic indurated patch
or ulcer appears, excision is the only treatment, as the probability of cancer
is so great as to make any other course unwise.
Ulcers of the Tongue. — Ulcers should be prevented by keeping the mouth
in an hygienic state especially when the general resistance is lowered by
constitutional disease. The hygiene of the mouth demands not only that
the teeth shall be in order but that the tongue shall be spared the irritation
of tobacco, alcohol, spices and hot foods. Glossitis should receive appropri-
ate treatment. Simple ulcers should have in addition to the above treatment
a daily application of chromic acid solution (i per cent.). A mild antiseptic
mouth wash should be used several times daily. Tincture of iodin and nitrate
of silver, while of benefit in many cases, produce irritation which may result
in cancer. This latter condition should always be watched for. An ulcer,
which does not make progress toward healing, and which has an indurated
circumference, should be treated as epithelioma, and removed with 0.5 to i
cm. (% e to % inch) of the surrounding tissue. An elliptic incision is best.
The wound should be closed with silk sutures.
The treatment of dyspeptic ulcer requires correction of the gastrointestinal
VOL II— 19
290 SURGICAL TREATMENT
disorder. A laxative is valuable. Restriction of the diet is called for. If
the disorder does not yield, chromic acid solution (i per cent.) may be applied
daily. A mild antiseptic mouth wash should frequently be used.
In the herpetic or aphthous ulcers of childhood, which are usually com*
plicated by involvement of the lining of the cheeks, the general health of the
child must be improved. If the disease is not controlled there is danger of
gangrenous stomatitis. The child should be placed in the fresh air; its bowels
should be kept open; and a liberal, simple diet instituted. Milk and eggs,
with a little fruit juice, constitute the best medicine. Some fresh vegetable
may be added to these. The ulcers should be touched frequently with boracic
acid solution.
The cause of traumatic ulcers should be removed; the sharp edge of a
tooth or pressure from a misfitting plate should be corrected. When the
cause has been removed a simple antiseptic mouth wash may be used. If
healing does not take place promptly, the suspicion of epithelioma should be
entertained, and the disease excised. Ulcer of the frenum resulting from
frequent spasmodic coughing requires treatment of the cause of the cough.
Boric acid solution should be applied several times daily.
The ulcers resulting from ptyalism, mercurial ulcers, are to be treated by
discontinuing the mercury, and using a mouth wash of permanganate of
potash. lodids should not be given. Belladonna may be used to check
salivation (see Hydrargyrism, Vol. I, page 289).
Tuberculosis of the Tongue. — The vigorous circulation in the tongue
prevents invasion by the tubercle bacillus. When tuberculous abscess does
occur, it is best met by free incision and frequent cleansing of the cavity
until a lining of healthy granulation tissue is secured. Tuberculous nodules
are treated by removing the disease with a sharp curette or by an elliptic
excision.
Tuberculous ulcers of the tongue should be treated the same as tuber-
culous ulcers elsewhere (see Tuberculosis, Vol. I, page 276). The improve-
ment of the constitutional resistance is most important. In general it may
be stated that the ulcer should be extirpated. Painful ulcers, even though
a cure is not to be expected should be removed. If excision is not practised,
the pain in incurable cases may be relieved by orthoform powder applied
locally; or by the use of a powder made of iodoform, 0.06 Gm. (i grain);
cocain, 0.015 Gm. (}/± grain); and morphin o.oi Gm. (% grain).
Syphilis, Actinomycosis, Trichinosis, Leprosy. — Lesions of these condi-
tions in the tongue are treated the same as when occurring in other parts.
For actinomycosis, excision is the only effective treatment.
Diseases of the Lingual Tonsil. — These conditions require the same treat-
ment as those of the faucial tonsils (Tonsils, page 212). There is the especial
danger of edema of the glottis for which reason greater watchfulness and
readiness for tracheotomy are necessary. In incising abscesses of this region,
the patient should be with the head lower than the trunk so that pus shall
run into the pharynx and mouth and not into the larynx.
Macroglossia (Hypertrophy of the Tongue). — This condition, when due to
chronic inflammation, syphilis, hydrargyrism, idiocy, cretinism, or other
discoverable etiologic factor should be met by treating the cause; and, when
macroglossia remains after everything has been done, then operative treat-
ment is called for.
True macroglossia, which is a cavernous lymphangioma, requires opera-
tive treatment. Usually the condition is congenital. The operation should
be done before speech begins and before deformity of the jaws has been pro-
duced. Ulcers and excoriations should be cured by methods already de-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
291
scribed. Usually the disease involves chiefly the front part of the tongue.
The operation essential for cure consists in the removal of a V-shaped piece
from the front of the tongue (Fig. 988). This is a simple operation. It
can be done rapidly. The tongue is grasped posteriorly on either side by the
ringers of an assistant. A tenaculum seizes the middle of the section to be
removed, and draws it forward. After the wedge, with its base forward,
is cut out, the main branches of the lingual artery are grasped and ligated,
and the wound closed with silk sutures.
Calcuh' of the Salivary Ducts. — Small stones sometimes lie so close to the
dilated mouth of the duct that they may be removed with forceps or a curet.
When this cannot be done the mouth of the duct may be enlarged by incision
and the calculus removed.
FIG. 988. — MACROGLOSSIA TREATED BY V-SHAPED RESECTION OF TONGUE.
Tumors of the Tongue.- — Ranula, due to obstruction in the ducts under the
tongue, requires removal of the obstruction. If the obstruction is caused by
a calculus, its removal may be expected to effect a cure. Usually the cystic
dilatation of the duct remains, if it is caused by stricture or inflammation,
unless the cyst is removed. Whether the ranula be caused by obstruction of
a mucous gland or a salivary duct, if it is of sufficiently long standing to have
caused a well-formed cyst, the cyst should be dissected out. This dissection
need not be complete. Most of the cyst should be removed, and the part
of the cyst which remains connected with the gland or duct should be sutured
to the mucous membrane of the mouth (Figs. 989 and 990). A submaxillary
ranula, bulging below the jaw in the neck, may be excised through the skin;
but if the gland still functionates it is necessary that the patency of the open-
ing in the mouth shall be insured. If the opening is closed, a new opening
through the mucous membrane should be made, and the glandular end of the
duct sutured to it.
292
SURGICAL TREATMENT
Cysts of the tongue should be excised either through the mouth or below
the jaw (see Cystomata, Vol. I, page 325).
Benign tumors of the tongue are treated the same as benign tumors
elsewhere (see Tumors, Vol. I, page 323). The exception to this is that papil-
loma should be removed as though it were a malignant growth.
Malignant tumors should be removed as soon as recognized (see Tumors,
Vol. I, page 327).
Carcinoma of the tongue should be prevented by the measures which pre-
vent inflammations and ulcerations of the tongue. Decayed and broken
teeth are noteworthy etiologic factors. The treatment of cancer consists
in free and wide extirpation. Warts, papillomata, and apparently benign
growths on the surface of the tongue, in persons past middle life, should
be removed by wide excision, because of the fact that they are almost certain
to become cancerous. The same is true of indurated ulcers and inflamed
areas, although not to the degree as papillomata. So important is this
that, it may be said, the best time to operate on cancer of the tongue is
before it becomes cancer.
PIG. 989. — OPERATION FOR RANULA.
A, Mucous membrane of mouth;
B, ranula; C, duct to gland; EF.
dotted lines show part to be excised.
C
FIG. 990. — RESULT AFTER RE-
SECTION OF RANULA.
The mucous membrane at F
has been brought up and sewed to
the mucous membrane at E.
The cyst has been converted into
a dimple (B).
If the growth in the tongue is small and the disease has been discovered
early, it should be removed together with i or 2 cm. (% to % inch) of sound
tissue on every side. Usually a wedge-shaped incision is adapted to small
growths and lends itself to being sutured to the best advantage. A growth,
involving the front of the tongue laterally, should be treated by removing the
most of that half of the tongue. As a rule, a lateral half of the tongue should
alone be removed only in cases in which the disease is in front of the middle,
is on the edge, and is not far advanced. If there is considerable growth in-
volving both sides anteriorly, the whole front part of the tongue should be
cut away; and if the growth is situated at the base of the tongue, the whole
tongue should be removed, even though the disease is apparently confined
to one side.
The lymphatics of the neck from the tongue are so arranged that the
two sides communicate. Cancer of one side of the tongue soon infects the
lymphatics of both sides of the neck. The further posterior the growth is
situated, the greater is the liability of bilateral lymphatic involvement.
A growth well forward on the side of the tongue causes later infection of the
opposite side of the neck. In any case, if the disease is seen so late that
a diagnosis of epithelioma is easily made, involvement of the lymphatics of
the neck should be taken for granted, and the operation planned for their
removal. This means that in every case operated upon for epithelioma of
the tongue, the adjacent lymphatics of the neck should be removed. But
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 293
one side of the neck need be operated upon if the operation is done early and
the disease is at the front of the side of the tongue; but if the disease involves
the back of the tongue, not only should the whole organ be removed, but the
lymphatics of both sides of the neck should be dissected out. Some surgeons
have come to the belief that both sides of the neck should be operated upon
wherever the growth.
The operations on the neck and tongue may be done in two stages if
necessary. The mortality is highest in the cases in which both operations
are done at one stage. In the cases in which the glandular involvement
is slight or not palpable, it is preferred to remove the tongue first, and then
after eight or ten days to remove the glands of the neck. In advanced cases,
in which the glands are decidedly involved, it is best to remove the glands
first, and then after a week or so, remove the tongue. This is because the
growth in the glands in these advanced cases proceeds much more rapidly
than that in the tongue.
It is a good practice to expose the anterior triangle and remove the lymph
glands, the submaxillary salivary gland, the fat and connective tissue close up
to the skin, the platysma, the upper part of the omohyoid muscle, the veins
lying in the connective tissue, sometimes part of the internal jugular vein,
and in some cases a segment of the external carotid artery . The superficial
tissues lying just below the maxilla and under the skin along the upper course
of the jugular vein should be removed. The tissues lying between the sub-
maxillary salivary gland and the skin should be removed so thoroughly
that but a thin flap of skin remains. It is best to take out in one mass all that
is to be removed. Special attention should be given to the space between the
mylohyoid and the hyoglossus muscles. The digastric triangle should be
dissected out. The glands lying along the internal jugular vein and under
the sternomastoid muscle should be removed. (For details of the technic,
see Operation for Carcinoma of Lymphatics of the Neck, page 363.)
Removal of the Tongue for Carcinoma. — The operation should be pre-
ceded by preparation aimed to prevent the complications which are prone to
follow this operation. The mouth should be made as clean as possible. For
several days before the operation a mouth wash (page 244) should be used.
Carious teeth should have been filled or extracted. Tartar should be re-
moved. Loose, dirty teeth had better be taken out. To operate when the
mouth is in a foul state is to invite sepsis. As a final preliminary, after the
anesthetic is established, the ulcerated surface should be dried and asep-
ticized. This may be done with tincture of iodin or phenol; or, if sloughing
tissue is present, the actual cautery should be used. The face and neck
should have been shaved if the skin is to be incised.
Besides the ordinary instruments for dissection and hemostasis, the sur-
geon should be provided with mouth gag; tongue forceps or tenaculum;
cheek retractor; strong, blunt, curved-on- the- flat scissors; sponge holders;
aneurism needles; soft clamps for temporary compression of large vessels;
materials for suturing vessels; and materials for closing the wounds.
In order to diminish venous engorgement, the best position is with the head
and thorax slightly elevated, the patient lying on an inclined plane. This
position is not to be recommended for patients with low blood-pressure; and,
in any case, the head must be lowered if shock appears or if a serious fall in
blood-pressure occurs during the operation. American surgeons are inclined
to operate in the lowered-head position when tracheotomy is not used.
A loop of thread should be passed through the patient's tongue to give
the anesthetist better control of it. The anesthetist and his assistant stand
at the head of the table, the surgeon at the patient's right side or at the side
294
SURGICAL TREATMENT
to be operated upon. The patient's face should be turned toward the well
side.
The complete operation, if it is the intention to remove the lymphatics
first, and then the whole tongue, is proceeded with as follows: An incision is
begun behind the angle of the jaw, carried downward and forward to the
level of the hyoid bone, and thence curved upward and forward to the sym-
physis of the lower jaw. A vertical incision is carried along the anterior bor-
der of the sternomastoid muscle from the first incision down nearly to the
sternum (Fig. 991). The anterior edge of the muscle is exposed, retracted
backward, and the internal jugular vein and carotid artery uncovered. The
flap formed by the upper curved incision is turned up and the submaxillary
gland laid bare (Fig. 992). The facial vein and artery are tied and divided
(Vol. I, page 412). The tissues lying between the submaxillary gland and
FIG. 991. — INCISION FOR REMOVAL OF TONGUE AND LYMPHATICS OF NECK.
the skin are removed. The whole gland with the surrounding connective
tissue and lymphatics is removed. This excision should clean out the sub-
maxillary space inward as far as the hyoglossus muscle.
The lymphatics lying along the jugular and carotid and under the sterno-
mastoid should now be dissected away. The surgeon should not be dis-
couraged, because every enlarged gland is not necessarily carcinomatous;
septic absorption from the ulcerated tongue is the foremost cause of enlarge-
ment of the lymph nodes.
Glands lying under the lower end of the parotid should be removed. The
dangerous glands are those lying above the level of the cricoid cartilage.
Here the jugular or carotid may be so closely incorporated with the glands
that resection of a part of the wall of one or both vessels may be called for.
If indicated, this part of the operation is well worth doing.
The lingual artery is next ligated (Vol. I,, page 411). The previous dissec-
tions make this ligation easy. The wounds are closed and covered with a tern-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
295
porary dressing. If it is determined to operate upon both sides, the patient's
head is then turned and the same operation repeated on the other side (see
page 248). If it is intended to remove the tongue without operating on the
lymphatics of both sides, the ligation of the lingual artery of the second side
remains to be done (Vol. I, page 411).
Both linguals having been tied, the anesthetic may be continued through a
nasal tube inhaler. The gag is inserted in the mouth on the side least affected,
and attention to its security given over to the anesthetist's assistant. A silk
thread is passed through the tip of the tongue and another posterior to the
place of division to control the stump.
The use of the cheek retractor will give still more room. The tongue is
drawn forward. With strong curved scissors the tongue is then cut out,
FIG. 992. — REMOVAL OF CARCINOMATOUS LYMPHATICS OF NECK.
Lymphatics with connective tissue of neck have been dissected up; a pad of gauze protects
the wound from cancer cells.
the cut being made well back of the disease. The ligation of the two
lingual arteries causes the bleeding to be but slight. Sponges in holders
quickly take up the blood; and, if the patient's head is turned to one side,
blood should not flow back to the pharynx (Fig. 993).
After removing the tongue, the dorsal mucous membrane of the stump
should be sewed to the mucous membrane of the floor of the mouth, provided
this can be done without making so much forward traction upon the epiglot-
tis as to prevent its closing the glottis. In some cases the stump may be
held forward by suturing it laterally to the wound in the mouth. If the raw
surface of the stump is not covered by suturing mucous membrane over it,
it should be dried and treated with compound tincture of benzoin, containing
5 per cent, of iodoform. A useful varnish is made of compound tincture of
296
SURGICAL TREATMENT
benzoin, in which, for the rectified spirit, is substituted a saturated solution
of iodoform in ether, the ether having mixed with it 10 per cent, of turpentine.
It is a wise precaution to leave the silk ligature through the base of the
tongue, in order to make traction in case the patient has intractable closure
of the glottis. This may be removed in twenty-four hours. A drain should
be placed under the sutured mucous membrane and brought out in the neck
wound to be left for twenty-four hours (Fig. 994). Gauze packing should not
be left in the mouth as it quickly becomes saturated and foul.
This operation ordinarily can all be carried out, and free removal of the
tongue secured. The dissection of one side of the neck should not take
longer than half an hour. The removal of the tongue requires but a few
minutes. If the condition of the patient demands it, the operation may be
FIG. 993. — REMOVAL OF TONGUE AFTER DISSECTION OF NECK.
The wound is temporarily covered with gauze and the flaps replaced while the operation in
the mouth proceeds.
brought to a close at any of its stages, and completed at a second sitting.
H. T. Butlin advised excision of the tongue, preceded by tracheotomy; and
then, after two weeks, operation on both sides of the neck.
Excision, without preliminary ligation of the vessels is preferred by some
surgeons. A thread is passed through the tongue. The anesthetic is admin-
istered through a nasal tube; or the pharynx is packed and a tracheotomy
done. The mouth is widely opened with a gag. The operation is performed
with strong curved scissors. The surgeon rapidly divides the frenum and
the structures under the tongue and then the connections between the tongue
and the anterior pillars of the fauces. This permits the organ to be pulled
far forward. The lateral cuts are continued until the lingual vessels are
reached. These are grasped with clamps and ligated through the mouth.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 297
The division of the tongue posterior to the disease is then made, and the
operation completed. Depending upon the condition of the patient, the
removal of the lymphatics of the neck may be proceeded with immediately
or at a subsequent operation.
In experienced hands, this operation is carried out with facility. The
location of the lingual arteries is quite constant; and in the hands of a surgeon
who has mastered the art of securing them, the operation has much to recom-
mend it. This is seen to be true when it is realized how much time may
be consumed in making the ligation of the arteries in the neck a distinct
operation.
Excision through a submaxillary incision, first described by T. Kocher, is
carried out through an incision on the diseased side. The incision begins
opposite the lobe of the ear, passes
down along the anterior border of
the sternomastoid muscle to the
level of the hyoid bone, and thence
along the anterior belly of the
digastric muscle to the symphysis
of the lower jaw. The flap is
turned up, and the facial and
lingual vessels are ligated. Be-
ginning posteriorly the surgeon
removes the lymphatic struc-
tures, the sublingual and sub-
maxillary salivary glands. The
mylohyoid muscle is cut through
and the mucous membrane of the
floor of the mouth divided. The
tongue may now be drawn into
the wound and cut away by scis-
sors passed through the mouth
orifice. The operation is appli-
cable to extensive lateral disease
or disease far back.
If the whole organ is to be re-
moved, it has been the custom to
ligate the lingual artery on the
other side of the neck, although it
is possible to secure it through the mouth.
Excision after division of the lower jaw has much to recommend it. A
median incision is made through the lower lip and carried down over the
chin and neck as far as the hyoid bone. Bleeding is checked, a central
incisor tooth is removed, and a hole drilled through the jaw on either side of
the median line. The jaw is now divided by two oblique cuts so planned as
to give immobilization after uniting the divided parts (Fig. 995). The two
halves of the jaw are then retracted and the mucous membrane and muscles
divided in the floor of the mouth. The tongue is drawn forward by a trans-
fixion thread and its detachment proceeded with from below. Scissors are
used. Bleeding vessels are secured. Most vessels can be controlled by
twisting. The lingual vessels are clamped preferably before their division.
The operation should be conducted with deliberation. As much of the tongue
and tissue in the floor of the mouth as is necessary may be removed. After
treating the stump the jaw is wired together and treated thereafter as a
fracture. Drainage is provided in the lower end of the wound. The dissec-
FIG. 994. — CARCINOMA OF TONGUE.
Wounds closed. Drain in place.
298 SURGICAL TREATMENT
tion of the lymphatics of the neck may precede or follow the operation on
the tongue.
This operation has the disadvantages that the after-treatment must be
prolonged, and the attachments of the tongue are so loosened that the larynx
is apt to lack anterior support. Its advantages are that it gives free access
for securing the lingual vessels through the mouth, and lends itself especially
to cases in which the floor of the mouth is involved.
Comments. — Removal of the tongue through the mouth is most satis-
factory. Excision through a submaxillary incision and excision after division
of the lower jaw are best reserved for the peculiar cases.
It should be borne in mind that recurrence after operation for epithelioma
of the tongue is usually in the lymphatics, showing that the difficulty has
not been in getting beyond the disease in the mouth. If a diagnosis of
epithelioma is made clinically, the glands of the neck should be removed in
all cases.
In order to secure more room for operating through the mouth, if that
which is afforded by the use of the gag and cheek retractor is not sufficient,
FIG. 995. — METHOD OF DIVIDING LOWER JAW FOR EXPOSURE AND REMOVAL OF THE
TONGUE.
The jaw is divided in such a manner that at the close of the operation a single suture will
hold it in place.
an incision may be carried outward from the angle of the mouth through the
cheek. If the disease involves the floor of the mouth, the operation is
much facilitated by extracting the lower incisor teeth.
Whether preliminary ligation of the lingual arteries is practised must
depend upon the surgeon's facility. It has the merit of saving blood and
allowing the operation to proceed with greater deliberation. It consumes
much time, and the facile surgeon is able to secure the vessels through the
mouth.
When the disease extends beyond the tongue, the operation will have to
be modified accordingly. Excision of part of the jaw, of the larynx, or of the
deep structures of the neck may have to be done. If the primary disease
can be removed, the surgeon is justified in its removal. Death from the
progressive advancement and breaking down of epithelioma of the tongue is
a condition from which the surgeon should endeavor to save his patient.
Recurrence in the lymphatics leads to a less distressing end.
The mortality following operations for epithelioma of the tongue has been
reduced by preventing sepsis, pneumonia, hemorrhage and shock. The well-
equipped surgeon has about 3 deaths following operation in too uncompli-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 299
cated cases, and 25 deaths following operations in 100 badly complicated
cases. Butlin estimates that the mortality in all cases should be about 12^
per cent. We have no adequate statistics as to recurrence.
After-treatment. — Immediately after the operation the patient should be
made to lie on his side with the head lowered and turned to one side so that
fluids will run out of the mouth. He should have fresh air which is as free
from dust as possible. Morphin should not be given as it diminishes the
reflexes upon which the patient must depend to cough up matter which enters
the larynx.
He should be caused to sit up in bed as soon as he has recovered from the
anesthetic. This should be within the first thirty-six hours, if possible.
The mouth should be washed out with boric solution every half hour or
every hour for the first two days. The patient should be instructed not to
swallow saliva or mouth secretions, but his head should be so placed that
they may flow from the mouth.
Rectal feeding should be used for the first two days. Then a tube should
be passed through the mouth or nose into the esophagus, and fluid food
administered. This stomach feeding may be begun earlier, if the patient
seems to need it.
The mouth must be kept clean. An occasional washing with an irrigator
should be practised. If the mouth becomes offensive, phenol, peroxid of
hydrogen, or other stronger solution should be used (page 244). The
patient should be up out of bed by the third or fourth day. He may be
allowed to swallow without the tube before the fifth day.
THE EAR
Anatomy. — The ear is divided into three parts: the external ear, made up of the auricle
or pinna and the external auditory canal; the middle ear, comprising the tympanic mem-
brane, the tympanic cavity, the mastpid cells, and the Eustachian tube; and the internal
ear comprising the vestibule, the semicircular canals, the cochlea, and the end-apparatus
of the auditory nerve (Fig. 996).
The external auditory canal, ending at the drum, is arched slightly upward, and is
directed inward and slightly forward. In using the speculum, it should be remembered
that the curve in the canal may be straightened by drawing the ear outward, upward and
backward.
The tympanic membrane closes the middle ear externally from the outer air. The
outer surface is concave. This membrane is divided into two portions. The upper por-
tion is flaccid (Fig. 756), the lower portion is tense. The chorda tympani is at the upper
portion. The little chain of three bones, the malleus, incus, and stapes, is attached to the
inner surface of the drum membrane. The handle of the malleus is contained between the
layers of the drum. These bones connect the drum with the nerve mechanism of the in-
ternal ear. The Eustachian tube passes from the tympanic cavity downward, forward and
inward to the outer wall of the nasopharynx just posterior to the lower turbinate bone.
The roof of the middle ear cavity is formed by a thin plate of bone separating it from
the middle fossa of the cranium. The floor is formed by this bone separating it from the
jugular fossa.
The mastoid antrum and the mastoid cells are situated in the mastoid process of the
temporal bone and all communicate. The antrum is located in the upper and anterior
portion of the process, just behind the tympanic cavity, and behind and slightly above the
external meatus. The antrum is about the size of a pea, is lined with epithelium, and con-
tains air which communicates with the tympanum. The opening into the tympanic
cavity is above the level of the floor of the antrum. The roof of the antrum is separated
from the cranial cavity by a thin plate of bone which is perforated by veins emptying into
the superior petrosal sinus. It is on a level with the lower border of the posterior root of
the zygoma.
The floor of the antrum is in relation to the mastoid cells. The Fallopian canal, trans-
mitting the facial nerve, lies at the inner side of the passage between the tympanum and
antrum. The posterior wall of the antrum is thin and perforated by veins passing to the
sigmoid sinus.
300
SURGICAL TREATMENT
The postmeatal triangle is bounded above by the posterior root of the zygoma, in
front by the osseous part of the external auditory meatus, and behind and below by' a
line connecting these two. If the osseous external auditory meatus is bisected by a hori-
zontal line, the upper half would be on a line with the antrum. This triangle, lyingjust
behind the meatus, represents the outer wall of the antrum, through which the antrum
should be opened (Fig. 997).
FIG. 996. — ANATOMY OF EAR.
Showing relations to brain, nerves and vessels, i, Superior ligament of malleolus
2, superior ligament of incus; 3, cerebral semicircular canal; 4, cerebellar semicircular
canal; 5, ampullary branch of vestibular nerve to 9 ampulla; 6, utricle; 7, ampullary branch
of vestibular nerve to 3 ampulla; 8, ampullary branch of vestibular nerve to 4 ampulla;
9, tympanomastoid semicircular canal; 10, utricular branch; n, saccus endolymphaticus;
12, vestibular nerve; 13, head of malleus; 14, saccular branch; 15, external ligament; 16.
cochlear nerve; 17, body of incus; 18, stapedius nerve; 19, facial nerve; 20, saccule; 21,
membrane of cochlear window; 22, auditory nerve; 23, chorda tympani nerve; 24, drum
membrane; 5, ductus cochlearis; 26, abducens nerve; 28, aqueductus cochleae; 29, ductus
utriculosaccularis; 30, hypoglossal nerve; 31, glossopharyngeal nerve; 32, occipital artery;
33, styloid process; 34, internal jugular vein; 35, internal carotid artery; 36, Eustachian
tube; 37, condyle; 38, medulla oblongata; 39, mastoid process; 40, external auditory
canal; 41, external carotid artery; 42, spinal accessory nerve; 43, glossopharyngeal nerve; 44,
hypoglossal nerve; 45, spinal cord; 46, pneumogastric nerve; 47, descending branch of
the hypoglossal nerve; 48, common carotid artery; 49, fissura santorini; 50, internal
carotid artery; 51, stapes in vestibular window; 52, cut cartilage of auricle.
It is important for the surgeon to remember that, in opening the antrum he should keep
close to the posterior, osseous wall of the external auditory canal and follow its direction.
If the opening is made too high the cranial cavity will be invaded; if the opening is made too
far posteriorly, the sigmoid sinus will be injured; if the bone is penetrated for a distance
greater than 1.75 cm., (% inch) the facial nerve, will be encountered.
When the surgeon, in operating for middle ear and antrum suppuration, cannot locate
the antrum, the soft parts may be elevated from the posterior wall of the osseous auditory
TREATMENT OF INJURIES AND DISEASES OF THE HEAD
301
canal, and a probe with a hooked end passed into the tympanum. It will find the opening
into the antrum at the upper and outer part of the tympanum, where it may be retained
as a guide. Or the posterior wall of the canal may be chiseled away until the antrum is
reached.
The external auditory canal contains a cartilaginous incomplete tube, between the bony
wall and the skin.
PlG. 997. POSTMEATAL TRIANGLE, WHICH CORRESPONDS WITH THE MASTOID ANTRUM.
This triangle is bounded above by the posterior root of the zygoma, in front by the
posterior osseous margin of the external auditory meatus, and behind by a line continuous
with the anterior surface of the mastoid process on a line from the end of the root of the
zygoma. It is through this area that the mastoid antrum may be opened with safety.
General Principles. — Wounds of the tympanic membrane made by the
surgeon heal promptly. The patency of the Eustachian tube requires to be
determined in treating middle-ear
diseases. This may be done by
making an expiratory effort while
the mouth and nostrils are closed.
Swallowing relaxes the opening of
the tubes and permits the air to
escape. The method of Politzer for
inflating the middle ear consists in
blowing into the nostril with a rub-
ber bag (Fig. 998) at the instant that
the patient swallows water. The
bag should have a capacity of 300
c.c. (10 ounces); the nozzle should be
large and connected by a short rubber
tube with an end piece fitting tightly
into the nostril. The patient takes
water into his mouth; the opposite
nostril is compressed and the tube
held in place by grasping the nose be-
tween the fingers; the patient is then
told to swallow; and as the larynx is
seen to rise at the beginning of the FlQ 998._PoLITZER.s BAG FOR IXFLATING
act, the bag is forcibly compressed. EAR IN OPERATION.
Or without swallowing the water, the
same effect may be secured by having the patient inhale deeply and then
forcibly blow between the partly closed lips while the operator performs the
inflation as described above.
302
Catheterization of the Eustachian tube is accomplished by means of a metal
catheter. The instruments should vary in size from i to 3 mm. in diameter.
The tip should be slightly curved, knobbed and rounded. The operator sits
facing the patient, lifts up the tip of the nose with the thumb of the left hand,
and with the right hand lightly inserts the instrument, its tip gliding along
the floor of the nose (Fig. 999). It is passed back until it reaches the pos-
FIG. 999. — EUSTACHIAN CATHETER IN NASAL CAVITY.
The catheter lies on the floor of the nose; it has just passed over the soft palate; when
it is rotated the point will strike the lateral wall of the nose at the entrance to the
Eustachian canal.
terior wall of the pharynx; the tip is then rotated inward 90 degrees and
drawn forward until it is felt to be stopped by the posterior edge of the
septum; it is then rotated outward and a little less than 180 degrees, and it
should then be at the mouth of the Eustachian tube. Or the catheter, with
its tip downward, may be drawn forward until it hugs the posterior surface
of the soft palate; if the tip is then rotated outward a little more than 90
FIG. 1000. — AURAL SPECULA.
degrees, or until the guide points to the outer canthus of the eye, the tip
will^be at the Eustachian opening. It is possible to catheterize the tube
from the opposite nostril by using a catheter with a longer tip.
Examination of the external canal and tympanic membrane is made with a
speculum and a good light. The latter is secured by means of a concave
head mirror or an artificial light. The small electric lamp worn upon the
forehead is useful. .The aural speculum (Fig. 1000) serves to straighten out
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 303
the canal. In order to secure access to the drum membrane in the infant
the auricle should be drawn downward, backward, and outward. In the
adult, the membrane is best exposed by drawing the auricle upward, back-
ward and outward. Bulging outward of the membrane is important as it
indicates abnormal internal pressure. Bulging which is uniform indicates
inflammation in the tympanic cavity (atrium); but when the bulging is
limited to the upper posterior portion of the membrane, it indicates inflam-
mation in the tympanic vault, a much more serious condition.
THE EXTERNAL EAR
Congenital Defects. — Malformations of the auricle, absence of the auricle,
and excessive development of the auricle are remedied by plastic operations
(see Vol. III). In stenosis of the canal an operation may be done to construct
a new canal; but these operations have not much improved the function
of hearing. Supernumerary auricles are to be excised.
Hematoma of the Auricle. — If seen early, hemorrhage may be checked
by cold applications or by light pressure. To make pressure, a pad of gauze
or cotton should be placed between the ear and the scalp, the ear covered
with another pad, and the whole compressed by a bandage around the head.
The pressure should not be so great as to cause pain. If the blood does not
become absorbed and is soft and fluid, the skin may be sterilized with iodin,
and aseptic aspiration done. If the blood cavity becomes infected, it should
be opened freely and treated as an abscess. Necrotic cartilage should be
removed.
"Cauliflower ear" is best treated by making a small incision, inserting a
curet and scraping out clots and detritus. The cartilage should be scraped.
The cavity shoulg then be washed out, and a compressing dressing applied.
This dressing should be moulded to fit the ear and side of the head. It
should be placed on each side of the ear; and a bandage around the head
should hold it. The ear should be in normal position so that it does not
become distorted.
Othematoma is hemorrhage under the perichondrium, and requires as-
piration or incision.
Wounds of the Auricle. — Wounds should be given the best possible aseptic
treatment because infection is prone to cause necrosis of cartilage (see
Wounds, Vol. I, page 186). Attempts should be made to restore all parts
of the ear when mutilated; and even when completely torn away, restitution
should be attempted. Cleft lobule, such as results from the tearing out of
ear-rings, should be repaired by the same operation that is applied to cleft
palate. To prevent suture-hole scars, a fine subcuticular suture may be used
for the outer part of the wound; or interrupted sutures may be passed from
the inner side of the lobule and only through the deep layer of the skin on the
outer side of the lobule.
Perichondritis and Cellulitis. — These should be treated the same as
inflammations elsewhere. The collection of fluid or pus demands early and
free opening. Necrotic cartilage should be removed. The loss of cartilage
results in deformity. To prevent this deformity, the ear should be kept
supported on a splint of some stiff material until healing has reached a point
where asepsis can be secured; then a piece of cartilage from the sternocostal
interval or elsewhere may be grafted in the defect. Chronic perichondritis
is treated by removing the cause. Ichthyol ointment (20 per cent.) is
applied locally.
304 SURGICAL TREATMENT
Cutaneous Diseases. — The treatment is the same as cutaneous diseases
elsewhere. Frost-bite (see Vol. I, page 318) requires that the temperature of
the ear should be restored gradually. This may be done by gentle friction
with snow or broken ice. Gentle massage should follow. If only the skin
becomes inflamed, 10 per cent, ichthyol ointment is of service. Perichondri-
tis, following frost-bite, should be treated by the methods above described.
THE EXTERNAL AUDITORY CANAL'
Wounds. — Fractures of the base of the skull may lay open the external
auditory canal. If the fracture is compound, the canal should be cleansed
and kept protected with a wet antiseptic dressing.
Acute Circumscribed Inflammation (Furuncle). — This is a cellulitis
beginning usually in the outer end of the canal and soon extending to the
cartilage and bone. The most swollen parts should be incised freely. This
should be the first step of the treatment. The operation should be done with
aseptic care. The incisions should be parallel to the long axis of the canal
and should be carried completely through the soft tissue. Without anesthe-
sia, the operation is very painful. Even though no pus is present the
incisions will hasten recovery. The wounds should be lightly packed
with antiseptic gauze, a bit of gauze inserted into the canal, and the whole
covered with a wet antiseptic dressing. The dressings should be renewed
twice daily, and once daily the canal should be irrigated with antiseptic
solution. Unless these precautions are taken successive reinfections are
apt to occur. Suction treatment, applied directly to the furuncle, is useful.
Diffuse Inflammation of the External Auditory Canal. — (See Cellulitis,
Vol. I, page 228). — When acute, the treatment of this condition is the same
as the circumscribed form. Hot applications are of value. By free incision,
invasion of cartilage and bone may be prevented, although the disease will
often subside under artificial hyperemia, cleansing the canal and dusting it
with calomel. When chronic, the disease should be treated as a dermatitis.
The parts should be cleansed and antiseptic applications made. Usually
the treatment of eczema is indicated (see Vol. I, page 830). Mycosis is
readily cured by antiseptics (see Vol. I, page 838). Silver solutions are
effective.
Exostoses of the External Auditory Canal. — Bony growths encroaching
upon the canal do not require operation if small. They should be removed
when large enough to confine secretions against the eardrum or occlude the
canal to such a degree as to interfere with hearing. Pedunculated growths
may be removed through the meatus. For sessile growths, the best method
is the subperiosteal operation. A curved incision is begun at the tip of the
mastoid process and carried upward back of the ear to a point above the
middle of the meatus, keeping about 0.5 cm. (%Q inch) away from the auricle.
The incision should go through the periosteum. The flap of soft tissue,
periosteum, and cartilage should be elevated from the bone, and the elevation
continued into the canal until the tumor is uncovered. Care should be taken
not to injure the eardrum. With a fine sharp chisel, the exostosis should be
removed in one piece by cutting into the underlying bone. These masses are
usually so hard that it is not wise to attempt chiseling them off in pieces.
It should be remembered that the facial nerve and semicircular canals are
near the drumhead posteriorly. If the growth is extensive, enough bone
should be removed to make a good free canal. The wound should be closed
by sutures and a packing of gauze inserted in the ear to hold the soft tissues
against the bony canal. If the above operation does not give sufficient
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 305
room the soft structures of the canal may be split. Recurrence is not apt to
follow.
Foreign Bodies in the External Auditory Canal. — Inanimate objects,
such as seeds, beads, buttons and pebbles may be grasped by fine forceps
and removed. Care should be taken not to push the body further in. If
too large to be grasped, a fine wire hook or loop may be used. Often a hook
can be used to roll the object out. Syringing is the most effective method.
A fine syringe, or a hypodermic needle with the end rounded, may be used to
inject water or oil to the inner side of the object. It is not necessary that the
nozzle of the syringe should pass the object. The fluid will pass it if injected
in the direction of its periphery, and gradually wash it out. Cement may be
applied to the outer surface of the body and cotton caused to adhere to it;
after a day or more, when the cement has dried, the cotton may be twisted
into a cord and the body pulled out. The manipulations should never be
prolonged. The surgeon should do the right thing, and not consume time
and cause irritation by unsuccessfully picking at a foreign body. The ear-
drum should not be injured.
Seeds and other bodies which have become swollen with moisture may
be dehydrated by alcohol and their size thus reduced. If the skin has become
swollen and edematous, time should be given for its treatment, by antiseptic
irrigation. If the drum is perforated, the body should be removed at once
if it totally occludes the canal; if drainage is possible, irrigation should be
practised frequently.
If the body cannot be removed, the curved incision behind the ear,
described above for the removal of exostoses, should be made, the cartilage
elevated from the bony canal, the soft structures split lengthwise, and the
parts retracted. This gives room for the removal of the body by taking the
cartilage out of the way. If more room is desired bone may be chiseled away
from the posterior wall. The body being removed, the wound behind the
ear is sutured and the canal packed with gauze which should be renewed
at least once daily.
Animate objects, such as flies, ticks, ants, and other insects, larvae, and
moulds, often require treatment. Insects can be dislodged by means of
gentle irrigation with water or antiseptic solution. The syringe may be used
to wash them out. A living insect will usually come running out if water
is dropped in the ear. Ticks sometimes attach themselve to the wall of
the canal and require to be dislodged with camphor water, diluted ammonia
water, alcohol or oil. A drop of chloroform on a piece of cotton will make
most insects change their plans. The death of a tick is not always followed
by its loosening its hold. It may be necessary to introduce a speculum and
grasp the animal with forceps. If it is attached to the drum it should be
removed by a twisting motion. Larvae can be killed by chloroform vapor,
alcohol or antiseptic solutions.
Impacted Cerumen. — As ear wax is mixed with oily matter it is easily
dissolved by alkalies. If a strong solution of bicarbonate of soda is dropped
in the ear and retained for a few hours or until the following day, the cerumen
may then be washed out with warm water injected from a syringe. Im-
pacted cerumen may be softened by filling the ear with olive oil at night;
in the morning the cerumen may be washed out with a warm saturated
solution of borax. A good solution for the purpose of softening cerumen
is made of 0.6 Gm. (10 grains) each of sodium bicarbonate and sodium bibor-
ate, dissolved in 15 c.c. (^ ounce) each of glycerin and water. Ten drops
of this may be put in the ear twice daily.
If cold water, hot water or too much force is used in syringing, the
VOL. 11—20
306
SURGICAL TREATMENT
patient may suffer pain, dizziness or syncope. In some cases a hard, dry
plug may be grasped by a hook or fine curet, and removed. Patient
syringing with alkaline solution is the safest treatment.
Epithelial Plug (Keratosis Obturans). — This condition is different from
impacted ear-wax in that the plug is made up of layers of epithelial cells.
It is not capable of being broken up by solution, but must be removed by
forceps, curet or hook.
Cholesteatoma. — Cholesteatoma of the ear is treated by following the
disease into all of its ramifications, and thoroughly cleaning it out with a
sharp curette.
THE MIDDLE EAR
Traumatic Rupture of the Tympanic Membrane. — Whether the rupture
of the drum is associated with fracture of the temporal bone or forms a
communication only with the middle ear, asepsis is most important. If the
discharge of blood or cerebrospinal fluid is profuse, the ear should be irri-
gated every two hours with antiseptic solution. If the discharge is but
slight, irrigation once or twice daily is sufficient. The fluid should run in
easily with the view of cleansing the outer surface of the drum membrane,
but should not be driven into the middle ear.
If the rupture is linear and the discharge stops
in a few days, healing may be hastened by mop-
ping the canal and membrane with a i 13000
alcoholic solution of bichlorid of mercury, and
applying to the drum membrane a sterilized disk
of writing paper, soaked in bichlorid solution,
to act as a splint and dressing. This gives the
minimum scar.
Blood accumulating in the middle ear and
preventing healing may be removed by blowing
through the Eustachian tube after the method of
Politzer. Simple ruptures are best treated by
applying by means of a powder blower a layer
of boric acid upon the drumhead and leaving the
ear undisturbed unless pain or suppuration de-
mand interference. This is the best treatment for
simple uncomplicated wounds of the drum.
Ulcerative Rupture of the Tympanic Mem-
brane.— Perforations resulting from otitis media
or other disease permit air and dust to enter the
•FiG. 1001. — EAR DOUCHE , , , , , • . ... ,^1. .
POINT WHICH PERMITS INFLOW ear and set UP repeated attacks of otitis. Their
AND OUTFLOW. early healing is desirable. When the causative
A constant stream of irriga- disease has subsided and discharge ceased healing
tion may be maintained. should be stimulated. An opening lined with
granulations may be touched with alcohol or tinc-
ture of iodin. If epithelium is growing over the granulations or if they
are feeble the edge of the opening may be stimulated by touching it with pure
nitric acid applied on a fine cotton- wrapped probe. If the membrane is
clean the paper disk, described above, may be used with advantage.
Acute Inflammation of the Middle Ear. — In the milder cases healing
may be secured by increasing the local hyperemia. This is done by hot
applications. Large wet compresses applied to the side of the head and ear
may be kept hot by means of a hot-water bag. In connection with this
treatment heat may be introduced against the drum by hot irrigation the of
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 307
external canal. For this purpose a douche point which has an opening for
return flow is useful (Fig. 1001). Through this a continuous stream of
heated water 44° to 49°C. (112° to i2o°F.) may flow in and out of the ear.
Warm glycerin dropped into the ear is useful in some cases. Dry heat, in
the form of a stream of heated air, or the application of heated bags of salt
or clay, or the hot coil, are useful.
When the disease begins as a nasotubal infection, repeatedly blowing out
the ear by the method of Politzer or by Eustachian catheterization is of
service in draining the fluid from the ear.
In any of these conditions, when the disease has produced exudate in the
middle ear which causes bulging of the drum and pain, especially if there is
pronounced fever, incision of the drum is called for. Some
surgeons practice incision of the drum at once in every case
of acute inflammation of the middle ear.
The operation of incision of the drum is done to secure
drainage. It should be preceded by swabbing the ear canal
with i : 5000 bichlorid alcoholic solution. The operation
should be done with aseptic precautions. Not a puncture
but a free incision should be made (Fig. 1002). Incision of
an inflamed drum is very painful and a general anesthetic
for a few seconds is desirable. The knife should be very
sharp. The drum should be well exposed by the speculum
and a good forehead light. The incision should be made
where the fluid is, whether in the attic or atrium. If the
atrium is filled with fluid, the knife may be inserted just
behind the short process of the malleus, below the posterior
fold, near the tympanic ring, and the incision carried down-
ward parallel to the posterior segment of the ring as far as
the bottom of the membrane. The fluid gushes forth, and
as soon as drainage ceases the wound heals promptly. The
reparative power of the drum is so great that healing often
occurs before the need of drainage has passed.
If drainage is not free, and especially if the secretion is
tenacious or thick, blowing through the Eustachian tube or
the application of a suction cup to the external ear will
hasten healing.
Following incision of the drum for infection of the middle
ear, irrigation with warm bichlorid of mercury solution
(1:5000) should be employed. The irrigation should be
practised several times daily. Gentleness should be used. KNIFE FOR INCIS-
Care should be taken that the fluid has free exit so that it ING EAR DRUM
shall not be driven into the middle ear. The irrigation should MEMBRANE.
be done every three hours during the day and every four
hours at night. Later the intervals may be lengthened. Once daily the
surgeon should swab out the canal with bichlorid solution. The patient
should be kept quiet. The dressing should be done with aseptic care.
A light protection of cotton should close the outer ear. At the same
time any other ear complication or nasal disease should receive attention.
Inflation of the ear through the Eustachian tube should be continued
daily; it helps clean out the ear and prevents the retention of exudate
which may become organized and bind together the structures of the ear.
As healing progresses and the tympanum becomes clean, inflation may be
done less frequently.
In acute suppurative otitis media, incision of the drum membrane should
308
SURGICAL TREATMENT
be done as soon as possible. If perforation has already taken place the
surgeon should make an examination, and if the opening is not ample it
should be enlarged. The best drainage is secured by having the patient lie
on the affected side with the face turned somewhat downward.
The indications for mastoid operation in acute olitis media are based on the
knowledge that in every acute inflammation of the middle ear the mastoid
is involved to some extent. Pain, temperature, local tenderness, and canal
symptoms are important indications. The bacteriologic examination of
FIG. 1003. — LINES OF INCISION FOR INCISING DRUM MEMBRANE.
AB, Incision made from above downward in case the atrium is filled with fluid; CD,
incision for evacuation of exudate; EF, incision made from below upward in case the
mucous membrane of the attic is much inflamed. The incision (EF) is carried through the
drum as far as the upper limb of the ring and then continued outward through the skin
of the postero-superior wall of the external meatus.
discharge, the amount and duration of discharge, history of previous attacks,
and symptoms of involvement of labyrinth must all be taken into considera-
tion. If several punctures of the drum membrane have had to be done in
previous attacks, if the disease progresses without abatement, if pronounced
defect of hearing develops, or if meningeal symptoms appear, operation is
indicated.
Chronic Suppurative Otitis Media. — When not due to tuberculosis or
some other rare chronic infection, the disease is a continuation of acute
FIG. 1004. — EAR SYRINGE.
otitis media. Neglected cases become chronic. The cause of the con-
tinuous discharge cannot always be discovered. The presence of hardened
exudate or necrotic material in the middle ear should be blown out by Eusta-
chian insufflation. If the opening in the drum is not large enough for free
drainage it should be enlarged. Exuberant granulations should be removed
with the curet or caustic. Frequent cleansing with antiseptic solution
should be practised. Irrigation should be done often enough to keep the
ear clean and the skin of the canal healthy. In the milder cases simple
cleansing is sufficient to effect a cure. The syringe should have a point which
does not obstruct the flow of fluid out of the ear (Fig. 1004). For the attic
a special syringe is used which must be inserted through a speculum.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 309
Often the discharge is kept going by granulation tissue in the middle ear
or some inaccessible focus of infection. Silver nitrate solution (i per cent.)
is of service. The patient should lie with the diseased ear upward after
irrigation and drying out have been done. A few drops of the silver solution
are allowed to run into the ear. This may be repeated every third or fourth
day for two weeks.
A method which I have found effective has been to clean the ear thor-
oughly by irrigation, then dry it out with cotton, then fill it with alcohol,
then dry out the alcohol, then drop in 2 or 3 drops of tincture of iodin
and quickly follow it with an equal amount of alcohol. This is then diluted
with more alcohol, the ear again dried out, and some antiseptic powder, such
as formidin, blown in.
Inspissated matter sometimes is attached to the drum membrane or
lodged in crevices. For this reason, inspection with a good light should be
made and such material removed with hooks or curets. If the opening in
the drum is large, peroxid of hydrogen may be used to dissolve it and throw
it out. Yeast is of value for this purpose. It also has the power to antago-
nize suppurative organisms. When it is used antiseptic drugs should be
washed out with salt solution, and the yeast introduced with sterile water.
There are other methods of using ear-drops which are effective. A solu-
tion of boric acid, 1.2 Gm. (20 grains), in alcohol, 30 c.c. (i ounce) , may be
applied after cleansing and drying the ear. This is used once daily, the
patient lying with the affected ear upward. After a few drops have been
introduced the auricle should be grasped and, in the adult, drawn upward,
backward and outward, to straighten the canal. The finger is then placed
against the tragus and the tragus repeatedly and rapidly pressed into the
external meatus. This operation pumps the fluid into the middle ear and
forces it into cavities and interstices.
Instead of boric acid some of the other above-mentioned solutions may
be used. Kuyk employs silver nitrate, 2 Gm. (30 grains) in 30 c.c. (i ounce)
of water. This he forces into the remotest recesses every second day by
means of air pressure. If no improvement is observed in two weeks, the
strength of the solution is doubled, and if necessary, gradually increased
until a 25 per cent, solution is used. Good results are secured in mild cases
from the use of the following solution: zinc sulphate, 0.3 Gm. (5 grains);
glycerin, 4 c.c. (60 minims), saturated solution of boric acid, 30 c.c. (i ounce).
The treatment of middle-ear suppuration by hot air is effective. After
removing all accessible foreign matter the cavity should be dried with cotton.
The larger the opening in the drum, the more effective the treatment.
Heated air is blown into the ear by means of some of the devices especially for
that purpose. This treatment has the advantage of the healing effect of
dryness upon granulations and infections together with the hyperemia which
it induces. Before applying it, it is well to send through the Eustachian tube
a cleansing solution to remove debris.
The use of drying powders is indicated if the opening in the drum is large;
if it is small or if there is detritus in the middle ear, powders are not of service.
Care should be taken that powder is not packed against the drum so as to
occlude the opening. Before applying a powder the canal and middle ear
should be thoroughly cleansed and dried. The best method of application is
by a powder blower. The applications may be made every day or two.
Boric acid, finely powdered and dry, is of much service. Formidin, nosophen,
xeroform and iodoform are of value. Silver nitrate, 0.6 Gm. (10 grains) in
zinc stearate, 30 Gm. (i ounce), may be used once or twice a week.
Another dry treatment is by means of gauze drainage. After cleansing
310 SURGICAL TREATMENT
and drying the ear, a strip of sterile gauze, i or 2 cm. (% or % inch) wide and
free from ravelings, is lightly packed into the canal. This is of service only
if the opening in the drum is large. The inner end of the gauze should enter
the middle ear. The gauze should be folded loosely. Its inner end excites
hyperemia, and drains off the discharge at the same time. As soon as it
becomes saturated, it should be removed, the ear cleansed, and the drain
renewed. This may be once daily or after several days. Instead of plain
gauze, the drain may be impregnated with antiseptic to keep it sweet. In
appropriate cases, the results of this treatment are good.
The treatment of subacute and chronic otitis media by means of bacterins
has given encouraging results in many cases. The best results seem to be
secured in cases in which the treatment is begun on from the seventh to the
sixteenth day of the disease. When there is continuous high temperature,
nephritis, or other complications the treatment with bacterins is not to be
used. It is of especial value in scarlatinal otitis. Autogenous bacterin is
to be used. When two organisms are found a bacterin should be made from
each, and each administered separately (see Vaccines, or Bacterins, Vol. I,
page 255). This treatment should be used in addition to the other treat-
ments but should not displace them.
Treatment by suction is applied through the nose, after stopping the
external auditory meatus with a rubber-covered cork. Ten minutes, twice
daily, of this treatment is useful.
Injections of bismuth paste have proved effective in the hands of some
surgeons. It should not be used in acute cases. The paste does not reach
the mastoid cells; if they are involved, paste can only be employed after a
mastoid operation (see Bismuth Paste, Vol. I, page 305).
The indications for operation are present when other treatment fails and
discharge persists. In some cases, after the eardrum has perforated, the
patient feels comfortable and suffers no inconvenience except the discharge
and the deafness. If the discharge persists in a person past middle life the
condition should be regarded as serious. Mastoid operation should be done
in these patients if the suppuration has lasted for six or eight weeks. This
is particularly important in persons over forty-five, even though no other
symptoms exist. If facial paralysis develops, operation should be done at
once in all cases.
If pus appears soon again after the ear has been washed out, it means that
there is a reservoir of pus somewhere in the mastoid, and mastoid operation
should be performed.
All cases of chronic suppurative otitis media are dangerous to the patient.
All cases, if properly operated upon, may be expected to recover.
Operative Treatment of Chronic Suppurative Otitis Media. — When the
above treatments fail to cure the disease an attempt at a more accurate
diagnosis should be made. If after several weeks the discharge continues
unimproved or but slightly diminished, it means that foci of necrosis are
present, and demand to be eradicated. It is not safe to allow the infection
to continue because of the danger of intracranial complications. A "run-
ning ear" is always a hazard. When the case is first seen by the surgeon, he
may be able to determine that there is necrosis which cannot be removed by
tentative measures, cleansing and medicinal applications, and he should pro-
ceed at once to its eradication. There are other conditions, such as polypi,
adhesions, obstruction to drainage from swollen mucous membrane and
detritus, which prevent healing and demand more radical measures.
The operative treatment may be applied either (i) through the drum
or (2) by a posterior incision turning forward the soft parts and freely expos-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 311
ing the middle ear. The latter is the more useful method. It possesses'so
many advantages that some surgeons do not bother with the former at all.
There are in some cases procedures which may be carried out by the first
method.
Operations through the drum should be conducted through the largest
speculum that fits the ear and with the best possible light from the forehead
of the operator. Incision of the drum membrane has been described, but
if : the opening is not large it should be still further incised. Polypi will
sometimes be found to be the cause of the continuation of the discharge.
They may be removed with the curet (Fig. 1005) or with the snare which is
similar to the nasal snare (Fig. 1006) excepting smaller in all its parts.
b
FIG. 1005. — AURAL CURET.
In some cases it will be found that the ossiclos are necrotic and the mucous
membrane of the tympanum granular or polypoid. Removal of the ossicles
and curettage of the middle ear may be done. A general anesthetic is best, al-
though local anesthesia, combined with adrenalin chlorid, is effective. A
strong patient needs no anesthetic. Cocain should be used with caution
in the ear as it is quickly absorbed. It is best for the patient that he be in
the recumbent position, but most operators use the upright position in order
to orient correctly. The first step is to liberate the malleus from the drum
membrane. The subsequent steps consist in dissecting out, one by one, the
necrosed ossicles, and then curetting the diseased mucous membrane. The
removal of the individual ossicles requires experience, patience and gentle-
FIG. 1006. — AURAL SNARE.
ness. It is best that the stapes should not be removed from the oval window
unless it is completely necrotic. Curettage of the attic is best accomplished
with the angular curet made for that purpose. The outer attic wall may
be removed by a bone gouge; this enlarges the canal and gives better room
and drainage. After the operation a gauze packing is inserted. The
dressing should be changed with precaution to prevent infection. Gauze
packing should be continued until healing is secured. Irrigation is not
necessary if the discharge remains clean. Purulent infection calls for
irrigation. Wide opening of the drum, removal of the ossicles and curettage
of the middle ear, will fail to cure if all disease foci are not reached.
The indications for radical mastoid operation for chronic suppurative
titis media are to be considered in cases which have lasted for a vear or more.
312
SURGICAL TREATMENT
The cases may be divided into three groups: (i) Cases with cerebral or
cerebellar symptoms due to encroachment of the infection or exudate upon
the meninges or brain urgently require operation. (2) Cases with caries of
the temporal bone, fistulous opening in the mastoid cells, cholesteatoma,
continuous growth of polypi, and inflammatory stricture of the external
meatus call for radical mastoid operation but are in no sense urgent symp-
toms. Operation is not a matter of immediate necessity. (3) Operation is
indicated in those cases of chronic suppurative otitis media in which no
positive symptoms other than the discharge are present and in which the
discharge cannot be cured by nonoperative measures.
Radical operation for chronic suppurative otitis media and masloiditis, by
turning forward a flap of soft tissue, is called for when treatment and opera-
tion through the drum have failed, when there is necrosis of temporal bone
in connection with the middle ear, mastoid disease, narrowing or atresiaof
FIG. 1007. — LINE OF POSTAURICULAR INCISION FOR OPENING THE MASTOID ANTRUM.
the external auditory canal. It is applicable to all cases of chronic suppura-
tion of the middle ear and mastoid. The technic of the operation is as follows:
The operation is similar to that for mastoid disease (page 317).
The patient should be prepared for general anesthesia. The hair should
be shaved for a distance of 7 or 8 cm. (3 inches) around the attachment of
the auricle in women, and in men and children the whole side of the head
should be shaved and the rest of the hair cut short. The pre-operative
cleansing should involve the meatus and auricle as well as the scalp. The
anesthetic is important. Ether increases the bloody oozing and obscures
the field of operation, unless given by a highly skilled anesthetist. The
patient lies with the affected side upward. A curved incision is made from
the tip of the mastoid process, upward behind the ear, 0.5 to i cm. (31 6 to
% inch) from the auricular attachment, and ends just above the upper
attachment of the auricle (Fig. 1007). It passes through the periosteum,
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 313
which, with the overlying soft tissues, is elevated from the bone, and hemo-
stasis secured. The flap is elevated with the cartilage of the canal, until
the posterior, inferior, and upper walls of the canal are exposed as far inward
as the drum. With a sharp bone gouge or chisel (Fig. 1008) the posterior
FIG. 1008. — CHISELS FOR MASTOID OPERATIONS.
wall of the canal is cut away in layers, and the mastoid antrum opened
(Fig. 1014). The antrum being opened, the rest of the posterior wall of the
canal is cut away, the inner end of the upper wall, and the outer wall of the
tympanic cavity (see Bone-cutting Instruments, Vol. I, page 688). The
cutting away of the external wall of
the tympanic cavity, which is the inner
end of the upper wall of the external
meatus, should be carefully done. The
semicircular canal and the facial nerve
may be injured if the cutting away of
the posterior wall is carried too low.
The cranial cavity may be entered
through the roof of the tympanum if
the roof of the inner end of the meatus
is cut too high.
It is for these reasons that the an-
trum should be opened early and then
the well between the antrum and the
middle ear cavity cut away until a free
communication is secured (Fig. 1009).
A good view is then obtained. The
ossicles may be removed, and rough
edges of bone smoothed. An occa-
sional packing with adrenalin gauze FlG- 1009.— MASTOID OPERATION.
will Control the bleeding. All necrotic The antrum has been exposed and its
arpas should hp rnrpf fpd outer wal1 removed- The wal1 between the
areas snould be Curetted. > antrum and external auditory canal is being
There are certain precautions to be removed. The inside of the mastoid cavity
observed. As the wall between the is left smooth and even.
antrum and tympanum is cut away the
roof of the semicircular canals comes in view. The facial nerve lies just below
the horizontal semicircular canal, whence it passes backward, downward and
outward to its exit. It passes close to the meatal canal in its inner and pos-
terior wall. The inner third of the posterior wall of the meatus must be
approached with care; its upper third may be cut away, but its lower two-
314 SURGICAL TREATMENT
thirds should slope upward and inward to the roof of the horizontal semicir-
cular canal. The floor of the middle ear is slightly lower than that of the
meatus; the step should be removed with the sharp curet. Here the dome
of the bulb .of the jugular vein rises in the floor of the tympanum. It may
encroach upon the meatus. Care should be taken to avoid it. If wounded,
gauze packing controls the bleeding. The carotid artery may be wounded
by careless curetting of the Eustachian tube.
The upper end of the Eustachian tube should be closed by curetting its
orifice. The disease may be found confined to the middle ear alone. Com-
monly the antrum also is involved. It may embrace all of the cells of the
mastoid, in which event the mastoid should be cut away until all of its cells
are removed. Necrosis of the roof of the antrum or tympanum calls for re-
moval of the diseased bone. Even without necrosis there may be infection
within the cranium. The surgeon should not hesitate to expose the lateral
sinus or the dura mater over the roof of the tympanum. Many operators, as
a routine measure, remove the thin shell of bone between the ear cavity
and the dura.
Before operation, the surgeon should have assured himself whether
symptoms of labyrinthine disease are present. (Vertigo is the prominent sign.)
Whether they are or not, the wall of the horizontal semicircular canal should
be examined for perforation and discharge of pus; likewise the oval window.
A suppurating sinus may communicate with the semicircular canal. Laby-
rinthine suppuration is apt to be associated with granulations about the oval
window. Free drainage should be secured by removing the bony wall of the
labyrinth. The lower wall of the horizontal canal should be left to protect
the facial nerve. If the involvement is slight, but a small area of the laby-
rinth need be exposed; if it is extensive the whole labyrinth should be de-
stroyed. The facial nerve lies above the oval window. In order to drain
the labyrinth, the window should be enlarged downward and forward.
Having removed all dead bone and foci of disease, smoothed off rough
edges, and secured hemostasis, the wound should be closed in such a way as
to secure the early covering of the denuded bone with a layer of skin. If the
wound is simply sutured and packed, skin must grow in slowly from the
periphery. It is, moreover, desirable for the sake of subsequent cleanliness
and inspection to provide an enlarged meatal opening. These ends are
secured by plastic operation. The method of Korner is as follows:
The entire thickness of the fibrocartilaginous meatus is cut through, at its
posterosuperior aspect, from the tympanum outward to the concha. A
second similar incision is made at the postero-inferior aspect parallel with the
first and about 6 or 8 mm. (${Q or ^6 inch) from it (Fig. 1010). This pro-
duces a tongue-like flap, attached only at the concha, which is destined to be
applied to the posterior wall of the mastoid wound. The cartilage and connec-
tive tissue of the meatus are then dissected entirely away, leaving only the
pliable skin of the meatal tube. The flap is then fixed by a few sutures into
the mastoid excavation. If possible its tip should be sutured to the perios-
teum of the posterior border of the wound. The loose meatal skin is spread
out over the meatus and extended as far into the tympanic cavity as it will
reach. This plastic procedure, by removing the cartilage of the meatus,
greatly enlarges the external auditory canal and partly covers the bony ex-
cavation with skin. If the cavity is sufficiently clean, a skin graft may be
placed at once in the tympanic cavity. If there is some question about the
cleanliness of the wound the grafting may be deferred for a week (see Skin
Grafting, Vol. III). The graft should be pressed in so that it adheres
everywhere to the raw surface' A hole may be snipped in its center to per-
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 315
mit the escape of air which might prevent pressing it down into place.
The postauricular wound is then closed by sutures (Fig. ion). A light
packing of gauze is pressed smoothly into the greatly enlarged meatus to
keep the skin against the bone. Packing too tightly causes sloughing of the
flaps; packing too loosely causes failure of adhesion of the flaps; the latter is
the least objectionable of the two; a medium degree of pressure should be
secured. Over all is applied a copious gauze dressing, held in place by a
head bandage (see Bandages, Vol. III).
In cases in which a larger excavation has been made, as in complete
removal of all the mastoid cells, or in case of exposure of the dura mater,
larger flaps of skin should be secured by the method of Panse, which is as
follows:
An incision is carried through the whole thickness of the middle of the
posterior wall of the soft tissues of the external auditory canal from the
tympanum outward well into the concha. The outer end of this incision is
crossed at right angles by a vertical incision about 12 mm. (^ inch) long,
FIG. 1010. — OPERATION OF KORNER FOR
CLOSING MASTOID WOUND.
The mastoid has been excavated.
Two parallel incisions are made through
the cartilaginous posterior wall of the ex-
ternal auditory canal.
FIG. ion. — -RADICAL MASTOID OPERATION
COMPLETED.
Drainage is secured through the enlarged
external auditory meatus.
making a I— . These cuts involve the whole thickness of the concha (Fig.
1012). The length of the first incision, as well as the second, must depend
upon the size of the cavity to be filled. The vertical incision is best given a
slight curve. The cartilage should then be dissected out of the canal and
the flaps, in order to make the flaps more pliable and the canal larger. The
flaps should be pressed into the wound, their denuded surfaces lying against
the denuded bone, and sutured to the periosteum and skin (Fig. 1013).
The post-auricular wound may then be closed, and a gauze packing inserted
into the meatus to hold the flaps secure.
Skin grafting may be added to this operation to cover the tympanic
surface, after thorough sterilization of the wound. The grafts are best
held in place by small tampons impregnated with soft paraffin, containing
i per cent, phenol. The tampons may be softened with hydrogen peroxid
on the fourth day and removed. Granulations appearing at the edges of the
grafts should be suppressed. If time does not justify or if the presence of
infection forbids plastic closure of the wound, it may be packed with gauze
316
SURGICAL TREATMENT
and drained. It may be allowed to heal by granulation or after a week it
may be again opened and the plastic operation done.
Operation for chronic mastoiditis does not differ essentially from the above.
A few modifications are occasionally necessary. The incision should be
carried slightly lower than the tip of the mastoid process. The posterior
lip of the wound should be elevated and retracted. The muscles attached to
the process may need to be cut away with scissors or knife. If the first in-
cision is not adequate a second incision may pass backward at right angles
to it. Free exposure of the surface of the skull is essential.
After securing hemostasis the surgeon should take account of the land-
marks. The posterior root of the zygoma passes backward horizontally
above the external meatus. This ridge is on a level with the floor of the
middle fossa of the cranium. Removal of bone above the ridge will expose
the dura mater. If the ridge cannot be found a line just above the meatus
passing backward and slightly upward may be taken instead. The post-
meatal triangle should be had in mind (page 301).
The antrum should be open first. A gouge is the best instrument for
this purpose. The cutting should be directed toward the meatus. Thin
FIG. 1012.— FORMATION OF FLAPS FOR
LINING MASTOID CAVITY.
FIG. 1013. — FLAPS FOR LINING MASTOID
CAVITY ARE SUTURED IN PLACE.
slices of bone are cut away, after each cut the surface being observed. After
opening the antrum, bone-cutting forceps may be used. A well-curved
probe is of service in exploring cavities. If the examination or the
previous symptoms show that the cells of the tip are involved, the cover-
ing of the rest of the mastoid cells is removed. A small sharp curet will
discover any areas of softened bone or unopened cells. If the disease has
resulted in perforation of the drum membrane or if middle-ear infection is
present, the wall between the antrum and the tympanum should be cut away.
This is the step of the operation which threatens the facial nerve and the
external semicircular canal. The key to the situation is the aditus ad
antrum (the opening between the middle-ear cavity and the antrum).
If a probe or a guide is passed through this opening, the bone may be cut
away freely external to it, the aditus representing the inner limit of the
cutting (see Operation for Chronic Suppurative Otitis Media, page 311).
This means removal of the posterior wall of the external meatus.
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 317
Removal of the external wall of the attic is to be done if the attic is dis-
eased. Remaining drum membrane or necrotic ossicles may be removed. It
is usually best to leave the stapes, and, accordingly, the incus should be dis-
articulated from it.
The object of the operation is to remove dead bone, other necrotic tissue,
granulations, and polypi, and to secure drainage. The amount of bone to
be removed must vary with each case. After opening the antrum, it may
be necessary to open only the aditus and the attic of the middle ear, or all
of the pneumatic cells of the temporal bone may require to be drained. While
one part is being explored the other should be packed with gauze to check
bleeding. Rough edges should be smoothed, and the wound should be closed
as above described.
Operation for acute mastoiditis is carried out the same as that for
chronic mastoiditis, except that the wall of the meatus is not cut away unless
FIG. 1014. — OPERATION FOR ACUTE FIG. 1015. — OPERATION FOR ACUTE
MASTOIDITIS. MASTOIDITIS.
The antrum has been opened. Wound partly sutured and lightly tamponed
its outer wall removed, and the with gauze.
cavity smoothly excavated. Pos-
teriorly is seen the rounded pro-
jection of the thin wall of the sig-
moid sinus.
there is destructive disease of the middle ear. The soft tissue, therefore, is
not to be retracted from the external meatus, but only the bone of the mas-
toid region exposed. The overlying soft tissues are often edematous and
pus can be traced, oozing from sinuses. The bone is often so soft that the
mastoid cells can all be curetted away without using the chisel. Overhang-
ing bone should always be cut away so to leave a bowl-shaped excavation.
After exposing and cleaning out the diseased cells and securing hemostasis
by pressure, the aditus ad antrum should be gently curetted in an outward
direction with a small sharp curet in order to insure a free communication.
The curet should not penetrate the tympanic cavity far enough to injure the
ossicles, the drumhead, or other structures. It will sometimes be found that
air cells in the posterior root of the zygoma are infected; these should be
looked for and cut out. After irrigating the wound to remove all debris
318 SURGICAL TREATMENT
an inspection should be made for other foci of infection. A communication
may be found leading into the middle fossa of the skull above or into the
sigmoid groove behind. If pus is oozing from such openings they should be
enlarged, great care being taken not to wound the dura mater. If the dura
is found covered with plastic lymph, it should be exposed, but not removed,
as it forms an effective barrier against infection. Such plastic deposit should
be removed only in case the dura or sinus is to be opened.
It will be seen that in this operation the bone between the antrum and
middle ear and that of the meatus has not been cut away (Fig. 1014). Sup-
puration within the middle ear is usually present, but by providing good
drainage through the aditus ad anlrum, it may be expected to heal without
great damage to the function of hearing. The wound should be packed with
gauze, the packing beginning at the opening into the tympanic cavity, and
a couple of sutures passed through the periosteum and scalp at its upper
end (Fig. 1015). The external auditory meatus should be cleansed, and
packed so as to press back against its bony wall the soft tissues which may
have been loosened. A copious dressing of gauze should be placed over the
wound, care being taken to see that the pinna is not confined in a painful
position.
The first change of dressing after masloid operations need not be done
until the fifth day, provided the patient is comfortable, the temperature
persistently below ioo°F., and the discharge slight. If there is persistent
discomfort, if the temperature suggests considerable septic absorption, or if
blood, serum or pus saturates the dressing, the wound should be inspected.
After removing the gauze packing the wound should be found lined with
intensely hyperemic granulations. Irrigation is not called for. The meatus
should be dried and repacked. The subsequent treatment of the mastoid
opening is that of a granulating wound. Dressing should be done every day
or every second day. New areas of necrosis should be watched for, and
curetted away when discovered. The skin should not be permitted to close
over the opening until it has become filled by granulations from the bottom.
The patient should be well enough to be out of bed a week after the opera-
tion and in ten days to go about. A month to six weeks is required for the
complete healing of the wound.
In operations upon babies, it should be remembered that under two years
of age the antrum is the only mastoid cell. The tympanic ring should be
exposed as a guide, and the antrum opened just behind and slightly above it.
The bone is very thin, and the utmost care should be taken lest the cranium
be opened by using too much force.
Intracranial Complications of Infections of the Temporal Bone. — Infec-
tions and thrombosis of the venous sinuses usually require operation. The
patient is prepared as for mastoid operation except that the whole side of the
head should be shaved and the neck should be included in the preparation.
The mastoid cells are removed as above described. Often the infected open-
ing through the bone leading to the inside of the skull can be found. The
bone between the mastoid cavity and the sigmoid sinus should be removed,
and at least 2.5 cm. (i inch) of the vessel exposed. This exposure should
be free. It may be necessary to continue the removal of bone as far back-
ward as the torcular or downward to the jugular bulb. The first opening
through the bone may be made with a sharp chisel, and the wound enlarged
with bone-cutting forceps. An extradural abscess may be encountered as a
guide. The thtombosed vessel being exposed, before it is opened the wound
should be thoroughly cleansed and all of the utensils of operation cleansed
or sterilized as though another operation were to be begun (Fig. 1016).
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 319
If an operation for mastoid disease has already been done, and the wound
healed, the incision for exposure of the sinus should be made posterior to the
old scar and the scar elevated. If the incision is carried down through the
scar, the knife may open the sinus inadvertently. The jugular should be
ligated in the neck before opening the sinus for the removal of a thrombus.
(For the technic of the further treatment, see Sinus Thrombosis, page 70).
Intracranial abscess of otic origin requires operative relief. The operation
should begin as for mastoid disease. The antrum and adjacent cells should
be widely uncovered, and if tympanic suppuration is present, the middle ear
should be freely opened. This removes the original focus of infection, gives
access to the cranial cavity, and often enables the surgeon to discover the
opening in the bone through which the
infection passed into the cranium. If no
guide is found, the roof of the antrum
should be removed. Infection of the ex-
tradural space will often be discovered.
An extradural abscess evacuates itself
through the antrum. After the pus has
been removed and the dura dried, fur-
ther examination should determine
whether a subdural abscess is present.
When the diagnosis is not clear, the
wound may be packed and further study
of the case made.
If the signs of brain abscess are suffi-
cient an attempt to evacuate it at once
should be made. If the dura bulges into
the bony opening, and especially if it is
dark or edematous, it may be touched
with iodin or phenol and alcohol, and an
aspirating needle passed into the brain.
Pus being found, the brain should be in- FIG. 1016. — OPERATION FOR MAS-
cised for its evacuation and a drainage TOID DISEASE WITH INTRACRAXIAL ix-
tube inserted. In cases in which there FECT ON'
seems to be a dangerous infection in the tJu\7tS roTo "h"™ Sg.
tympanomastoid wound, the abscess moid sinus exposed below.
should be opened through a clean area
in the temporal region (see Abscess of the Brain, page 73).
Chronic Nonsuppurative Otitis Media. — The treatment of this disease
by nonoperative measures has met with little success. A small proportion
of cases have been helped by operation. In properly selected cases a fair
measure of success may be expected. Incision and excision of the membrane
of the drum have been practised with temporary improvement in hearing.
Removal of the ossicles has given good results in the hands of some.
The treatment of advanced tympanic deafness requires the patient skill of
the otologic specialist. Inflation of the middle ear by air, driven through
the Eustachian catheter, has little or no value. Good hygiene is most
important. If a chronic inflammation of the Eustachian is present, the best
treatment consists in cocainizing the entire length of the tube and injecting
it with 5 or 10 per cent, silver nitrate solution or 25 or 50 per cent, argyrol.
Removal of the ossicles of the ear is helpful in cases in which the bones are
bound by adhesions.
Labyrinthine Disease. — Labyrinthine hemorrhage (Meniere's disease), if
the patient is- seen early in the attack, should be treated by measures to
320
SURGICAL TREATMENT
relieve cephalic congestion. The patient should be kept quiet with the head
elevated and hot applications to the lower extremities. Constriction of the
limbs to confine the blood by producing venous obstruction may be of
FIG. 1017. — OPERATION FOR SUPPURATIVE INFECTION OF LABYRINTH.
The semicircular canals have been ablated. Posterior drainage has been provided
for the vestibule. The auricular flap has been sewed in place. The probe is seen passing
upward and backward through the enlarged oval window into the vestibule. The bridge
of bone contains the facial nerve.
FIG. 1018. — OPERATION FOR MIDDLE-EAR SUPPURATION WITH DURAL INFECTION.
The mastoid has been opened and its inner wall removed, exposing dura mater. The
vestibule has been drained. The probe is seen passing forward and outward beneath the
bridge of bone containing the facial nerve. The probe lies in the canal made by opening
the first and second turns of the cochlea.
help. The blood is ultimately absorbed, but the lost hearing is rarely
restored.
Labyrinthine and per {labyrinthine involvement, following middle-ear
suppuration, are operated upon as follows: The curved incision behind the
TREATMENT OF INJURIES AND DISEASES OF THE HEAD 321
ear is made and the flap containing the external ear is turned forward expos-
ing the bony meatus. The horizontal semicircular canal is opened with a
small gouge at its most prominent convexity. This opening is enlarged
downward and backward until a probe can easily enter the vestibule. The
facial nerve lies just below the horizontal semicircular canal. The cochlea is
then opened by removing the small bridge of bone between the oval and
round windows. A probe may now be passed into the horizontal semicircular
canal downward and forward and then outward beneath the facial ridge, and
coming out at the middle ear (Fig. 1017). lodoform gauze should be
packed lightly into the cochlea, semicircular canal and middle ear. Ten
days later skin grafts may be applied to the mastoid cavity. This is the
method used by E. B. Bench.
In cases in which pronounced constitutional symptoms show approach of
the infection to the meninges, the operation of Neumann is to be preferred.
The radical mastoid operation is performed, and the lateral sinus is exposed in
the posterior part of the wound. The dura in the middle cranial fossa is
also exposed. The dura is gently separated anteriorly from the overlying
bone by means of a probe or elevator. The bone is then removed anteriorly,
care being taken not to wound the dura. Presently the posterior semicircular
canal is opened. The openings from the superior and the horizontal canals
next come into view as more bone is taken away. A fine probe is then passed
into the upper opening and caused to pass into the vestibule. The opening
into the vestibule is then enlarged with the gouge. The cochlea is drained
as described above (Fig. 1018).
If there is infection of the dura the dura should be separated from the
bone still further inward, and a wider exposure made by removing still more
bone until the sheath of the auditory nerve is reached. Usually a meningitis
secondary to labyrinthine disease is found in the subtentorial space near
the auditory nerve.
VOL. II— 21
THE SPINE
Anatomic Considerations. — The spinal cord extends from the skull to the second
lumbar vertebra, below which point the spinal canal is occupied by the bundle of nerves
destined for distribution to the lower abdomen, pelvis and lower extremities. The nerve-
roots do not correspond with individual peripheral nerves but with parts of several nerves;
and for this reason division of a root does not cause complete paralysis of a muscle or sensory
area. Complete paralysis means an extensive lesion. The trophic centers of the motor
fibers are in the anterior horn of gray matter. The trophic centers of the sensory fibers
are in the ganglia located on the posterior roots. The fibers of the cord itself lack neu-
FIG. 1019. — SENSORY DISTRIBUTION OF POSTERIOR SPINAL ROOTS. (According to Seiffer.)
rilemma sheath; and when the nerve elements of the cord are divided they are not capable
of regeneration. So far as is known, when the cord is divided, reunion and the reestablish-
ment of nerve impulses is impossible. It is futile, so far as known, to attempt suture of the
wounded spinal cord.
Between the dura mater, lining the spinal canal, and the pia mater, covering the cord,
is the arachnoid space, filled with cerebrospinal fluid, communicating with the ventricles
of the brain, and serving to preserve the cord from jar and friction. The structure of
the spine is peculiar because of its numerous and complicated joints and because of the
strong ligaments which embrace the bones on every side. The relations of the cord to its
periphery are shown in Figs. 1019 and 1020, and in the accompanying table.
322
THE SPINE
323
A*, to rectus lateralis
I . '±to rectus antic, minor
C.I ) /x Anastomosis with ht/poglossal
Anastomosis with pnvutnogastrtc
A', to rectus antic.major.
JT. tomastotd region.
Great auricular n.
Transverse cervical n.
~=~S(lf. to Trapeztus, Ang. Scap. and Rhomboid.
_ Supra clavicular n.
_ Supra-acromiat n.
Phrenic n.
N. to levator ang. tcap.
N. to rhomboid
Subfcaputar n*
Suiclavicular n.
Jf. topectoralis major.
.^Circumflex n.
\lo-cutancous n.
Jtfedton n.
Kadtat n.
Ulnar n.
•mall internal cutaneous n.
- nio-nypogastrtc rt.
. llio-Ingutnal n.
•...External cutaneous i
Gen«o-crural n.
Anterior crural n.
.Obturator n.
If. to obtura,
Jf. to ophinctcr ani.
Qoccygeal n,.___
Superior gluteal n.
A', to pyri/ormls
> A', to gemellus super.
A', to gemellitt Infer.
1 A*, to ouadralus
. Small sciatic n.
Stfaticn.
FIG. 1020. — RELATIONS OF THE NERVE ROOTS TO THE VERTEBR/E. (According to
Dejerine and Thomas.)
324
SURGICAL TREATMENT
Segments. Muscles.
C. IV. Diaphragm.
Supraspinatus.
Infrasp inatus.
(Teres minor\f\.)
Biceps.
Deltoid.
Supinator longus.
Rhomboids.
Scaleni.
C. V. Biceps.
Brachialis*
Deltoid.
Supinators.
Spinati.
Pectoralis major.
Serratus magnus.
Rhomboids.
Scaleni.
Teres minor.
C. VI. (Subscapularis.)
Pronators.
(Teres major.)
(Latissimus dorsi.)
Pectoralis major.
Triceps.
Serratus magnus.
Biceps.
Brachialis.
Extensors of wrist and fingers.
C. VII. Extensors of wrist and fingers.
Triceps.
Flexors of wrist (?).
Pronators.
Pectoralis major.
Subscapularis.
Latissimus dorsi.
Teres major.
C. VIII Flexors of wrist and fingers.
Interossei.
Extensors of thumb (?).
Segments. Muscles.
D. I. Interossei.
Other intrinsic muscles of hand.
Extensors of thumb.
L. I. Abdominal muscles.
Iliopsoas.
Cremaster.
Sartorius.
L. II-III. Flexors and adductors (III):
of thigh.
Sartorius (III).*
L. III-IV. Extensors of thigh.
Adductors of thighs (III).*
Abductors of thigh (IV).*
Quadriceps femoris (IV).*
Tibialis anticus.
L. V.-S. I. Flexors of knee (L. V.).*
Glutei (S. I-II).*
Calf muscles (S. I-II).*
External rotators of thigh.
Peronei (S. I-II).*
S. I-II. Calf muscles.
(Glutei.)
Peronei.
Intrinsic muscles of foot.
(Long extensors of toes and foot.)1
Erector penis (II-III).*
S. III-IV. Perineal muscles (III).*
Ejaculator muscles (III.)*
Bladder (IV).*
Rectum (IV.)*
S. V. Levator ani.
Sphincter ani
* Bracketed numbers refer to the segment in Thorburn's table.
0 Dorsal flexion of ankle.
Sprains of Spinal Joints. — The treatment should be carried out upon the
same principles as are applied to sprains of other joints (see Sprains, Vol. I,
page 650). Immobilization may be secured by rest in bed, or, if this is not
sufficient, by means of a plaster-of-Paris support such as is used for spondy-
litis. The early pain may be relieved by hot applications. Stiffness and
swelling may be relieved, after the acute symptoms have subsided, by
massage.
Contusion and Concussion of the Spinal Cord.— The shock attending these
injuries is often severe and is the chief condition demanding treatment
(see Shock, Vol. I, page 213). Whatever is done, rest is an essential. If
there are local or general symptoms the spine should be treated locally as
for sprain or contusion. The general treatment should secure rest of both
body and mind (see Traumatic Psychoses, page 102).
THE SPINE 325
Extrapial Hemorrhage Compressing the Cord. — Usually this condition
is associated with fracture, dislocation or other severe traumatism, and the
treatment must be directed to the causative lesion. When due to local dis-
ease or hemorrhagic diathesis, if external to the dura, the latter may be
caused to press upon the cord. In such a case the recognition and treatment
are the same as for extradural tumor. Hemorrhage into the arachnoid
space diffuses itself with the cerebrospinal fluid. Unless the source of the
bleeding is known, it is difficult to locate it. The bleeding stops when the
pressure within the spinal canal becomes sufficiently raised. The hope of
treatment is to identify the site of the hemorrhage. If that can be done, it
may be exposed and the bleeding checked. If the arachnoid space is opened
while hemorrhage is still going on, and the bleeding point is not found and
controlled, the condition is only made worse, because when the pressure is
relieved the bleeding increases.
Hemorrhage into the Cord (Hematomyelia). — Whether traumatic or a
spontaneous apoplexy, localization of the hemorrhage is usually not difficult,
but even then the question of the expediency of operation is a difficult one.
Most cases are best kept quiet, and it will be found that the paralyses almost
or entirely subside. Operation is often militated against by the extension
of the hemorrhage for a long distance in the length of the cord. When the
clot is distinctly localizable, and the pressure symptoms are serious, the lesion
may be treated the same as a tumor, and the clot removed by laminectomy.
But it should be borne in mind that when hemorrhage has ceased, from that
time on, without operation, the tendency is toward improvement.
Stab Wounds and Bullet Wounds of the Spine. — In stab wounds the im-
portant thing is to prevent sepsis. The wound should not be probed. It
should be covered with an antiseptic dressing, and the patient kept quiet.
Operation is indicated for the same conditions as in compound fracture —
bone or clot pressing upon the cord, which can be removed. Any foreign
body, such as a broken knife blade, should be removed. Infection develop-
ing in the wound tract and involving the meninges demands free opening of
the wound, the removal of splintered bone, and the uncovering of the men-
inges by laminectomy.
Bullet wounds should be treated the same as above. When a bullet is
lodged in the spine and does not encroach upon the cord, it may be removed,
but its removal is not necessary (see Bullet Wounds, Vol. I, page 222). If
the bullet or any other foreign body or splints of bone occupy the spinal
canal and press upon the cord, they should be removed. The operation
should not necessarily follow the path of entrance, but after a careful lo*
calizing examination, supplemented by the x-ra,y, laminectomy (see page
339) should be done at the site of the foreign body. Later operation may
be required for the removal of compressing exudate.
In cases of bullet wounds of the spine, if the symptoms point to complete
transverse lesion of the cord, operation is not to be advised unless the #-ray
shows that the bullet or a fragment of bone lies in such a position that it may
be responsible for pressure upon the cord. If the lesion of the cord is in-
complete the cord should be exposed by laminectomy to remove the foreign
body or splinters of bone. Even when no compressing body may be removed,
the laminectomy as a decompressing operation may be expected to relieve
the symptoms which are due to edema. In the event that suppuration along
the track of the bullet is present the danger of infecting the cord by exposing
it should not be incurred.
In any case of injury to the cord the laminectomy may reveal edema of the
meninges or fluid compressing the cord, and simple incision may give relief.
326 SURGICAL TREATMENT
Traumatic Spondylitis (Non-tuberculous, Rarefying Osteitis). — The local
treatment is similar to that of tuberculosis of the spine. Gentle manipula-
tion under anesthesia should be applied to correct recent deformity. Ex-
tension, immobilization and recumbency are the essential measures in the
early treatment. Later a jacket is required, to be followed by massage
during the later stages. Repair is slow, and support and immobilization
should usually be continued for at least six months.
Osteomyelitis of the Spine. — As soon as the disease is recognized it
should be exposed and drained (see Osteomyelitis, Vol. I, page 469) . Necrotic
bone should be removed. In the cervical region the operation is done pos-
terior to the sternomastoid muscle. In the dorsal region, excision of trans-
verse processes and the adjacent ribs permits access to the bodies. The
lumbar vertebrae may be approached through an extraperitoneal incision
such as is made for exposing the kidney.
A transverse incision at one side of the median line should expose the
muscle. This incision should be fully 15 cm. long. The heavy mass of spinal
muscles is crossed transversely by two parallel lines of hemostatic sutures,
divided between, and the muscles retracted upward and downward. The
laminae and transverse processes are thus exposed, and the transverse process
of the diseased vertebra is removed with rongeur forceps. In the dorsal
region the inner end of the rib also is resected. The nerves should be pro-
tected from injury. The psoas muscle is separated from the body of the
vertebra by means of an elevator, and retracted by means of a long retractor.
This exposes the side of the body which may be penetrated by a burr or
gouge, and the diseased area opened and drained. This is practically the
operation described by L. Mayer (Jour. Am. Med. Assoc., March 2, 1918).
The spinal nerves should be watched for and spared from injury. A jacket,
brace or splint should be applied as in tuberculosis. The spine should be
held in slight lordosis until the body of the vertebra becomes strong.
Typhoid Spondylitis.' — Rest, recumbency, immobilization and artificially
induced hyperemia are the essentials of treatment. The patient should be
kept in bed or on a frame stretcher until the acute condition has subsided.
Hot applications or other hyperemic treatment is of service at the beginning.
A brace or jacket should be applied as soon as the acute stage is passed. At
least six months are required for recovery.
This disease should be watched for in typhoid cases. Pain in the back
in the third or fourth week of typhoid should be met by immobilization of the
spine at once. An autosensitized autogenous vaccine should be given. The
culture may be gotten from the blood, urine or feces. If an autogenous
vaccine cannot be made, stock vaccine should be used. By applying a
light jacket of leather or felt the pain is relieved. Abscess is prevented.
The pain must be met by hot applications. Dry air or the actual cautery
are to be employed for the relief of the radiating pains.
Anterior Poliomyelitis. — This disease, although medical in its acute
stage, leaves paralyses which are amenable only to surgical treatment, and
therefore is entitled to surgical consideration. The treatment is best
carried out with injections of specific serum. The mortality has been de-
cidedly lowered by serum treatment. It seems to possess the power of pre-
venting paralysis when given early. The serum is injected intraspinally
in small doses and at the same time intravenously in larger amounts.
Spondylitis Deformans.— The general treatment is that described for
arthritis deformans (Vol. I, page 661). Massage and hot baths give comfort.
Immobilization and support by means of a brace or jacket are of service
during the progressive period of the disease. Later the stiffened spine may
THE SPINE
327
be helped by vibratory massage and painless passive movements. Attempts
to break up adhesions under anesthesia to increase the suppleness of the
spine seem to do more harm than good. Support is no longer needed when
the progress of the disease has stopped; although the comfort of the patient
may require its continuance for an indefinite period.
Non-tuberculous Abscess of Spine. — Whether arising from osteo-
myelitis or other non-tuberculous disease, the abscess should be opened,
necrosed bone removed and drainage established (see Abscess, Vol. I,
page 251). Abscess connected with the bodies is reached the same as
tuberculous abscess (see page 335).
Tuberculosis of the Spine (Tuberculous Spondylitis, Pott's Disease). — •
The general treatment is the same as that for tuberculosis elsewhere (see
Tuberculosis, Vol. I, page 276). Local treatment is aimed to secure the
best possible immobilization, to hold the vertebrae in good position pre-
paratory to the inevitable ankylosis, and to relieve as much as possible the
softened bones from superimposed weight. Immediate, forcible and com-
plete correction is no longer used. Gradual correction of the deformity is
best.
Treatment by recumbency is usually employed in children under five years of
age, in all very acute cases, in cases with much pain, in cases which have not
done well in the upright position, in cases with abscess, paralysis or threatened
FIG. 1021. — THE "RECLINING PLASTER-BED," IN THE TREATMENT OF TUBERCULOSIS
SPONDYLITIS.
paralysis, in dangerously high cervical disease, and in cases with pronounced
lateral curvature. For all classes of cases it gives more effective rest to the
diseased parts. Its objection is that it confines the patient closely. Hori-
zontal fixation should be in a position of overextension, thus placing the
pressure upon the articular processes and taking it from the bodies. In the
adult, horizontal fixation is not so essential because the spine is more rigid
and can be held by appliances which do not necessitate confinement in bed.
Moreover, young children tolerate recumbency better than adults.
For securing horizontal fixation my former teacher in Vienna, Lorenz,
made a "reclining plaster-bed." The patient was placed upon its abdomen
with the shoulders and pelvis slightly elevated thus giving an increased
extension of the spine. The body was covered with a tricot shirt and a
piece of cloth was placed on the back of the head and neck. Several layers of
crinolin, impregnated with plaster-of-Paris, cut in such a shape as to extend
from the top of the head to the middle of the sacrum and wide enough to
embrace the posterior half of the head, neck and trunk, were rubbed together
with water. This cuirass was laid upon the patient, molded so as to con-
form to its posterior aspects, and held in place by a few turns of gauze band-
age until it became hard. The child could then be turned over and was
found to lie in a well-fitting and comfortable bed, in which it could be carried
328
SURGICAL TREATMENT
about and deposited wherever desired. The use of this simple apparatus
gives much satisfaction (Fig. 1021). In high dorsal disease a jury-mast
may be attached to this splint and extension upon the head secured (Fig.
1022).
Treatment upon the tubular frame of Bradford (see Vol. I, page 666)
is most in favor in America. The frame should be about 10 cm. (4 inches)
longer than the child.
The width of the frame should correspond to the distance between the
two shoulder joints. The covering of the frame should be tight. Strong
canvas, laced across and protected in the middle with rubber cloth, is the
best covering. Two pads of felt should be sewed to the canvas on either side
of the diseased bone so that the disease shall be lifted away from the canvas
and sustain no pressure. These pads should be about 15 cm. (6 inches)
FIG. 1022. — RECLINING PLASTER-BED IN THE TREATMENT OF HIGH TUBERCULOUS
SPONDYLITIS.
Jury mast added for high dorsal or cervical disease.
long and 2.5 cm. (i inch) thick. The child wearing only an undershirt is
fixed to the frame by a broad band about its trunk and bands about the legs.
An opening in the canvas, back of the anus, covered with a separate strip
allows of defecation and urination without taking the child from the frame.
This frame may be carried about, and the child deposited wherever desired.
As the patient becomes accustomed to the frame, the lateral tubes should be
bent backward in order to give overextension to the spinal column (Fig.
1023). The frame may be made with sliding tubes or a turnbuckle so that
its length and width may be regulated. Once daily, the fixation should be
liberated and the child gently turned on its side to have its back washed and
rubbed with alcohol and the underclothes smoothed out.
In disease of the upper dorsal or cervical region a chin and occiput halter
is applied. Extension may be made by connecting this with a weight and
pulley; but what is still better is simply to fasten it to the top of the frame
and secure traction by raising the upper end of the latter. Thus the weight
THE SPINE
329
of the body makes the extension and the patient is in a better position to see
what is going on about. Fixation to prevent lateral motion and rotation is
also desirable in cervical disease. In disease of the upper parts of the spine
the legs need not be confined, but in disease in the lumbar region the legs
should be fastened. The curvature in the frame should correspond to the
site of the disease. In upper dorsal and cervical disease, it is desirable that
the head should be dropped well back so as to insure extension. Flexion of
the thigh from psoas abscess should be met by continuous traction upon the
leg in the flexed position, gradually lowering the leg as the disease improves.
FIG. 1023. — FRAME BENT TO SECURE OVEREXTENSION OF SPINE.
Ambulatory treatment is carried out with jackets of stiff material, such
as plaster-of-Paris, and with braces. It does not meet the local require-
ments as well as treatment by horizontal fixation, but it gives the patient
greater liberty. It is not used in children younger than four years, except
as a support after all active disease has subsided. In older children it may
be applied after treatment by recumbency has been used for a short time.
In adolescents and adults the ambulant method is used from the beginning.
Jackets are used in the early stage; in the convalescent stage, braces are pref-
erable. Jackets of plaster-of-Paris are applied by winding smoothly about
the body moistened plaster-of-Paris bandages, the spine having been placed
in the desired position. When the plaster has dried, a firm support is se-
FIG. 1024. — SUSPENSION HAMMOCK FOR APPLICATION OF PLASTER JACKET IN TUBER-
CULOUS SPONDYLITIS.
cured. The jacket should extend as high as possible and as low as possible.
The jacket is of greatest value in disease of the lower dorsal and upper lumbar
regions.
Jacket Applied with Patient in the Prone Position. — A hammock of un-
bleached muslin, slightly narrower than the width of the thorax, is sus-
pended from a frame, and the patient placed upon it longitudinally, face
downward (Fig. 1024). The amount of curve can be increased by increasing
the slack. An ordinary iron bed-frame or a tubular iron frame is useful
for this purpose or the hammock may be swung from two hooks or rings.
The smallest possible number of layers of muslin to support the patient should
330 SURGICAL TREATMENT
be used. One thickness suffices for a small child. A tricot cotton covering
or a cotton jersey underskirt is used to cover the skin. A small pad of gauze
or cotton should be fixed over bony prominences such as the anterior-su-
perior spines of the ilium. A pad of gauze or felt at least 2 cm. (% inch)
thick should be placed on either side of the spinous processes of the diseased
vertebrae in order to prevent pressure. The hammock is then lowered to
extend the spine to the desired degree. Extension may be carried to the point
of causing slight discomfort. The plaster bandages then are applied,
covering the trunk. The bandages should be from 8 to 13 cm. (3 to 5 inches)
wide and 6 meters long. From three to six are required for a child's jacket
(see plaster-of-Paris Bandages, Vol. I, page 477. The bandages should be
applied with even tension, and the layers well rubbed together. The thick-
ness of the jacket should be from 3 to 7 mm. Q£ to Y± inch). It should fit
with especial snugness around the pelvic brim. Some strips should run ob-
FIG. 1025. — PLASTER-OF-PARIS JACKET TO IMMOBILIZE SPINE,
liquely. When it is nearly hard its edges should be trimmed. In most cases,
in front, it should reach from the upper end of the sternum to the front of the
pubes; behind, from the spine of the scapula to the lower end of the sacrum.
It should be cut away around the axilla to prevent pressure on the arms, and
across the groins to allow flexion of the thighs (Fig. 1025).
The muslin of the hammock may be trimmed off above and below and
left in the jacket. It is possible to so place the muslin of the hammock under
the shirt that it can be pulled out and removed. It is a good plan to place
a strip of linen about 5 cm. (2 inches) wide under the shirt, back and front,
and a little more than twice the length of the jacket. The two ends of each
strip are sewed together, their purpose being to give cleansing friction to the
skin. The upper end of the shirt or a separate collar should fit snugly
around the neck to prevent crumbs dropping under the jacket. A nice
covering for the jacket is secured by having the tricot lining long enough to
THE SPINE
331
be doubled up over the outside and sewed end-to-end after the jacket is hard.
The health of the skin is most important. When the skin becomes broken,
the discharge of the sore has a peculiar odor, which should call for removal
of the jacket.
Jacket Applied with Patient Lying on the Back. — The preliminary
dressing should be the same as above. The head and shoulders may rest on
FIG. 1026. — FRAME FOR APPLYING PLASTER JACKET WITH PATIENT IN RECUMBENT
POSITION.
one support and the buttocks on another (Fig. 1026). Support of the spine
may be secured by passing a piece of canvas about 13 cm. (5 inches) wide and
150 cm. (60 inches) long, under the back. This should be well padded and
support the kyphosis. It is attached to a spreader about 75 cm. (30 inches)
long, which is supported by a rope passing over a pulley. Sufficient ele-
vation is made to give the desired correction and the plaster is applied over the
canvas which emerges at the sides. When the plaster has hardened the
FIG. 1027. — SUPOPRT FOR APPLICATION OF PLASTER JACKET.
ends of the canvas are cut off. This method should be used very carefully
lest the rope or canvas become loosened and the spine suddenly fall because
of the loss of support (Fig. 1027).
Jacket Applied with Patient Suspended. — This method serves for adults
but is not well adapted to children. It does not give as good extension as
the above methods. The patient is prepared as above, and the suspension
332
SURGICAL TREATMENT
apparatus adjusted. The apparatus consists of a bridle which is capable of
making traction under the chin and occiput, and rings to which the patient
holds with his hands elevated (Fig. 1028). An apparatus can be extemporized
with rope, pulleys, a stick of wood and a little cotton cloth. Traction
should be made until discomfort begins to be felt, the traction desired should
partly lift the body of the patient so that the heels are slightly raised, or
the patient is slightly lifted from the sitting position. By maintaining some
of his weight with his raised arms the ribs are raised and the chest expanded.
One person may sit behind the patient and one in front and a third may
hold the apparatus to prevent swaying and rotation. While the jacket is
hardening the assistants rub in the
plaster and make corrective pressure
in order to secure some extension of the
spinal joints. If the patient becomes
fatigued or must be taken down before
the jacket is hard, he should be laid on
a hammock face downward or in the
recumbent position with an elevating
support behind the back opposite the
disease. This vertical suspension
method has been superseded by the
horizontal position in the treatment
of tuberculous spine.
For Cervical and Upper Dorsal Dis-
ease.— The jacket above described is
most effective for disease in the lower
dorsal or upper lumbar regions. If the
disease is higher than the ninth dorsal
vertebra, the upper dorsal vertebrae
should be included in the jacket. This
may be done by carrying the plaster
over the shoulders, as in the high jacket,
or by supporting the head by braces.
Disease above the middle dorsal verte-
bra requires support of the head.
In applying the high jacket (Calot)
the patient is prepared and suspended
as usual. An additional layer of cotton
is placed on the front of the chest, and
the neck and shoulders are covered
with a layer of cloth. The head sus-
pension is best secured by two strong
strips of muslin, 2 cm. (2 inches) wide,
under the chin and occiput, connected above the ears, and prevented from
displacement forward and backward by having sewed to them a connecting
strip on either side of the neck. The supporting strips are fixed to the
crosspiece of the suspension apparatus. If the hammock is used, traction
is just as easily applied. Counter-extension is made through adhesive straps
to the thighs, and to facilitate breathing a hole is cut through the hammock
or a pad placed under the forehead. An opening must be cut under the neck
to permit the bandage to pass in and out. The dorsal position may be used
with the patient supported upon a frame. The arms should be at right angles
to the body. The plaster is applied as usual except that the jacket is made
thicker and carried over the shoulders and about the neck.
FIG. 1028. — SUSPENSION FOR APPLICA-
TION OF PLASTER-OF-PARIS JACKET.
THE SPINE
333
In disease in the upper dorsal region the jacket should come well up
against the occiput and chin. In cervical disease, the head should be covered
with cloth and the plaster made to embrace all of the head, leaving exposed
only the face and ears. The head should be tilted back by upward pressure
on the chin.
The front of this jacket may be cut away so as to make a large fenestrum ex-
posing the mid-thorax and abdomen (Fig. 1029). Calot cut an opening in
the back over the dorsal disease, placed pads over the deformity, and pressed
it forward by additional turns of plaster bandage, repeating the process
at intervals of a month and carrying the pressure to the point of toleration.
This pressure should not be made at the apex of the deformity but by pads
FIG. 1029. FIG. 1030. FIG. 1031.
FIG. 1029. — PLASTER-OF-PARIS JACKET FOR DORSAL DISEASE.
Note large window to give freedom for respiration.
FIG. 1030. — PLASTER JACKET FOR HIGH DORSAL OR CERVICAL DISEASE. Front view.
FIG. 1031. — PLASTER JACKET FOR HIGH DORSAL OR CERVICAL DISEASE. Rear view.
close to it on either side. The proper application of this jacket requires
experience. For cervical disease, the plaster jacket need not embrace the
pelvis, but it should support the head (Figs. 1030 and 1031).
More comfortable and better than these appliances is treatment, with
traction in the recumbent position (Fig. 1032). Metallic braces are used
in connection with the jacket in treating high disease. In high dorsal
disease, the jury-mast (Fig. 1033) band or head-support is of service (Fig.
1034). The head bands are as effective as the jury-mast and less con-
spicuous. This apparatus is commonly connected with metallic body-
braces, but the head-supporting part may be incorporated in a plaster jacket.
If deformity of the chin occurs as a result of pressure, a forehead band should
be'applied with occipital support.
334
SURGICAL TREATMENT
In the later stages of spondylitis, and in the early stages, in experienced
hands, the whole treatment may be conducted in braces. The most effective
consist of two steel rods, lying on either side of the spine, connected by
transverse pieces, and strapped to a broad apron of canvas or leather in
front of the body (Fig. 1035). Braces should be made to order for each
patient.
After treatment on the recumbent frame, a plaster jacket may be applied
to a child by placing it face down in the muslin hammock and returning it to
the frame before the plaster has hardened. This gives the exact position
of the frame to which the spine has become accustomed.
The care of the skin demands that braces should be removed frequently
and the skin bathed and rubbed with alcohol. A plaster jacket should be
left on for about three months. If not comfortable, or if there are signs of
skin irritation, it should be removed sooner. In many cases a jacket may be
FIG. 1032. — TREATMENT OF HIGH DORSAL OR CERVICAL DISEASE BY TRACTION IN RECUM-
BENT POSITION. (After G. R. Fowler.)
left on six months or longer. Before removing the jacket everything should
be ready for applying another. When the jacket is taken off the patient
should be kept suspended or in the horizontal position. If the skin is sore
the old jacket should be replaced and held by adhesive plaster until the health
of the skin is restored.
Treatment by corset is employed in the later stage of the disease (Fig.
1036). A corset is made by cutting a strip, i or 2 cm. wide, out of the thick-
ness of the jacket in the median line in front. Any necessary extra padding
is added, the front edges are bound with leather, provided with hooks for
lacing, the top and bottom are bound, and the corset laced in place. A
more elegant corset may be made by making a plaster cast of the torso in
the original jacket as a mould. About this cast a corset of paper, celluloid,
wood, aluminum or other composition is made.
In lumbar disease, especially low down, the body jacket alone does not
suffice. Here braces are most effective. They should be constructed in
combination with a crutch-like top to press up in the axilla?; a support
should rest upon the crest of the ilium on either side; and a band should
THE SPINE
335
embrace the pelvis. In some cases of low disease, this will fail to give the
necessary immobilization; then there must be added to the above, splints
for immobilizing the hip-joints. This is done by continuing down back of
each thigh a flat rod, such as is used in the hip splint of Thomas.
The prognosis in tuberculous spondylitis varies with the location of the
disease, the earliness of treatment, and the general hygiene that can be
secured for the patient. In the lower spine the prognosis is good, although
psoas abscess and contracture are often present; healing with but little de-
formity is usually secured. In the middle dorsal region,
although the symptoms are easily controlled, deformity
usually results. In the upper dorsal and lower cervical
regions recovery with no apparent deformity may be ex-
pected. In the upper cervical region, if the head is well
supported to take the weight from the small neck bones,
recovery without deformity may be expected; but if
the support is not secure, paralysis and death may
easily occur.
PIG. 1033. — JURY
MAST IN TREATMENT
OF HIGH DORSAL AND
CERVICAL DISEASE.
FIG. 1034. — HEAD SUPPORT IN TREATMENT OF HIGH
DORSAL DISEASE.
Treatment of abscess has already been described (see Tuberculous Abscess,
Vol. I, page 281). The greatest care should be taken to prevent mixed
infection. Retropharyngeal abscess usually should be evacuated promptly
because of the danger of invasion of the larynx and the obstruction to swallow-
ing which it often causes. In an emergency the abscess may be incised in
the middle line of the pharynx through the mouth. The free evacuation is
best done through an incision along the posterior border of the sternomastoid
muscle. This muscle and the omohyoid are retracted upward and the splenius
336
SURGICAL TREATMENT
capitis is exposed. The fibers of the longus colli are separated and the side
of the vertebra reached. The vertebral artery should be avoided (Vol. I,
page 410). If the abscess is purely tubercular, and there is no emergency
threatening, a better result can be secured by aspiration. This may be done
through the neck wound when the dissection has nearly reached the abscess,
or it may be done through the mouth and mucous membrane. In the latter
operation the tongue is depressed, the mucous membrane bulged forward by
the abscess is touched with cocain, it is then dried and touched with tincture
of iodin, and the aspirating needle inserted. The needle should be connected
to the syringe or bottle by a non-collapsible rubber tubing.
PIG. 1035. — METALLIC BRACE FOR
SPONDYLITIS.
FIG. 1036. — CORSET FOR IMMOBILIZA-
TION OF SPINE.
The corset has been divided, and is
provided with hooks for lacing.
An abscess of the middle cervical region may be aspirated or opened in the
side of the neck. Abscess of the upper dorsal region may become urgent
because of pressure on the trachea or bronchi. When the thorax is invaded
and urgent pressure symptoms demand relief, a vertical incision is made just
to one side of the spinous processes exposing one or two costovertebral
articulations, and the joints resected. Blunt dissection along the side of the
bodies of the vertebrae discovers the abscess. If the abscess gives no lateral
symptoms the opening should be made preferably on the right side.
In abscess of the lower spinal region urgency is not apt to arise. Here
tentative measures should first be taken. Aspiration should be practised if
spontaneous rupture threatens or if the presence of the abscess interferes
with proper treatment of the bone disease. Aspiration should be repeated so
THE SPINE 337
long as mixed infection is not present or permanent evacuation is not de-
man;L'd. Aspiration may prevent the abscess from becoming large even
though it does not cure it. Incision should be the last resort as a confession
of defeat. It should be about i cm. long, just large enough to admit a rubber
tube; it should be at the most dependent point; it should be made under the
most rigid asepsis; a tube should be inserted and a dressing of antiseptic
gauze applied covered with a copious mass of dry gauze; dressings should be
done as infrequently as possible, and always with strict asepsis; and the tube
should be left out as soon as it can wisely be dispensed with. These rules
apply to lumbar, psoas, femoral and inguinal abscess, or abscess in any part
of the flank or pelvic region.
Spinal abscess due to mixed infection, as evidenced by temperature,
leukocytosis and other signs of pyogenic infection, must be incised at once.
If the incision permits, any accessible dead bone should be removed at the
same time.
Treatment of paralysis should first be prophylactic. The earlier and more
effective the immobilization and the hygienic treatment, the less apt is
paralysis to occur. Treatment by recumbency should be practised as soon
as the first sign of paralysis appears. Traction or extension may with
advantage be added to this. If there is much deformity, considerable cor-
rective force is justified. The best position is on the stretcher frame. A
radiograph should be of service in showing whether the pressure upon the
cord is due to crushing of the bodies of the vertebrae or to abscess. Abscess
causing paralysis should be opened. If the disease is in the upper dorsal or
cervical regions, traction by weight and pulley may be applied. A paralyzed
patient must receive careful treatment of the skin. To prevent bed-sores
in adults a water mattress is of service. Fortunately most cases occur in
children and the prognosis is good. Extension may be secured by drawing a
strong band of muslin transversely behind the lesion; and by making it
tight to a lateral framework, the body is elevated at the site of the disease
and extension secured.
Laminectomy is rarely of service, and it has the disadvantage of weaken-
ing the posterior part of a canal with an already weakened anterior* "part.
In cases in which everything else has been done to relieve paralysis, if the
paralysis steadily grows worse or persists after a year or eighteen months
despite extension, it may be assumed that there is some pressure within the
spinal canal which may be removable. Laminectomy, with or without
opening the dura, is done as for tumor (see page 339). Often some plastic
exudate or other product of the disease will be found within the canal. This
should be removed. The whole operation should be conducted with expedi-
tion, as these patients are very susceptible to shock and the mortality is high.
Operations upon the bodies of the vertebra are indicated when an abscess
at the disease requires to be opened, or when much bony debris or sequestra
are present. The opening of an abscess made near the disease gives an op-
portunity for the removal of dead bone. It is not advisable to attempt to
curet away all of the necrotic bone, but what is loose and accessible may be
removed. The bodies of the cervical vertebrae are reached through the
incisions described for retropharyngeal abscess (see page 205). The dorsal
vertebrae are reached by an incision lying back of the transverse processes;
the heads of the adjacent ribs and the transverse processes are removed
(see page 326). The lumbar bodies are reached by an incision from the
last rib to the ilium just back of the transverse processes at the border of
the quadratus lumborum. The dissection is carried to the psoas muscle,
some fibers of which should be detached from the transverse processes and
VOL. 11—22
338 SURGICAL TREATMENT
the sides of the bodies reached by blunt dissection. The transverse proc-
esses may be divided if necessary. If dead bone is removed the cavity
may be packed with iodoform gauze.
The duration of treatment of tuberculous spondylitis varies greatly. At best
the healing is slow. The first stage of the disease is the active and destruc-
tive stage, in which the vertebral body breaks down. It is then especially
that support, immobilization and extension are zealously to be maintained.
Treatment should be continued as long as tuberculosis is present. This
may be determined by test for tuberculin reaction. When pain and dis-
comfort have ceased, it should not be assumed that the disease is well.
Muscular spasm usually persists until the disease has nearly disappeared.
So long as pain or muscular spasm appear when passive motion is applied,
it may be assumed that treatment must be continued. When the active
stage has ended, consolidation and fixation take place, and the spinous
processes of the diseased vertebrae become more prominent.
Tuberculosis heals most quickly in the cervical region. Here at least
two years must be given to treatment. In the dorsal region at least four
years elapse before treatment can be discontinued. When pain, tenderness,
abscess and spasm are absent, the support may be removed. The removal
of support should always be regarded as tentative, and it should be reapplied
at once upon the reappearance of symptoms. It is best to go from the hori-
zontal frame to the jacket; from the jacket to a light corset or brace; from
braces to a light corset or lighter braces. When no more tuberculosis is
present, massage and electricity to the back muscles are of value in restoring
their strength. While the muscles are being developed braces or a corset
should be worn to hold the spine from becoming distorted. Kyphosis is
very apt to develop in the upper dorsal region. The deformity in the cervical
and lumbar regions may be slight or not present.
Operative Treatment of Tubercular Spondylitis. — Operations for complica-
tions have been described above. The operative treatment, applied as a
curative measure to the disease itself, consists in operations for immobilizing
the intervertebral joints. This was first done by implanting metallic bars on
either side of the spine. Later bone grafting, transplantation and operations
to cause ankylosis have supplanted all other operative measures. This
treatment has the merit of effectively fixing the spine, and giving better
immobilization than can be secured by any form of jacket, corset, or brace
(for Operative Treatment, see Vol. I, page 776).
Tumors of the Spine and Cord. — Tumors of the Vertebra. — As the great
majority of tumors of the spine are secondary and malignant, operation has
little to offer. Primary sarcomata of the vertebra have been removed.
Benign growths become serious only when they press upon the cord or
nerves or seriously weaken the vertebral column. Operations for secondary
malignant deposits may be regarded as useless. Such tumors should be
treated by conservative measures. Collapse of the spine may be prevented
or delayed by fixation as for tuberculosis. Operations for callus and
exostoses are promising.
Intraspinal tumors may be extradural, subdural or medullary. Histories
show that most of these tumors are located posteriorly or laterally rather
than anteriorly. Before operating, the question of help from antisyphilitic
treatment should have been settled. Even though syphilis is the cause of the
disease inflammatory tissue may remain and act as a tumor, and relief may
be secured only by its operative removal. As soon as diagnosis of a com-
pressing tumor is made, if the tumor is not yielding to antisyphilitic treat-
THE SPINE 339
ment and if it is not associated with incurable primary malignant disease,
operation for its removal should be attempted by laminectomy.
Laminectomy is done not only for tumor of the spinal canal but for the
exposure of the canal, for operations on the nerve roots, and for the removal
of foreign bodies and the products of inflammation. When there is much
uncertainty about the location of the disease, it is well to wait until the
anesthesia reaches a constant upper level. The operation is not difficult.
It is usually done under general anesthesia, but the operation is easily done
with 0.5 per cent, novocain solution. From 50 to 100 c.c. of this solution
are required.
The patient is placed on his side, rotated toward the prone position, and
held by sand pillows so as to elevate slightly the part to be operated upon.
The convenience of the operator is secured by having the patient on his left
FIG. 1037. — LAMINECTOMY.
Dorsal muscle and tips of spines exposed.
side. A long incision is made slightly to one side of the median line of the
back, following the spines of the vertebrae. The middle of the incision
should be opposite the disease, and at least three or five vertebrae should be
exposed (Fig. 1037). The muscles should be separated from the sides of the
spinous processes and ligaments by means of knife and elevator. At the
angle between the spines and laminae the periosteum should be divided and
reflected back with the muscles, until the laminae are exposed to their outer
limits. The exposure of the laminae is done first on the lower side and then
on the upper side of the median line and hemorrhage checked. Strong
right-angle retractors hold the muscles outward. To secure better exposure
the deep fascia may be divided transversely at the ends of the wound, and
the muscles may be separated from the backs of the articular processes.
340
SURGICAL TREATMENT
While working on one side of the spines the wound on the other side should
be kept packed with gauze.
The spinous processes are cut off with angular bone-cutting forceps
or the rongeur (Fig. 1038). For removing the laminae, the rongeur is most
satisfactory. Care should be taken not to injure the dura mater or make
undue pressure upon the cord. At no stage of the operation is the hemor-
rhage anything more than venous oozing, easily controlled by pressure. As
the laminae are cut away the surgeon should be on the lookout for the cause
of the pressure. During these steps of the operation, an extradural tumor,
inflammatory exudate, fragment of bone, blood clot or other cause of pressure
may be discovered and removed. After the laminae of three vertebrae
FIG. 1038. — LAMINECTOMY.
Spines have been cut away, muscle retracted and laminae exposed.
have been removed and no extradural pressure has been found, a probe may
be passed carefully between the dura and the bone, above and below, to
palpate for the cause.
If the dura does not pulsate, it may be judged that there is tumor,
exudate, or some other condition which closes the subdural space. A
subdural tumor cannot often be palpated through the dura. A tumor of the
substance of the cord or an intradural tumor is apt to obstruct the flow of
cerebrospinal fluid. If the dura is opened below the tumor the first flow
will be slow; if above the tumor, the first flow of fluid will be vigorous and
indicative of tension.
To open the dura it should be picked up with fine forceps and incised
longitudinally in the median line. The flow of cerebrospinal fluid will not
obstruct the view if that part of the spine has been elevated. This is best
accomplished by lowering the head of the table. The dura should be
THE SPINE
341
retracted carefully by fine retractors or silk sutures passed through its edges,
and a good view of the cord secured (Fig. 1039). The tumor may be found
covered by edematous arachnoid, which must be teased apart to expose it.
Tumors of the cord are often encapsulated and easily shelled out with a small
scoop or by blunt dissection. The incision of a slight thickness of cord
substance may be necessary. This should always be in the longitudinal
direction. Thin bands of tissue may require to be cut, and small vessels
ligated with finest catgut.
It may be found that a nerve root is so involved that it has to be divided or
resected. The simple division of a nerve root should be remedied by suture.
Cysts may be evacuated. The sponging should be most gentle. Blood
FIG. 1039. — LAMIXECTOMY AND EXPOSURE OF CORD.
Laminae of three vertebrae have been removed, the dura mater exposed and opened.
Retraction of dura is made with silk threads.
is best washed away by a stream of warm saline solution. In working about
a solid tumor, it may be best to remove it in pieces to prevent undue pressure
upon the cord.
In operating for localized medullary tumors, C. A. Elsberg and E. Beer
(Am. Jour. Med Sci., cxlii, No. 5, Nov. 1911), after laminectomy and free
incision of the dura mater, advised making a small incision not more than
0.5 or i cm. (%e or % inch) long, in the posterior median column a few
millimeters from the posterior median fissure, where the growth seems to
be nearest to the surface. The incision should pass down to the tumor.
The deepening of the incision is best made with a blunt instrument. When
the tumor is reached it will then bulge into the incision. Now the surgeon
should not make the mistake of attempting to remove the tumor; for he will
do serious injury to the cord. It must be left to nature. Nature will slowly
342
SURGICAL TREATMENT
extrude the tumor with the least amount of damage to the cord. The dura
should not be sewed. The muscles and skin should be sewed over the cord,
and the wound dressed. At the end of about a week the wound should be
opened and the tumor will usually be found lying outside of the cord. Its
removal requires only dividing a few adhesions. If any injury to the cord
is required in removing the tumor, if it is benign, it is best to defer its
removal. The pia should then be closed. The dura, muscles, and skin
should be sutured over all.
Intramedullary tumors which extend the height of several vertebrae
may be treated in this same manner, even though they infiltrate the cord
substance. A small incision, made at the place where pressure seems
greatest, or at the level of the most pronounced symptoms, may result
in extrusion sufficient to give relief. This method of treatment may also
FIG. 1040. — LAMINECTOMY.
Closing dura with continuous suture.
be applied to blood clot in the cord, spinal gliosis, and syringomyelia. A
central cavity may thus be drained into the subarachnoid space.
In incising the cord, the utmost gentleness should be used. The incision
should be made slowly with an exceeding fine knife. Sponging should be so
gentle that no pressure is made on the cord. The cord should not be grasped
with forceps or anything else. If it is necessary to lift it from its bed, the
dura or pia may be grasped. This treatment of intramedullary tumors,
which Elsberg has named "the method of extrusion," is the most im-
portant modern advancement in the treatment of these lesions (see C. A.
Elsberg- "Surgery of the Spinal Cord," W. B. Saunders Co., 1916).
For exposure for operation on a tumor the laminectomy should be
THE SPINE 343
complete. Not less than three lamellae and spinous processes should be
removed. The lamellae should be removed well out to the articular processes.
The anterior surface of the cord may be exposed by dividing a slip of the
dentate ligament, grasping the stump of the ligament with fine forceps and
rotating the cord. If still more exposure is desired, a posterior root must be
divided.
If the tumor cannot be removed division of the posterior nerve roots at
and above the level of the tumor may be done to give relief from pain.
Additional laminae may be removed to expose the growth. If symptoms
of tumor have been present and no tumor is found, laminae should be re-
moved to the highest limit corresponding to cord disturbance. This may
require the removal of laminae of four or five vertebrae above the original
wound. The disease is apt to be higher than suspected. If the operation
is done for kyphotic paralysis or old dislocation or fracture paraplegia,
enough of the laminae should be removed to free the cord from pressure.
The operation should be discontinued at any time when the patient shows
severe depression. Some surgeons as a rule prefer to do all operations for
tumor in two stages, closing the first wound with a few temporary sutures.
At the termination of the operation the dura should be sutured with
fine catgut (Fig. 1040). The muscles should be replaced and held with
sutures of chromic catgut, obliterating all cavities. The deep fascia should be
sewed separately. The skin is best closed with a subcuticular suture.
Postoperative care in laminectomy cases is important. If there is no dis-
ease which has softened the bodies of the vertebrae, support by jacket or
braces is not necessary. A water or air mattress is always of advantage
if paraplegia is present. It is not necessary for the patient to lie always on
the back, but he may be turned to one or the other side for relief. Even
though pressure was relieved by the operation, the subsequent traumatic
edema keeps up the pressure for some time. Improvement may not occur
for two weeks, or it may be immediate. The pain following the operation is
apt to be severe because of edema about the sensory roots. It should be
relieved by morphin. The length of time which the patient should be kept
in bed varies with the pathologic conditions present. At least three weeks
should elapse before the patient is allowed to sit up. So far as the strength
of the spine is concerned, it should be remembered that its support is not in
the posterior parts but in the bodies and articular processes.
The results of laminectomy for approach to the cord have steadily im-
proved. Deaths have been due to shock and meningitis. Loss of blood is
borne poorly by these patients and every drop possible should be conserved.
When much damage has been done the cord by long pressure the removal of
the compression has not been followed by the hoped for results. In cases,
especially of extradural tumor, in which operation has been done without
delay the results have been striking and gratifying. Improvement some-
times continues to go on after two years. Operations on medullary tumors
offered little hope of success until Elsberg's two-stage operation was intro-
duced. In tuberculous lesions the results are best after the infection has
subsided. Operations in the presence of the tubercle bacillus are not apt to
give as good results as the ordinary orthopedic treatment, and moreover
there is always danger of setting up tuberculous meningitis.
To secure the best results operation for pressure, if it is to be done, should
be done early. The results in chronic meningitis with effusion have been
good. I have given a patient permanent relief from pressure symptoms by
removing long strips of plastic lymph, of unknown origin, from the dura.
Often the decompression secured by laminectomy gives relief even though
344 SURGICAL TREATMENT
no tumor is removed. It is possible that in subpial tumors a two-stage
operation is best. Elsberg has reported a case in which, after incising the
cord over the tumor, he has temporarily closed the wound, and one week
later found a tumor, 5 cm. (2 inches) long, spontaneously extruded and lying
outside of the cord.
Spinal decompression is the operation described above. It consists in
laminectomy, to expose the cord, and incision of the dura mater. It is
indicated in the same conditions as decompression in the cranium. Because
there are intradural conditions which present symptoms similar to tumor,
this operation has a considerable field of usefulness. In obscure cases of
spinal disease, even though there is no increase of subdural pressure, decom-
pression often gives relief.
Osteoplastic laminectomy was advocated by F. J. Gaenslen (Jour. Am.
Med. Assoc., Oct. 6, 1917). It consists in splitting the spinous processes
in the median line as is done in the bone-grafting operations for spondylitis
fixation. One-half is fractured at its base and reflected laterally with its
periosteum unbroken. This is done with all the split spines on one side.
The other half is then fractured at their bases. The posterior periosteum of
the laminae is peeled up with that holding the fragment of spine. This
elevation of periosteum is carried out well upon the transverse processes.
The laminae are then removed, and the cord exposed. After the operation
on the cord the two halves of the spines are brought together with their at-
tached flaps of periosteum and soft tissue, and sewed in place. If desired a
graft of bone may be implanted in the median line between the fragments.
Operations on the Posterior Nerve Roots. — This field of surgery owes
its development to Munro, Abbe, Bennet, Foerster and Kuettner. The
sensory roots of the spinal nerves are easily exposed in the vertebral canal by
laminectomy (see page 339). Division of the posterior roots (rhizotomy) is
done for intractable neuralgia, spastic paralysis, spasticity, gastric crises of
tabes, and other conditions in which it is desired to cut off centripetal
impulses from the periphery.
Only lesions with true reflex spasticity, as the result of loss of cortical
inhibitory fibers, are suitable for rhizotomy. Such conditions as chorea,
athetosis, mobile spasms, and spasmodic torticollis are not usually amenable
to this operation; although some cases of athetoid and choreiform movements
have been entirely cured. Cases with but slight spasm and considerable
paralysis are not helped. Innervating fibers of the pyramidal tract must be
present. The operation is possibly worth while in cases with severe spasms
and total voluntary paralysis, in which there remains considerable voluntary
excitability which is only obscured by the spasms and only apparent after
they have been eliminated. It is not wise to do the operation until the
disease has become stationary. Progressive diseases, such as disseminated
sclerosis, are not benefited; although slowly progressing diseases, such as
spastic spinal paralysis, may be helped. In these spastic cases the operation
must be followed by years of faithful attention to exercises of the muscles.
Such limbs should be held in corrective splints, only to be removed for exer-
cises several times daily. Operations on tendons and muscles may also be
required. It is in cases of spasm, with lesions in the pyramidal tract, that
the operation has its largest field. The mortality following the operation
up to 1918 was between 15 and 30 per cent. The operation, therefore, is too
serious a procedure to be employed in any but the most desperate cases.
The operation is best done within the dural canal. If attempted outside
of the dura (Fig. 1041), motor fibers are apt to be cut, and this is undesirable
unless the motor fibers go to an amputated limb or athetoid movements are
THE SPINE
345
present, or some other condition exists which renders the motor fibers of little
importance. Division of the posterior root external to the ganglion is apt to be
followed by regeneration unless the ganglion is destroyed. Hemilaminec-
tomy is best done when dealing with the brachial roots. The lumbo-
sacral roots are best divided at the cord rather than at the dura.
Division between the ganglion and the cord can only be done within the
dural tube. This operation results in permanent degeneration of the fibers
from the point of section up the posterior columns of the cord. If but one
side requires operation, the laminectomy may be unilateral, leaving or re-
_,
FIG. 1041. — DIVISION* OF POSTERIOR XERVE ROOTS OUTSIDE OF THE DURAL CANAL.
The posterior and anterior roots are being separated by fine hooks. This is difficult and
less satisfactory than the operation within the dura.
moving the spinous processes as seems best. The local use of adrenalin
renders the field bloodless.
A careful study should determine what roots need to be attacked (see
page 322). It should be borne in mind that the division of a single root is
not sufficient to cause sensory paralysis of any area, as the nerves to a given
area emerge by several roots. A case is reported in which the division of the
upper five lumbar roots gave no appreciable loss of sensation.
Four or five laminae should be removed and the exposed dura opened
its whole length. The head should be lowered to prevent too free an escape
of cerebrospinal fluid. The roots may be identified by recognizing their place
346
SURGICAL TREATMENT
of exit through the dura. If it is desired to identify a motor root, it may be
done by weak faradic stimulation. But one root need be identified, the
others may be counted from that. The four of five roots to be cut may be
caught up on a blunt hook and divided at their point of entrance in the
dura and again close to the cord. This represents a resected segment of 7
to 13 mm. (^ to ^ inch) (Fig. 1042).
In operating for neuralgia, it is possible that the laminectomy may un-
cover the cause of the pain — a tumor or inflammatory deposit involving the
sensory roots — and a radical and curative operation may be done. The
FIG. 1042. — INTRADURAL DIVISION OF POSTERIOR NERVE ROOTS.
The dura has been incised and is held open with fine silk retractor threads. The posterior
root is picked up with a hook.
hazard of this neurectomy, in patients not depressed by serious disease, is
not great. If all of the roots supplying the painful area are divided, the
results are good. The resection of too few roots may give relief but not
cure. When the pain is in the arm, the third to the eighth cervical and
the first three dorsal roots must be divided. For pain in the leg, the tenth
to the twelfth dorsal, all the lumbar and all the sacral roots must be divided.
Only in localized pain in which the affected nerves may be identified may
fewer be cut.
The treatment of spastic paralysis by this method gives fairly gratifying
results in cases either of spinal or cerebral origin. The exaggerated reflexes
THE SPINE 347
are cut off and involuntary contractions cease, but voluntary contractions
are under control. Following the operation the patients must be trained to
use and control the muscles normally. Apparatus must often be used for
a while to prevent the continuation of unnatural movements. Better re-
sults have been secured in the legs than in the arms. Children which have
not been able to take a step are made to walk. Spasticity due to trauma to
the spine is benefited by this operation if motor power is not lost. Three
or four of the lumbosacral roots are divided for leg spasticity.
Cerebral diplegia, hemiplegia, compression myelitis, and even multiple
sclerosis may be benefited if the case displays spasmodic contractures.
Fair results have been had in cases of spastic contractures due to tubercu-
lous spondylitis and hydrocephalus. The operation should be reserved for
cases in which other treatment has failed. Often the disease has caused such
atrophy of the parts that cure of the spasticity has little to offer. After op-
eration daily massage, passive motion, and active motion of the parts should
faithfully be carried out.
A. Stoffel (Presse Med., March 23, 1912) did partial division of the nerve
roots supplying innervation to the affected muscles, leaving some fibers to
supply enough innervation to balance the antagonistic muscles.
Rhizotomy for tabetic gastric crises gives fairly uniform and satisfactory
results. The operation should be done only in the severe cases, such as re-
quire morphin and suffer with inanition. The operation aims to resect
the sensory gastro-intestinal fibers of the sympathetic nerve. This may re-
quire resection of the posterior roots of the twelfth up to the fifth dorsal
nerves, or higher. Failures follow division of too few roots. By studying
the location of the pains and the hyperesthetic areas in the skin, the exact
nerves that require resection may be mapped out. Thus a case is reported
in which the crises recurred after resection of the seventh to the ninth roots,
but ceased entirely after the tenth and eleventh roots had been resected.
In some cases it will be necessary to continue the resections down to include
the first lumbar roots. The operation, of course, is of no value if the crises
are due to vagus irritation or to direct irritation of the vomiting center in the
medulla.
Franke advocated and practised avulsion of the intercostal nerves outside
of the spine instead of the intraspinal operation. Each nerve is exposed,
lifted up on a hook and pulled away from its spinal attachment. By doing
this on both sides from the fifth or sixth to the ninth or tenth dorsal nerves
inclusive, long-standing relief has been secured in many cases. The object
of the operation is to tear away the ganglion with the root, thus destroying
the communicating branches which are the origin of the splanchnic nerves.
If it fails to do this it fails to cure. It is a rather uncertain procedure. It
may be expected to cure about half of the cases operated on. The mortality
is lower than in the intraspinous operations. It should be borne in mind
that only the pains which have to do with the splanchnic nerves are
amenable to operation.
Ligation or division of the roots between the ganglion and the dura
mater blocks the reflex and causes degeneration of the sensory fibers. A
laminectomy is required for this operation. The anterior motor root may be
included in the ligature or incision. This need not be so serious as it might
seem, because the slight paresis of the abdominal muscles which results may
be treated by wearing a belt.
The vagus being responsible for the crises in a certain proportion of cases,
division of the posterior roots should be done only in the cases in which there
is a zone of hyperesthesia in the gastric region and the epigastric reflexes
348 SURGICAL TREATMENT
are increased. When careful diagnosis is thus made, relief of the symptoms
may be expected in half of the cases operated upon.
The treatment of paralysis agitans by division of the posterior roots has
given some encouragement. Sensory stimuli which keep the muscles in a
constant state of agitation are shut off by this operation. The operation may
be done by the extradural technic. The nerves to be divided must be de-
termined by the area which seems most affected. There may be value in
partial division of the roots and in dividing alternate roots instead of each
successive one.
The excision of the spinal ganglia was done by Sicard and Desmarest
(Presse Med., Nov. 6, 1912, vol. xx) for the relief of gastric crises. Laminec-
tomy is done but the dura is not opened. The operation is applicable
only in the dorsal region. The root in its sheath is ligated close to the cord,
and grasped with forceps further outward. It is then cut close to the liga-
ture, and torn loose peripherally by twisting it upon the forceps. The
nerve tears beyond the ganglion. The stump, containing the ganglion is
thus brought away.
Recapitulation. — Division of posterior spinal nerve roots should be done
in severe cases only, as the mortality is high, and success is usually secured
only by doing an extensive operation.
For pain, the operation gives permanent relief only when a large number
of roots are divided because of the overlapping of the sensory nerve supply.
For gastric crises (visceral crises of tabes), relief may be expected in most
cases.
For spasticity and spastic paralysis, due to disease of the corticospinal
path, especially the pyramidal tract, the mortality is lower. C. A. Elsberg
had no deaths in a series of twelve cases. At least five roots must be
resected.
The second, third or fourth lumbar root should not be divided as it is
necessary for the extension of the knee. The nerve which controls this
function should be determined by the electric current.
The general rule is to resect for the leg from the second lumbar to the
second sacral, inclusive, excepting the fourth lumbar. For the arm, it is
necessary either to resect from the fourth cervical to the second dorsal, in-
clusive, excepting the sixth cervical ; or to resect the larger part of the nerve
bundles of all of these roots, including the sixth cervical.
Anastomosis of the anterior nerve roots within the spinal canal may be
done to supply innervation to paralyzed muscles in cases in which the pa-
ralysis is due to a spinal lesion and a functionating nerve root may be found
which is accessible. In a case of paralysis of the bladder due to injury to
the cord, C. H. Frazer (Surg., Gyn. and Obst., xvi, 1913) removed the laminae
of the twelfth dorsal and the first and second lumbar vertebrae, divided the
first lumbar anterior root at its point of exit from the cord, divided the third
and fourth sacral roots, and did an end-to-end anastomosis with fine silk
between the lumbar and the two sacral roots. The sacral roots to be used
were identified by the electric current. The nerves functionated and the
patient regained urinary continence.
Tapping the Arachnoid Space (Lumbar Puncture). — For the technic of
the operation, see Spinal Anesthesia, Vol. I, page 155.
This operation is done for purposes of introducing medication into the
subarachnoid space, for withdrawing fluid for therapeutic and diagnostic
purposes, and for cleansing.
Subarachnoid puncture is useful in cerebrospinal meningitis. The
cerebrospinal fluid, if rich in pus may be drawn off to advantage and replaced
THE SPINE 349
with salt solution or antimeningococcus serum. As much as 60 c.c. of the
purulent fluid have been withdrawn by lumbar puncture. This procedure
is more fully discussed under meningitis. In tumors of the brain, lumbar
puncture is so dangerous that it should rarely be undertaken.
Spina Bifida. — The prognosis is very unfavorable. Most cases die,
with or without treatment. The tendency of the tumor is to increase in
size. Ulceration and perforation of the thin wall is common. If the child
survives the first few weeks, paralyses are apt to prove intractable. The
cases which survive five years are usually meningoceles. Myelomeningoceles
are usually fatal. Even though a closure of the cleft is accomplished by
operation, death may result from increase of cerebrospinal pressure or
paralyses. Hydrocephalus, complicating the disease, is the more important
of the two; if it is not remedied, it is not worth while attempting operation
for the spina bifida.
Meningoceles are most hopeful for operation, but both myelomeningo-
celes and myelocystoceles may be helped by operation if not cured. With-
out such treatment the prognosis is positively bad. When ulceration of the
skin is present it should be cured if possible before the sac is incised; if it is
not cured it may be sterilized by phenol or tincture of iodin.
For operation, the patient should lie on the side on a table which permits
quick lowering of the head. Any ulcerated area should first be excised
before opening the sac. An incision should be made about the base of the
tumor, planned to remove an ellipse of skin of such a size as to permit easy
coaptation of the wound edges. The skin should be dissected free outward
from the sac. The sac should then be dissected free down to its pedicle.
In large myelocystoceles a considerable portion of the sac can be removed
without harm. In meningoceles, after dissecting free the sac, it should be
opened by a longitudinal incision placed so as to avoid the nerves as much as
possible. Usually this incision will be on the side. This gives a view of the
interior of the sac.
Any nerves running in the sac wall should be dissected out or that part
of the sac should be isolated and replaced in the vertebral canal. Nerves
which are not trunks but which seem to end in the sac need not be preserved.
If there is any question as to their importance, their distribution may be
tested by a mild faradic current. Rather than take time to dissect out
nerve trunks, it is best simply to save that part of the sac. The sac wall
should be cut laterally in such a way as to give enough tissue to close the
canal. This closure should be made snugly and smoothly, apposing the inner
surfaces. It is desirable that there should be no leakage of fluid. A running
suture of chromicized catgut is best.
Myelocystoceles may be opened in the middle line or where the wall is
thinnest. Care should be taken that the cauda equina shall not be damaged.
In opening the sac, the cerebrospinal fluid should not be permitted to
escape too fast. At this stage of the operation it is well to lower the head
of the table, and to obstruct the flow by a sponge or by pressure at the neck
of the sac.
It is probably not worth while to attempt closing the bony defect by
osteoplastic methods. Recurrence will take place if there is obstruction or
other disease which causes hydrocephalus. If hydrocephalus is present
closure of the spina bifida will probably make it worse. The skin having
been dissected free laterally, the superficial layer of the deep fascia is exposed,
and by lateral incisions liberated so that it may be sewed across the middle
line to support the closed sac. In this part of the operation it is often
possible to liberate a bundle of muscle on either side and place it also over
350 SURGICAL TREATMENT
the spinal opening. It is best to plan the skin incision so that when the skin
is sutured the line of closure lies to one or the other side of the suture of
the fascia. A subcuticular suture is best for the skin, and a collodion cov-
ering to prevent soiling.
The operation is apt to be attended with serious depression. It should
be done with despatch and every effort made to save blood and prevent
shock and rapid loss of cerebrospinal fluid. Infection occurs easily. Hydro-
cephalus, even though not observed before operation, may develop appar-
ently as a result of slow infection. The mortality following operation is about
50 per cent., and is due to shock, meningitis, hydrocephalus, and paresis.
Paralysis of the lower extremities, rectum or bladder are not apt to be cured
by operation. The operation entails certain risks, and offers the removal
of an unsightly and uncomfortable tumor and obviates the danger of its
spontaneous rupture and infection. Its advantages outweigh its disadvan-
tages. Paralysis is an indication for operation. Hydrocephalus cannot be
regarded as a contraindication. If the tumor is not growing larger and
is causing no serious symptoms, operation may be deferred until the child
has reached the sixth or twelfth month of age.
In cases in which the meningocele has been controlled and the patient
is left with defect of the posterior wall of the spinal canal, which causes
weakness and lordosis, the spine may be strengthened by inserting a long
bone graft on either side according to the method used by Albee in spinous
process fixation.
Spondylolisthesis. — If the disease is recent and due to traumatism, a
jacket, corset or brace is indicated to prevent the forward curvature. In
congenital cases, massage, vibratory massage, and position to prevent the
deformity are indicated, and may be expected to control the disease.
Rachitic Spine. — The constitutional treatment is most important (see
Rickets, page 321). The correction of deformity is accomplished by the
same measures as are applied to spondylitis. For kyphosis the child should
be placed in a position of extension of the spine and put in a jacket or brace.
The support should be removed once or twice daily and massage applied.
Active motions to strengthen the erector spinae muscles should be practised.
Hyperextension should be applied at the same time. In pronounced cases
treatment on the horizontal frame is indicated.
Lumbago (Lumbosacral Pain, Painful Back). — The scientific treatment
of this condition aims to discover and remove the cause of the pain; but often
after everything in this direction has been done, the symptoms persist.
Then if motion causes pain, rest should be secured by confinement in bed,
or by a brace or corset of plaster-of-Paris, fixing the pelvis and lumbothoracic
spine. Some patients obtain comfort by the tight envelopment of the pelvis
in a broad strip of adhesive plaster. Counterirritation is of much help in
some cases.
The search for the cause should never be abandoned. There is a wide
range of difference between the treatment of aneurism of the aorta and
fatigue in a neurasthenic, both of which give rise to lumbago. Fracture
of the transverse process of a vertebra, curvature of the spine, and disease
in the psoas muscle should be corrected. Examinations during intervals
of freedom from pain should be made to find the tender point. Even when
disease of the vertebra cannot be found, an immobilizing jacket often gives
relief. When the cause is not known, hot applications (either moist or dry)
offer the best chance of relief. Massage and vibratory treatment are also
effective.
THE SPINE
351
At the old Chambers Street Hospital in New York, we treated these cases with the
actual cautery. The metal, heated to a cherry red, was rapidly waved back and forth over
the affected area, as children play with a fire stick to make the appearance of streaks of
fire in the air. The hot point in its rapid movements was brought nearer and nearer to
the skin, occasionally touching it, as indicated by the patient's jumps, the faint cloud of
smoke, the odor, and the series of long, slightly curved red stripes, which told the story of
treatment well administered. Our percentage of cures seemed to be very high, because
the patients were told to come back for another treatment if there was any return of the
lumbago, and I do not recollect that any ever returned.
Kyphosis. — Non-tuberculous kyphosis, usually habitual and called
"round shoulders," requires correction of the cause such as weak feet, and
then treatment by forcible extension of the flexed portion of the spine.
FIG. 1043. — EXERCISES FOR THE
CORRECTION OF CURVATURE OF THE
SPINE.
FIG. 1044. — EXTENSION EXERCISES
FOR KYPHOSIS.
This is best done over the edge of a table. Forcible correction under anes-
thesia is required in advanced cases. Massage to strengthen the erector
spinae muscles is of help. Exercises to stretch the contracted ligaments are
of service (Figs. 1043 and 1044). Heavy clothing should not be hung from
the shoulders. The erect position in standing should be encouraged. By
having the patient to lie prone when reading, extension of the spine is secured.
A light brace may be used at times during the day, but never constantly.
Such exercises as are employed in the treatment of scoliosis are of service
(see below).
352
SURGICAL TREATMENT
Lordosis. — The treatment of this symptom should be directed to the
cause. When this has been done some relief may be secured by a jacket
or brace, applied in the position which is secured by having the patient lie
on the back with the thighs flexed.
FIG. 1045. — SCHOOL DESK WHICH is ADJUSTABLE TO STANDING AND SITTING POSTURES.
Scoliosis (Lateral Curvature of the Spine). — Prophylaxis has much to
offer. The causes should be avoided and corrected. Among these are to be
noted: (i) deformities in other parts, such as shortening of one leg; (2)
unequal paralyses of muscles of the back; (3) distorting thoracic disease,
FIG. 1046. — EXERCISES FOR STRENGTHENING MUSCLES OF THE BACK.
such as empyema; (4) distorting disease of the spine, such as spondylitis or
fracture; (5) bad habitual posture; and (6) rickets. Posture in the young
is most important. Correct school desks and seats should be insisted upon
(Fig. 1045). Improvement of the general health and the local tone of the
THE SPINE
353
muscles of the back are essential, and best accomplished by work in the open
air which requires the use of all the muscles of the back up to the point of
fatigue. If this cannot be done then gymnastic exercises may be used
(see Teschner: Annals of Surgery, Vol. XXII, page 230).
Heavy dumb bells are of service. Muscle-building exercises are used,
especially applied to the back muscles. The patient is held prone with the
body above the groins projecting over a table and caused to extend the spine
as many times as possible (Fig. 1046). He is caused to stand and bend
downward and upward (Fig. 1047), and to flex the spine laterally as far as
possible (Fig. 1048). A tendency to recur between treatments should be
overcome by a corset, applied with the patient suspended (see Spondylitis,
page 332) and with lateral bandages so applied as to make pulling pressure
FIG. 1047. FIG. 1048. FIG. 1049.
FIG. 1047. — EXERCISES FOR STRENGTHENING EXTENSOR MUSCLES OF BACK.
FIG. 1048.— LATERAL BENDING EXERCISES TO STRENGTHEN MUSCLES OF THE SPINE.
FIG. 1049. — PLASTER-OF-PARIS JACKET FOR TREATMENT OF CURVATURE OF SPINE.
The jacket may be reinforced by a steel brace. The window is cut on the concave side.
upon the convexities. The corset should be removed for treatment daily,
and reapplied with the patient suspended. It should be worn only at such
times as the patient is in repose and apt to relapse into scoliotic positions
(Fig. 1049).
Self-suspension, in the suspension apparatus used for applying spinal
supports, aids in straightening the spine. The inclined plain seat, raising the
side ,of the pelvis so as to overcorrect the curvature is of service and may be
used in all of the patients' sitting places (Fig. 1050). The same correction
may be secured in the standing position by a lift of 1.3 to 4 cm. (^ to i^
inch) under the shoe. The correcting corset may be worn at night; or in its
place the patient may lie recumbent in a plaster-of-Paris bed-trough.
The treatment of functional or postural scoliosis requires especial attention
to the general hygiene of the child. The weight of the clothing should be
taken from the shoulders. Clothes should be suspended from the waist.
VOL. 11—23
354
SURGICAL TREATMENT
Errors in vision should be corrected. The corrective gymnastic exercises
are most important.
Treating organic or structural scoliosis is a more difficult matter. It
should be borne in mind that while there are changes in the bone contour
bone may be made to change its form also in the direction of correction. The
spine should be forced into normal position and held there while nature
makes the changes in the structure of the bone. Gymnastic exercises have
little to offer in pronounced cases any more than they would have in a case of
club-foot or knock- knee. Gymnastics may be used alone in slight curvatures
to restore flexibility and strengthen the muscles on the convex side. A
support should be used to hold what is gained. In these cases jackets are
necessary.
FIG. 1050. — LATERAL INCLINED SEAT FOR SCOLIOSIS.
The dotted line shows the curvature which is present when the pelvis is level. The over-
correction is secured by tilting the pelvis.
The method of treating scoliosis devised by E. G. Abbott (Monde Medical,
February, 1915) has given better results than have been secured by most
other methods. The principles laid down by Abbott are that overcorrection
must first be made, and that lateral correction is best secured in the flexed
condition of the spine rather than in the extended condition. For this
purpose the patient is placed in a hammock with the vertebral joints all
flexed, while lateral correction is made (Fig. 1051). A plaster jacket is
then applied as the child is held in the overcorrected position. This jacket
has a large decompression window on the back and side (Fig. 1052). This
window is over that part of the chest which it is desired should be moved
toward the opening. Two anterior loop-holes are made and one posterior
loop-hole (Figs. 1053 and 1054). The jacket grasps the pelvis firmly.
Through the anterior loop-hole strips of felt padding are introduced to
overcorrect the deformity. The great opening permits the displacement
THE SPINE
355
necessary (Figs. 1055, 1056 and 1057). This correction may go on gradually
as the state of the patient permits. The patient is allowed to be about.
The removal of the jacket at the end of two months may be followed by
the application of another if the desired overcorrection is not found. When
satisfactory overcorrection is secured a removable celluloid or other thin
jacket is applied, to hold what has been gained, and gymnastic exercises
inaugurated (Figs. 1058 and 1059).
Hysterical Spine (Neurotic Spine). — The treatment of this condition
rests upon accurate diagnosis, the removal of causes, and the treatment of
the neurosis (see Traumatic Psychoses, page 102).
n
FIG. 1051. — HAMMOCK FOR FLEXION OF SPINE AND LATERAL CORRECTION.
Diseases of the Sacro-iliac Joint. — Tuberculosis requires rest and pro-
tection. This can be secured best by recumbency. The only splint
that is effective must fix the thorax and pelvis and cause the weight of the
body to be transmitted to the axillae while standing, walking or sitting.
Because of the difficulty of immobilization, perhaps, the best treatment of
this condition is exposure of the joint, resection or erasion, and local treat-
ment with iodoform or other antitubercular agent and artificial hyperemia.
356
SURGICAL TREATMENT
FIG. 1052. — CORSET WITH DECOMPRESSION WINDOW OVER RIBS WHICH WERE FORMERLY
DEPRESSED.
FIG. 1053. — DECOMPRESSION CORSET.
Showing anterior openings.
THE SPINE
357
Sprains or relaxation of the ligaments occurring as a result of injury, long
confinement in bed, childbirth, or obliteration of the natural lumbar lordosis,
should be treated by correction of position in a plaster jacket, by avoidance
of the positions or movements which give pain, by rest in bed if due to violent
FIG. 1054. — DECOMPRESSION CORSET.
Side view.
traumatism, and by massage and artificial hyperemia if due to constitutional
weakness. A broad snug band of adhesive plaster about the pelvis gives
relief in some cases.
FIG. 1055. — SECTION SHOWING OPENINGS IN DECOMPRESSION CORSET.
Coccygodynia (Coccygeal Neuralgia). — In a few cases a constitutional
or local cause may be discovered and removed. Tumor, constipation,
sacrococcygeal joint disease, or nerve disease may be reached. Often there
is a displacement of the coccyx and undue mobility. Relief may often be
358
SURGICAL TREATMENT
secured by vibratory massage. The most effective treatment is massage
by means of the index-finger in the vagina or rectum and the thumb on the
outside, holding the coccyx and the sacrococcygeal joint between them.
The bone should be moved up and down and the soft parts should be moved
on the bone and joint. At first the manipulations should be very gentle;
the force may be increased as the pain becomes less. A few treatments
every other day will cure most cases.
FIG. 1056. — SECTION SHOWING MODERATE COMPRESSION IN DECOMPRESSION CORSET.
The pressure is made with pads of felt.
There are a certain number of cases which yield to injections of alcohol.
The patient, with the rectum empty, lies in the lateral pelvic position with
the thighs flexed on the abdomen. A syringe containing i c.c. (15 minims)
of 70 or 80 per cent, alcohol and having a 5-cm. (2-inch) needle is used. The
index-finger is inserted in the rectum and the place of greatest tenderness is
FIG. 1057. — SECTION SHOWING FULL CORRECTION IN DECOMPRESSION CORSET.
discovered by pressure between the thumb and index-finger. The needle
is inserted in the skin in the median line and the point passed to the painful
point, and the contents of the syringe injected. This operation should be
repeated every week. From two to six such injections are used. Each
injection should be made in the most tender spot.
Removal of the coccyx should be done if the above methods fail. This
THE SPINE
359
is done with the patient on the side with the thighs strongly flexed or on the
back with the pelvis elevated and the thighs flexed. An incision is made in
the middle line from above the last sacral vertebra to the tip of the coccyx.
The soft tissues are divided down to the bone and strongly retracted laterally.
The lateral muscular attachments are divided close to the bone. The
FIG. 1058. FIG. 1059.
FIG. 1058. — SCOLIOSIS IN GIRL OF SEVENTEEN.
Scoliosis of four and a half years' duration, before treatment by forcible correction and
continuous overcorrection with corset.
FIG. 1059. — SCOLIOSIS IN SAME GIRL AFTER FOUR MONTHS' TREATMENT.
connections to the sacrum are cut, bearing in mind the two cornua. The
bone is then grasped with forceps, and with curved scissors its superior and
terminal connections are separated. The wound is closed by deep sutures
to obliterate the cavity, and the skin is closed with a subcuticular suture.
Prompt and permanent relief is secured by the operation.
THE NECK
General Injuries. — Cut-throat, with wound of the air passages, when no
large vessels are cut, is serious because of the danger of cellular infections
and of pneumonia. The insufflation of blood may cause dyspnea. For
these reasons prompt closure of the wounds is imperative. The wound
should receive the treatment already, described for wounds (Vol. I, page 186).
Each divided structure should be identified and separately sutured. Any
penetrating wound of the trachea, larynx, or esophagus, should be sutured in-
dependently, best with fine chromicized catgut. These structures should be
snugly closed so that leakage may not occur either from within or from without
(see Wounds of Larynx and Trachea, page 219). Wounds of the esophagus
should be closed with two layers of suture, and the overlying connective
tissue should be sutured so as to obliterate cavities. A small drain may be
placed in the most dependent part of the wound. If the wound of the esoph-
agus is a punctured wound or bullet wound, the danger of infection of the
deep cellular structures of the neck is so great that it is usually best to
enlarge the opening down to the esophagus, suture the esophageal opening
and place a drain down to the esophagus.
Cut-throat, with wound of blood-vessels, is serious even though the vessels
are not large. Aside from the dangers of infection, even small vessels, such
as the lingual, thyroids, or facial, may lose an amount of blood which is
fatal. They should be ligated at once on either side of the wound. Wounds
of the carotid artery or internal jugular vein are fatal unless the bleeding is
checked within a few seconds. In the case of these large vessels life may be
saved by prompt occlusion of the vessel. Pressure should be made at the
anterior edge of the sternomastoid muscle and applied backward so as to
press the vessels against the transverse processes of the cervical vertebrae
and their muscles. Occlusion of both distal and proximal sides of the vessel
wound should be secured. If external pressure is not promptly effective,
the thumb or two fingers should be introduced into the wound and pressed
directly against the bleeding place. The hemorrhage being controlled, the
pressure should be continued while the parts are cleansed and the vessel
exposed, if necessary, by incisions above and below the bleeding point
(see Ligation of Carotid, Vol. I, page 406). Or pressure may be made above
and below the wound and the vessel dealt with directly in the wound.
After exposing the vessel on either side of the wound, it may be ligated
in two places or sutured (see Wounds of Vessels, Vol. I, page 334).
In these wounds the surgeon should beware of a sense of security arising from a cessa-
tion of bleeding from pressure alone. A clot may temporarily occlude the wound, but
infection and an increase of blood-pressure are apt to produce secondary hemorrhage.
The ligature or suture of vessel wounds and drainage of the infected overlying tissues are
the essentials. Large cut-throat wounds may be closed, leaving ample provision for
drainage. Each divided structure which can be identified should be separately sutured.
The mistake should not be made to thrust clamps into the depths of the wound and blindly
grasp for bleeding vessels.
Wounds of Nerves of the Neck. — These injuries may require treatment
in cut-throat, bullet or other wounds and in operations. The presence of
the wound may become known only through the resulting paralysis. The
360
THE NECK 361
important nerves which may require attention are the pneumogastric,
hypoglossal, phrenic, spinal accessory, recurrent laryngeal, and the brachial
plexus. Division of these nerves should be treated by free exposure of the
nerve and suture (see Suture of Nerves, Vol. I, page 852). None of these
are so important that their suturing need be regarded as a matter of emer-
gency, but as soon as the patient's condition will warrant, the nerve should
be sutured.
Wounds and Diseases of the Thoracic Duct. — It should be borne in mind
that, while usually the duct empties in the left subclavian vein, it may
empty on the right side or on both sides. A mouth on either side may ac-
count for some of the successes secured after injury or destruction on one
side. When the duct is opened in the neck the outflow of chyle is so great
as to seriously interfere with nutrition, and it must be checked. The method
most in favor consists in packing the wound tightly to occlude the outflow.
In the cases which have been cured by this method, it is not known whether
the chyle found its way into the proximal segment of the wounded duct
or whether the duct became wholly occluded; perhaps the latter is the case,
and accessory mouths emptied the chyle into other vessels.
Compression by packing should be given the first trial. If the patient
is losing a serious amount of chyle, despite packing, and there is deficient
nutrition, great thirst, weak heart, emaciation, or syncope, ligation of the
duct should be done to stop the waste. When this is done it is hoped that
there is another outlet into another vein; commonly there is. This is so
often the case that some surgeons regard immediate ligation as the operation
of choice. The ideal operation, of course, would be suture of the wounded
duct or implantation of the duct into a vein. These operations have been
attempted, but it is doubtful whether they have succeeded in their aim.
In dealing with rupture of the thoracic duct in the thorax or abdomen, aspira-
tion is called for to remove the chyle from the pleural or abdominal cavities.
Such cases have recovered after repeated aspirations. When the chyle does
not pass through the pleura or peritoneum, but dissects its way in the con-
nective tissue, it does not require treatment unless its pressure causes serious
disturbance. If it bursts through the skin in the neck, groin or elsewhere
the sinus should be kept well protected against infection.
In septic infection of the receptaculum chyli, a transperitoneal exposure
of the viscus may be made, gauze packing introduced to provoke protective
adhesions, and after two days the infected viscus opened and drained.
Emphysema of the Neck. — The treatment of this condition is not dif-
ferent from that of emphysema elsewhere. The causative lesion should be
remedied. The surgeon should be ready to perform tracheotomy or intuba-
tion for swelling of the glottis. The swelling tends naturally to subside.
Infective Processes in the Neck. — Cellulilis and abscess of the neck should
not be put off with palliative or tentative treatment. Free incision into the
infected area is the one and imperative thing to be done. This is urgent
because of the dangers of deep phlegmon of the neck. An indurated area
in the neck should be exposed by incision if it is associated with symptoms
of infection. The surgeon should not wait for swelling or redness of the
skin as may be done in other parts of the body. The incision should not be
made blindly but should be a dissection down to the center of the infection.
It may be made in front of the sternomastoid muscle, behind it, or through it,
preferably in the lines described for operations upon the neck (see Anatomy
of Neck, Vol. I, page 404; Operations on the Neck, below).
Having reached the infected area, the dissection should be continued
downward to secure drainage of its lowest limit. This is important, even
362
SURGICAL TREATMENT
though the operation be carried to the sternum or clavicle. Pus may not
be discovered, but the operation is more timely and effective if it is not.
A continuous skin incision need not be made, the lower opening may be
independent. There is always danger that the surgeon may stop short on one
side of a plane of fascia when infection lies on the other side. Unless the
nfection is reached, uncovered and drained a fatal invasion of the thorax may
result. The dissection should be largely a blunt dissection, done with round-
pointed scissors, artery forceps, or the handle of the scalpel. Gauze, wick
or rubber- tube drainage should lead from the infected regions (Fig. 1060).
In superficial cellulitis the operation should be done because of the danger of
deeper extension.
In Ludwig's angina (sublingual phlegmon) the operation is necessary
to save life. The incision should be just below the border of the jaw. It
should expose the submaxillary salivary gland, and extend through the
mylohyoid muscle.
FIG. 1060. — INCISIONS AND DRAINAGE FOR DEEP CELLULITIS AND ABSCESS OF NECK.
In ligneous induration (woody phlegmon) incision seems to have little
effect in shortening the course of the disease ; nevertheless it is the rational
procedure. The disease, being due to impairment of resistance to infection,
is naturally chronic, and should not be confused with neoplasm. The
tendency is toward recovery. After the mass has been incised freely to its
depths, and drainage provided, wet, hot applications are most useful. Exci-
sion of the infiltrated tissues may be practised in some regions. Autogenous
vaccines may be employed.
In these infections of the neck, the surgeon should be ready always to do
a tracheotomy or intubation. This same condition of woody phlegmon may
occur in other parts of the body and require the same treatment as here
described.
THE NECK
363
Diseases of the Lymphatics of the Neck. — These diseases are usually
secondary to lesions in other structures.
Anatomy of the lymphatics oj the neck should be had well in mind, as they lie in intimate
relation with the important structures. The retropharyngeal glands lie between the phar-
ynx and vertebrae, and drain the nasopharynx and middle ear. The occipital glands receive
lymph from the posterior part of the scalp. The retro- auricular glands drain the outer ear
and auricular region of the scalp. The parotid glands lie in the substance of the parotid
salivary gland and adjacent to it, and drain the ear and temporal region. The subpar-
otid glands lie between the parotid and the pharynx, and drain the lateral pharynx and
posterior nasal region. The submaxillary glands lie in a chain below the lower border of
the lower jaw, and drain the cheek, lips, nose, gums, and sides of the tongue. One of
these glands is closely adherent to the submaxillary salivary gland. The submental glands
are just below the symphysis of the lower jaw, and drain the tip of the tongue, middle of
FIG. 1061. — LYMPHATICS OF THE NECK. UPPER CHAIN.
the lower lip, gum and chin. The above-described groups of glands represent a hori-
zontal chain or collar encircling the upper part of the neck. From this collar lymph- vessels
pass downward to empty into a descending chain which follows the internal jugular
vein, and empties into the thoracic duct near its termination.
The internal jugular glands (descending or substernomastoid glands) not only drain the
upper group or collar, but also receives special tributaries from the same regions as are
drained by the upper group. Independent glands are also scattered about the neck in the
posterior triangle. The supraclavicular glands are located in the angle bounded by the
clavicle, sternomastoid and trapezius, and receive tributaries from the scalp, neck, shoulder,
upper arm, axilla, breast, and the interior of the thorax (Figs. 1061 and 1062).
Carcinoma of the Lymphatics of the Neck. — Operation for this condition
is called for in carcinoma of the tongue, lip, cheek, jaw and other regions of
the head. In carcinoma of the tongue and lip it should be done as a routine
(see Treatment of these Diseases and Regions). The operation performed as
adjunct to that for carcinoma of the tongue will be described. In cases
364
SURGICAL TREATMENT
with palpable carcinomatous glands of the neck, it is best to operate on the
neck first, and the tongue a few days later. If the condition of the patient
seems good the tongue operation may follow at once. The radical operation
should be done.
The patient is placed on his back with a sand pillow behind the shoulders
and the face rotated away from the diseased side. A curved incision is
carried from the middle line below the chin along below the lower jaw back
to the tip of the mastoid process, thence the incision curves downward
along the anterior border of the sternomastoid muscle, and backward along
the upper border of the clavicle as far as the middle third of the bone (Fig.
FIG. 1062. — LYMPHATICS OF THE NECK. DEEP CHAIN.
1063). The anterior flap is dissected up, care being taken that it consist
only of skin in the submental and submaxillary regions and along the upper
part of the external jugular vein. The thin flap is important because in
these regions are glands which lie close to the skin. The digastric triangle
is then clearly dissected out, all of the fat and loose connective tissue being
removed. A gland is often found between the outer edge of the mylohyoid
and hyoglossus muscles. The deep fascia covering the submaxillary gland
is then opened and the gland retracted forward. The facial artery is tied
and cut. The dissection of the digastric triangle is then completed, the
dissection being carried up over the lower border of the jaw and some
of the facial fat removed. The back part of the digastric triangle, posterior
THE NECK
365
to the stylomaxillary ligament, is cleaned out. The lower portion of the
parotid gland, which often encloses glands, is removed, also the subparotid
glands. The anterior triangle of the neck is then dissected out from before
backward. This means a systematic removal of the loose fatty and con-
nective tissue, enclosing the lymphatics, lying on the muscles and fasciae.
When the anterior border of the sternomastoid is reached, the posterior
flap is dissected free. The sternomastoid is divided at the level of the omo-
hyoid and the lower portion is turned down. The clearing out of the anterior
and posterior triangles from below upward is proceeded with. The fascia
covering the great vessels is dissected up in this operation, and the dissection
is continued upward beneath the parotid gland. The dissected-up contents
of the triangle are kept together with the upper part of the sternomastoid
muscle, and the whole mass is cut off together with the muscle at its insertion.
This mass of tissue contains the chain of internal jugular glands. To make
FIG. 1063. — THE Z-!NCISION FOR EXPOSING THE LYMPHATICS OF THE NECK
sure of the removal of this most important chain of glands, the internal
jugular vein must be removed.
A less wide exposure is secured by carrying an incision from the mastoid
process to the sternoclavicular joint along the anterior border of the sterno-
mastoid muscle, and a second incision from the bottom of the symphysis of the
lower jaw downward and backward to meet the first incision at the level of
the upper border of the thyroid cartilage (Fig. 1064). The sternomastoid
muscle is cleaned off and retracted backward. The anterior triangle is dis-
sected out from below upward, followed by dissection of the digastric and sub-
mental regions.
In'operating for cancer of the tongue the anesthetic is best administered
through two tubes passed to the pharynx through the nostrils, the back of
the mouth being packed with gauze. Blood may be saved by temporarily
clamping the carotid low down and high up with soft arterial clamps. The
structures of the neck are best removed in one mass. The common carotid
366
SURGICAL TREATMENT
FIG. 1064. — SINGLE INCISION FOR EXPOSURE OF LYMPHATICS OF THE NECK.
FIG. 1065. — DOUBLE FLAP INCISION FOR REMOVING LYMPHATICS OF THE NECK IN OPERA-
TION FOR CANCER OF THE TONGUE.
THE NECK
367
is exposed by an intermuscular incision above the clavicle, and the temporary
soft clamp applied. An incision is made below the lower jaw from the chin
to the mastoid process. A second incision is begun at the angle of the jaw and
carried down to the junction of the inner and middle thirds of the clavicle
(Fig. 1065). The flaps are reflected back to expose the anterior and digastric
triangles and submaxillary and internal jugular regions. The sternomaxil-
lary muscle is divided near the clavicle; the internal and external jugular
veins are tied at the base of the neck and divided. The dissection is then
carried upward, dissecting free everything external to the deep plane of the
FIG. 1066. — DISSECTION UPWARD OF LYMPHATICS OF NECK.
Folded towels or gauze protect the environment. The internal jugular vein has been dis-
sected out with the glands and connective tissue.
neck. All the fascia, the muscles, veins, fat and connective tissue are dis-
sected free up to the floor of the mouth (Fig. 1066). If the operation is for
cancer inside of the mouth, the jaw is then divided, and the diseased focus
extirpated along with the cervical mass. The pneumogastric nerve is not in-
jured. The clamps are removed from the carotid as soon as possible. If
the growth is not extensive and no operation is to be done in the mouth, the
dissection may be made from above downward (Fig. 1067). The sterno-
mastoid muscle may be preserved and sutured back in place, although its loss
does not cause any considerable disturbance of function (Fig. 1068).
In any of these operations if deeper structures are found involved in
disease which must be removed to effect a cure they should be excised.
Such excision may involve not only the internal jugular vein, but the carotid
and vagus nerve as well.
Operations on the Tonsil and Pharynx Through the Neck. — Tumors of
the tonsil, pharynx and the adjacent regions may be reached by operation
368
SURGICAL TREATMENT
laterally through the neck, called lateral pharyngotomy. An incision is
made along the upper half of the anterior border of the sternomastoid muscle.
A second incision is carried forward from the upper end of the first below the
lower jaw for about 8 cm. The deep fascia is divided and the muscle
retracted backward. By drawing aside the great vessels and nerves the
wall of the pharynx is exposed. With retractors in place the pharynx
is opened and the disease attacked. If this does not give room enough
the jaw may be sawed through between the second and third molar
teeth. This is the most satisfactory approach to tonsillar neoplasms. After
the opejation the wound may be partly or completely closed. The safest
FIG. 1067. — DISSECTION OF LYMPHATICS OF NECK.
Dissection from above downward. The mass of glands and connective tissue is placed on a
pad of gauze as the dissection proceeds.
method is to suture the mucous membrane, partly close the external wound,
and insert a drain down as far as the mucous membrane.
Tuberculous Lymph Glands of the Neck. — The general treatment of
tuberculous adenitis of the neck should be the same as that for tuberculosis
in other regions (see Tuberculosis, Vol. I, page 276). Most cases should
be cured by general treatment.
The first step in treatment is to improve the hygiene of the patient. It
may be assumed that a healthy person does not develop tubercular glands
of the neck. Diseases of the tonsils, teeth, and adenoids should be cor-
rected. The patient should live out of doors and in the sunshine. The value
of tuberculin and the #-ray is probably not inconsiderable. Surprisingly
good results are secured by ar-ray treatment.
Small glandular swellings should always be expected to disappear under
appropriate treatment. When the glands become fairly large, or if the
THE NECK
369
general resistance of the patient is not good, or if the disease is clearly
progressing, operative removal of the glands is called for. Operation offers
the advantage that it expeditiously removes the tuberculous focus, which£is
always a hazard, and leaves less scar than will remain if the glands are left
to break down without surgical treatment.
Usually after removal of tuberculous glands the health of the patient
improves. If all of the infected glands have been removed the patientjis
cured, but there is no guarantee that reinfection of other glands may not
take place just as before. If all the tubercular glands are not removed the
tendency of the remaining glands is to continue to grow and ultimately
demand operation. Recurrence is common after these operations if
FIG. 1068. — -DISSECTION OF NECK.
•Structures sutured to close deep wound after removal of lymphatics,
sewed to the sternomastoid muscle.
The platysma is
all of the infected glands were not removed. So large a percentage of
these patients ultimately succumb with tuberculosis of other organs that the
operation should be made much more thorough and the disease thought of
more seriously than it has been. If cellulitis or sinuses are present, the non-
tuberculous infection should first be cured before an extensive dissection is
attempted.
K. Ewald (Wiener Klin. Woch., xxiii, Nos. 35 and 36), reviewing
a large experience, came to the conclusion that most of these cases are better
off not to be operated upon. He advised operating upon only single isolated,
unchanging glands which have persisted for years. Opening up the lymph
spaces, he claims, in the ordinary case, spreads the infection, and recurrence
is the rule. He employs general hygienic and antitubercular measures. If
the glands become soft and cheesy, the broken-down matter should be gently
curetted out, but other tissue should not be attacked.
VOL. 11—24
370
T. von Mutschenbacher (Beitrage zur klin. chir., September, 1912, vol. 80),
basing his opinion on 1344 cases treated in four years, concluded that treat-
ment should be absolutely conservative or absolutely radical. Systematic
constitutional and antitubercular treatment is most important. If a gland
breaks down, its contents should be aspirated through the smallest needle
possible. The cavity should then be injected with iodoform-glycerin. Such
an'injection should be made every third or fourth day. Five or six such treat-
ments will heal most such foci.
This conservative treatment is coming to be more and more accepted by
surgeons who once operated upon all of these cases as a routine measure.
The technic of operation for tuberculous glands is similar to that for car-
cinomatous glands, excepting that in tuberculosis it is not so important that
impalpable glands shall be removed. The incisions may be similar. Inas-
much as tuberculosis is more common in the young and hopeful, the cosmetic
FIG. 1069. — POSTERIOR INCISIOR FOR DISSECTION OF TUBERCULOUS GLANDS OF THE
NECK.
This incision is placed posteriorly within the hairy scalp.
results must be considered, and the scar should be as small and inconspicuous
as possible. Usually it is not necessary to carry the submaxillary incision
farther forward than a point midway between the angle of the jaw and the
symphysis of the chin. An incision which leaves a less conspicuous scar
begins on the side of the neck just below the jaw, passes backward below
the tip of the mastoid process to the hairy scalp, thence curves downward
and then forward and passes along above the clavicle as far forward as nec-
essary. It may end at the middle of the lower end of the sternomastoid
(Fig. 1069). Another useful incision is made transversely, and lies about
2 cm. (% inch) below the angle of the jaw.
Whatever incision is used, the skin is turned back with the platysma,
and the sternomastoid and deep fascia are exposed. The muscle is freely
THE NECK
371
exposed so as to be easily retracted. The dissection of the neck is facilitated
by division of the sternomastoid muscle if the glands are extensive (Fig.
1070). Removal of the glands is best begun below (Fig. 1071). They are
removed from the supraclavicular triangle, cleared away from the subclavian
and internal jugular veins. Care should be taken not to wound the thoracic
duct, which may be on either side. The lymphatic mass is kept together
and dissected upward, following the internal jugular vein. A more satis-
factory dissection is made if the vein is freely exposed at once and kept
exposed as the operation progresses than if it is left covered with fascia and
avoided as much as possible. The small veins which pass to the jugular
vein from lymph nodes must be watched for and tied.
FIG. 1070. — TUBERCULOUS GLANDS OF NECK EXPOSED BY POSTERIOR INCISION.
The sternomastoid muscle has been divided, and the skin flap is drawn forward.
If there is no mixed infection of the glands or periadenitis the removal of
the glands may be affected largely by blunt dissection. If infection and
adhesions are present the dissection is much more difficult. It is accom-
plished with scalpel, scissors and blunt instruments. The sternomastoid
is retracted both forward and backward.
The spinal accessory nerve leaves the sternomastoid at its middle and
passes back to the trapezius; it should be saved. The dissection of the glands
is continued upward. The muscle is retracted outward and backward to
expose the region of the bifurcation of the carotid. The submaxillary and
submental glands are next removed. Glands must often be removed from
the substance of lower part of the parotid in which they are embedded and
372
SURGICAL TREATMENT
from close relation to the submaxillary salivary gland. In order to have
the least scar, the wound should be closed with a carefully applied subcu-
ticular suture.
Tumors of the Neck. — Cysis of the neck should be excised. Congenital
cysts and echinococcus cysts should be removed (see Cystomata, Vol. I,
page 325). Lymphatic cysts cannot often be excised unless very small; in
childhood they are prone to disappear spontaneously; incision and tamponing,
to cause obliteration of the sac, is, perhaps, the most effective treatment.
Hemorrhagic cysts may be dissected out; when the dissection reveals connec-
tion with a blood-vessel, the opening in the vessel must be closed or the vessel
ligated (see Aneurism). Bur sal cysts in the thyrohyoid region require
excision, or incision and destruction of the lining.
FIG. 1071. — DISSECTION OF TUBERCULOUS GLANDS OF NECK FROM ABOVE DOWNWARD.
Solid tumors of the neck should receive the same treatment as in other
regions. Benign tumors require more urgently to be removed because of
disturbances incident to pressure and for cosmetic reasons. Secondary
carcinoma has already been discussed (page 363). Malignant lymphoma
may sometimes require excision for the relief of distressing pressure.
Branchial fistula and cysts require the dissection of the mucous tract.
The fistula should be injected with methylene blue solution in order to trace
it. A fine probe kept in the lumen is also of help. A cyst is but a stopped-
up fistula. The surgeon should be prepared for a long dissection as these
fistulas often lead to the great vessels and thence in devious ways. They may
be expected to have an internal opening in the laryngobuccal cavity.
Unless every trace of the mucous membrane of the fistula is removed, re-
currence will take place. Median fistula of the thyroglossal tract are more
easily removed. Unless these fistulae are removed the only treatment that
THE NECK 373
remains consists in keeping the fistula clean and dry by injections of such a
fluid as equal parts of alcohol and water. No treatment but excision is
curative.
Burns of the Neck. — Burns in this region should receive the most careful
treatment (see Vol. I, page 821). To secure healing with the least possible
infection and scar is necessary to prevent deforming contractures. When
healing has been secured massage with oil may help to relax the scar.
The injection of fibrolysin may be of service. The best results will be
secured by plastic operations (see Vol. Ill), which should be done before the
distortion has caused changes in other structures.
Cervical Ribs.— These ribs arising usually from the seventh, sometimes
the sixth, cervical vertebra, require treatment when they cause unpleasant
symptoms. Most cases give no symptoms. But it should be borne in mind
that the presence of these ribs means high position of the vertebral artery
and the pleura, which should be guarded in operations. Removal of the
anomalous rib should be done if it causes symptoms. It is best that opera-
tion should be done even when the symptoms are slight — anesthesia, tingling
or neuralgic pain in the arm — -as more serious disturbances may supervene.
Only the troublesome side need be operated upon. The operation may be
depended upon to give relief. The rib is exposed by a horizontal incision
just above the outer end of the clavicle. If necessary this may be combined
with a vertical incision between the sternomastoid and the trapezius. The
subclavian vessels, pleura, phrenic nerve, brachial plexus, and thoracic duct
are to be looked out for. The nerves and muscles should be retracted and the
rib divided close to the vertebra. Sharp edges and exostoses often connected
with the vertebra should be smoothed off. The rib should then be followed
forward to its anterior attachment — usually to the first rib — and cut free.
Care should be taken not to stretch or compress unduly the brachial plexus.
Torticollis. — Acute torticollis presents pain or tenderness. Removal of
the cause is the first requisite of treatment. The ordinary stijf neck is best
treated by hot applications. These may be employed in the form of woolen
cloths wrung out steaming hot with warm water. The treatment must be
applied to the sternomastoid or posterior muscles, whichever are affected.
Ironing consists in repeatedly passing a hot smoothing iron over a thin
cloth laid on the skin. This gives heat and massage. Massage alone or
vibratory treatment is often effective. Aggravated cases require fixation of
the head and neck.
Fixation is best preceded by massage or hot applications. The apparatus
used in spondylitis of the neck is employed. The plaster-of-Paris cuirass,
embracing the head, neck and thorax, is most useful. It need not extend
below the thorax. The jury-mast is also of service. In cases with contrac-
ture of muscles which is not overcome by massage, heat or gentle force, an
anesthetic is required and forcible correction followed by fixation in an over-
corrected position. Cases in which the above measures fail, should have the
contracted parts cut.
Chronic torticollis embraces the great majority of cases which come to the
surgeon's hands both acquired and congenital. Acquired torticollis is usually
preventable. Most cases of more than six months' standing may be called
chronic. The contracture of the sternomastoid or posterior muscles is
resistant. Pain and tenderness are not present. In infancy the contrac-
tures may be overcome by systematic stretching and manipulation of the
contracted parts. Several times daily the child should be placed on a firm
surface; the shoulders should be held down by a pair of hands; the head
should be rotated; and flexed or extended, in the direction opposite to the
374 SURGICAL TREATMENT
deforming tendency; and the contracted parts massaged. When the child
lies in bed or in its mother's arms, the position of overcorrection should be
given to its head. These measures should be given a fair trial; if they fail,
operation should be done. Operation will rarely be required if the patient
is seen early enough and given proper treatment.
Operative treatment is indicated in most cases of torticollis when seen by
thejsurgeon. When the contracture is limited to the sternomastoid muscle,
division of its lower tendon is practised. Subcutaneous tenolomy is done
FIG. 1072. — TORTICOLLIS, SHOWING HEAD FIXED IN* PLASTER-OF-PARIS DRESSING IN A
POSITION OF OVERCORRECTION.
through an opening just large enough to admit the tenotome. It may be
employed in mild cases. The patient should be anesthetized and placed on
his back, with a sand pillow behind the upper thorax to permit the head to
drop back. The head should be held rotated and abducted so as to put the
contracted muscle well on the stretch. The structures to be avoided are the
subclavian vein, the thoracic duct, the internal jugular vein and the great
arteries. The tenotome is inserted at the inner border of the sternal attach-
ment, i or 2 cm. (% or ^4 inch) above its insertion. The blunt-pointed
tenotome is then substituted for the sharp point, passed outward behind
the muscle, to the outer edge of the sternal fasciculus, rotated, and the muscle
THE NECK 375
cut forward toward the skin. If this does not relieve the contracture, the
clavicular attachment may be divided in the same way.
Open tenotomy is the preferable operation. In the case of a broad inser-
tion two longitudinal incisions should be made, one over the middle of each
tendon; in most cases a single incision is adequate. The patient is placed in
the same position as for subcutaneous tenotomy. An incision is begun
about 3 cm. (ij-^ inches) above the clavicle, between the sternal and clavicu-
lar fasciculi of the muscle, and carried downward to the clavicle. The skin
is dissected back a little, and the muscle exposed. A director is passed behind
the sternal portion and the muscle divided upon it as a guide. The clavicular
portion is similarly divided. Resistant bands of fascia and the sheath of
the muscle toward the clavicular side will also require division. This may
be done by retracting the wound edges and operating by the aid of sight.
These incisions of fascia require to be but slight nicks of resisting fasciculi.
The parts should be put well on the stretch to bring out these resisting bands.
The fascia and skin are then sutured separately, and the head, neck and
upper thorax put up in plaster-of -Paris (Fig. 1072) in the overcorrected
position, after having thoroughly stretched and broken up all resisting
fibers not divided.
Division of the posterior muscles also will be found necessary in aggravated
cases. This is done through an incision, concealed by the hair, extending
backward from the mastoid process. The front edge of the trapezius and any
other contracted muscles or fasciae inserted in the occipital bone are divided
as extensively as is necessary.
The after-treatment is important. After dividing the resisting parts, over-
correction, to stretch the uncut tissues, is applied. After passive motion has
overcome all resistance, the head should be put up in plaster-of-Paris. The
head should be rotated so that the chin is over the middle of the clavicle of
the side operated upon. The head should be abducted toward the opposite
shoulder. The neck should be kept straight in the middle line. A fenestrum
may be cut to remove the dressing. The splint should be worn for one or
two months. Following this passive motion should be practised and massage
should be given to the neck on both sides. At least twice daily the head
should be placed in the position of extreme overcorrection. Traction
applied daily by means of the suspension apparatus is of service.
If the tendency to recurrence is pronounced the splint should be applied
again in overcorrection and the treatment continued for from three to six
months. If the head rotates into place when suspension is applied, the
jury-mast may be used instead of the plaster splint. This support may be
used for several months. More rapid progress will be made if the appliance
is put on so that it may be removed daily, and massage and passive motion
given. Following operation in adults usually no apparatus is needed. In
bilateral contractures, the treatment is conducted upon the same general
principles as in unilateral contractures.
Some surgeons do not use retention apparatus after tenotomy. The head
is placed in an overcorrected position and held between pillows. Passive
motion is begun on the second or third day. These movements are increased
and are later followed by massage.
Excision of the siernomastoid muscle was advocated by Mikulicz, because
he regarded simple division of the muscle as inadequate for confirmed cases.
Loss of the muscle does not materially impair the movements of the head.
An incision is made along the lower two-thirds of the contracted muscle,
and the sternal and clavicular attachments lifted up and divided. The mus-
cle is then separated from its bed up to a point above the spinal accessory
376 SURGICAL TREATMENT
nerve. The nerve leaves the muscle about the middle of the neck. The
lower two-thirds of the muscle are cut away and the wound closed. The
after-treatment is as above.
Spasmodic torticollis occurs in adults, is not associated with discoverable
structural changes, involves usually the sternomastoid, but the trapezius and
other muscles may become affected, the spasmodic clonic spasms some-
times involving the facial and upper thoracic muscles. The treatment is
the same as that of muscular cramps elsewhere. Discovery and elimination
of the local or general cause is the first thing. In mild cases, improvement
of the general hygiene combined with massage of the affected muscles is
sufficient. Overcorrected position by means of supports cures some cases.
Rather than resort to these appliances, much quicker results are secured by
dividing the nerves supplying the affected muscles. If the sternomastoid
and trapezius alone are affected, resection of the spinal accessory nerve gives
relief.
Resection of the spinal accessory nerve accomplishes the same results as
excision of the lower two-thirds of the sternomastoid muscle as above de-
scribed. The operation paralyzes the sternomastoid and the trapezius (see
Spinal Accessory Nerve, Vol. I, pages 885 and 890). Simple resection of the
nerve is a less mutilating operation. The nerve emerges at the jugular
foramen, passes downward and backward, and enters the anterior part of the
sternomastoid muscle about 2 cm. (% inch) below the level of the tip of the
mastoid process, which is about opposite the angle of the lower jaw. The
incision should extend from the tip of the mastoid process downward for about
8 cm. (3 inches), exposing the muscle. The anterior border of the muscle is
retracted backward, and the lower part of the parotid gland forward.
At the bottom of the wound, lying in a direct line below the mastoid process,
is the transverse process of the atlas, which is easily exposed by blunt dis-
section. Running downward and forward from the mastoid process is the
posterior belly of the digastric muscle. The carotid and internal jugular
lie internal to this belly; the tip of the transverse process of the atlas is about
on an anteroposterior plane with its middle. The nerve usually is found a
few millimeters in front of the tip of the transverse process, where it is easily
identified in the connective tissue. By strongly retracting backward the
anterior border of the sternomastoid muscle, the nerve will be seen passing
under the posterior belly of the digastric, just in front of the transverse process
of the atlas, to enter the inner surface of the muscle near its anterior border
at a point opposite the angle of the lower jaw. If there is any question about
it, mechanical or electric stimulation of the nerve will be found to cause
contraction of the muscles. About 2.5 cm. (i inch) of the nerve should be
resected. Some surgeons have been satisfied to stretch it in each direction.
Some do both. No fixation apparatus is necessary. If the disease has been
of long standing, division of contractured parts may be required. The
operation should be followed by massage, and passive and active motion of
the neck muscles.
Resection of the posterior cervical nerves is done in cases in which the spasm
involves, besides those supplied by the spinal accessory nerve, the posterior
neck muscles on the same or the opposite side. Paralysis of these muscles is
secured by division of the posterior branches of the upper spinal nerves.
The nerves to be paralyzed are those which supply the splenius capitis, rectus
capitis posticus major, and obliquus inferior. They are supplied from the
second and third cervical nerves and the suboccipital nerve from the first
cervical. A transverse incision 5 to 10 cm. (2 to 4 inches) long, terminating
at the middle line, is made 2 cm. (% inch) below the level of the lobule of the
THE NECK 377
ear. The trapezius muscle is divided transversely. The nerve to the occip-
italis major is found where it leaves the complexus muscle, about i or 2
cm. (% to % inch) below the level of the skin incision, by lifting the trapezius.
Sparing this nerve, it is followed through the complexus muscle, the muscle
being cut transversely, until its junction with the second cervical is reached.
The posterior branch of the second cervical is then resected. The first
cervical is then located just above, and resected. The third cervical is
located 2 or 3 cm. (% or i^ inches) below the second; the external branch of
its posterior division should be resected as far as the main trunk. The
wounds in the muscles may be sutured.
The nerves may be reached by an incision, about 8 cm. (3 inches) long,
carried from the occiput downward parallel to the cervical spines and 2.5
cm. (i inch) from them. This incision is continued through the trapezius
to the edge of the splenius capitis. The complexus is divided so as to expose
the occipitalis nerve. With this as a guide, the posterior branches of the
three upper cervical nerves are exposed and resected.
Exceptional forms of torticollis require the treatment peculiar to the disease
which they represent. In paralytic torticollis, such as complicates diphtheria
and anterior poliomyelitis, it should be remembered that the turning of
the head is not done by diseased muscle, but by a normal muscle which is
unopposed. Later contractures may take place and require correction by
massage, forcible motion, or division of tissue; but the curative treatment at
first should be directed to the relaxed muscles, and not the contracted ones.
Care should be taken that imbalance of the cervical muscles, due to asthenia
or central irritation is not treated for cervical tubercular spondylitis. The
same may be said of rachitic torticollis and rheumatic torticollis. Habitual
torticollis and ocular torticollis require attention to their respective causes.
SALIVARY GLANDS
The parotid gland is under the deep fascia; it embraces the ramus of the
lower jaw in front; it is bounded by the zygoma above, and the external ear
behind. Its lower lobes occupy the space between the styloid process and
the sternomastoid muscle. Stenson's duct passes forward across the masseter
muscle 2 cm. (% inch) below the zygoma, and enters the mouth opposite
the second upper molar tooth.
Parotid salivary fistula, an opening of one of the ducts of the parotid
through the skin, occurs usually as a result of a wound; and in treating and
making wounds of this region, the duct should be had in mind. The fistulous
opening may be closed by the old method of Deguise. A silver wire is passed
from the mouth of the fistula inward and forward through the cheek to emerge
in the mouth. This is done by means of a small trocar and canula just
big enough to receive the wire (Fig. 1073). The other end of the wire is
similarly passed 3 or 4 mm. from the first. This leaves the loop of the wire
in the mouth of the fistula. The two ends are then tightly tied or twisted
on the inner side of the cheek (Fig. 1074). This forms a new canal by which
the saliva is conducted into the mouth. The external opening may be dis-
sected free and sutured, or this may be done at a subsequent operation. If
it is not sutured, the tendency is for it to close. The suturing of the external
opening is aimed to make a plastic operation to overcome the dimple which
otherwise results (Fig. 1075).
This operation is not apt to be successful if the wire is passed through the
masseter muscle; the opening should be anterior to the masseter. If the
fistulous opening is much posterior to the front edge of the masseter, the
378
SURGICAL TREATMENT
salivary tube must be lengthened. It may be possible to find the natural
opening in the mouth, and by passing a filiform bougie through it and then
a few strands of thread, the distal part of the duct may be dilated and the
severed ends of the duct united.
FIG. 1073. — OPERATION FOR SALIVARY FISTULA. FIRST STAGE.
Wire being passed through cheek by means of trocar and canula
FIG. 1074. — OPERATION FOR SALIVARY FISTULA. SECOND STAGE.
Wire twisted on inner side of cheek.
FIG. 1075. — OPERATION FOR SALIVARY FISTULA. THIRD STAGE.
Wire twisted on inner side of cheek, and opening on outer side of cheek freshened and
closed by sutures.
Nicoladoni advised reconstructing a canal of mucous membrane. The
skin opening is excised by a transverse elliptical incision; the outer surface
of the mucous membrane lining the cheek is then uncovered anterior to the
masseter; an oblong piece of this mucous membrane is freed on three sides
THE NECK
379
turned back and constructed into a tube, which is sewed to the discharging
end of the duct; the external wound is then closed over all (Fig. 1076). It
is not necessary to fold the mucous membrane into a tube. If the strip of
mucous membrane is simply drawn through from the mouth to the parotid,
and sewed to the gland opening or to the stump of the duct, a tube will form.
The patency of the mucous channel may be assured by leaving a pair of
strands of chromic catgut lying on the mucous surface. The wound in the
mouth from which the strip was cut should be sewed.
Cellulitis and abscess of the parotid are serious because of the danger of
secondary intracranial infection. This may begin in the gland or in its em-
braced lymphatics. The general and local treatment of cellulitis should be
expeditiously applied. Streptococcus infection and tubercular infection
demand their specific treatment. As soon as an abscess forms, or sooner,
the gland should be incised. Incisions should be placed so as not to injure
the facial nerve or the great vessels.
FIG. 1076. — PLASTIC OPERATION FOR SALIVARY FISTULA OF CHEEK.
The cheek has been opened by a short incision parallel with the filaments of the facial
nerve. The fibers of the buccinator are separated and widely retracted, exposing the mucous
membrane of the mouth. A flap is cut from the mucous membrane, turned back and sewed
as a funnel about the end of the duct. The mucous membrane wound is to be sewed, and
the muscles allowed to go back into place.
Salivary Calculi. — Stones form usually in the duct of the submaxillary
gland, although they may be found in any of the salivary ducts at their mouths
or in the substance of the glands. Appearing in the terminal ducts near
their mouths, it is best to incise the duct at the stone and lift it out. The
wound heals without further attention. Stones developing in the substance
of the submaxillary gland are best treated by removal of the gland. This is
not difficult, and if the stone alone is removed a fistula and a disorganized
gland are apt to remain. Stone in the substance of the parotid gland should
be exposed and removed; removal of the gland should not be attempted, but,
if the stone is near the periphery, the disease lobe may be removed.
Tumors of the Salivary Glands.— (See Tumors, also Anatomy of the
Neck.) The surgeon should not withhold his hand from these tumors because
they involve important structures. Any and all of the lateral structures of the
380 SURGICAL TREATMENT
neck on one side may be sacrificed; and so far as the trachea, larynx and
esophagus are concerned, they also may be excised.
THE THYROID GLAND
Anatomy. — The thyroid gland is behind the anterior muscles — the platysma, sterno-
mastoid, sternohyoid, sternothyroid and omohyoid. It is surrounded by a layer of the
deep fascia which forms an external capsule. This fascia also embraces the great vessels
which lie in relation to the external posterior border of the gland. The top of the isthmus
lies just below the larynx, and the processus pyramidalis arises in the median line injfront
of the larynx. Posteriorly the fascia, constituting the outer capsule, is adherent to the fascia
and connective tissue embracing the trachea and esophagus. The recurrent laryngeal
nerve lies in a groove on the median posterior aspect of each lobe, in the angle between .the
esophagus^and trachea, enclosed in the external capsule. A large number of accessory
FIG. 1077. — THYROID GLAND.
Showing relations to larynx, trachea, and the vessels of the neck.
veins course in the external capsule. The gland rests in the arms of a great vascular u
(Fig. 1077).
The parathyroid glands vary in number and location, but usually there are four, two
upper and two lower, embedded in the connective tissue of the external capsule. They are
brownish-red; 2 to 10 mm. long, and i to 4 mm. thick. The upper pair are at the posterior
median edge of the upper part of the lobes. The lower pair are just below the lower ends
of each lobe. The accessory thyroids vary much in size and location, but may be found about
the hyoid bone, larynx, trachea or the root of the tongue.
Inflammations of the Thyroid. — Acute thyroiditis is treated the same as
other inflammations. Hot applications are used. Abscesses should be opened.
Necrosis demands removal of the affected portions. Acute strumitis (^inflam-
mation of a goiter) should be treated as above, and it will usually subside.
THE NECK 381
When suppuration occurs, the abscess should be incised. If the abscess is
confined to the goiter, and the surrounding tissues are not infected, the
goiter may be taken out at this time. If infection has invaded the surround-
ing tissues excision of the goiter is best not undertaken. Abscesses should
be incised promptly and drained.
Chronic thyroiditis should be treated by discovery and elimination of
the exciting cause. The general hygiene should be improved. If so much
of the gland is diseased that the patient is suffering from insufficiency of
thyroid secretion, thyroid preparations should be given. If the gland is
chronically enlarged and hyperthyroidism is present, the enlarged portion may
be removed. In operating for chronic inflammation it should always be
borne in mind that the functional activity of the remaining part may be
impaired, and an adequate amount of gland should be left. Chronic stru-
mitis should be prevented by the removal of goiter before it becomes
inflamed. Extirpation of the chronically inflamed goiter is the most satis-
factory treatment. If there is central softening and the condition of the
patient forbids excision, the broken-down parts may be incised and treated
with antiseptic packing. For such treatment iodoform, iodin, nosophen,
f ormidin or other powder may be used. Syphilis of the thyroid gland should
be recognized and treated specifically. Tuberculosis is to be given the general
treatment of that disease and the infected portion of the gland excised.
Malignant Tumors of the Thyroid (Carcinoma and Sarcoma) . — In order
that treatment of these grave conditions may be successful, extirpation of the
growth must be attempted before it has reached a point at which positive
diagnosis can be made. The frequency of malignant disease in the thyroid
makes it imperative that tumors of this gland should be removed. This must
mean the removal of benign as well as malignant growths, for to wait for
the purpose of clinical differentiation is to delay too long. A thyroid gland
which continues to enlarge steadily after puberty should be suspected of
malignancy; and an enlargement beginning and steadily continuing after
middle life should suggest carcinoma, and be removed. Operation before
the capsule has become involved is imperative. The capsule should be re-
moved with malignant disease. If metastases have developed, operation is
rarely worth the pains.
The extension of the disease may require the removal of important
structures of the neck. The extent to which such operations may be carried
must depend upon the general condition of the patient (see page 363,
Carcinoma of the Neck). If operation for radical cure is impossible, tentative
measures may be of service (see Inoperable Cancer, Vol. I, page 331). Tra-
cheotomy may become necessary. At the best it is difficult; it may require
partial removal of the growth to make it possible; and fatal infection is apt
to follow.
Goiter (Struma). — Although a benign disease, goiter is serious because
its natural tendency is to increase in size; it may cause serious dyspnea from
compression upon the trachea or blood-vessels; it impairs the action of the
heart, by causing pressure-dyspnea, compression, obstruction in the great
vessels, or thyreotoxicosis; and it may undergo malignant degeneration.
For these reasons treatment is important. Hygienic treatment may do
something for these patients. A change of abode where water from a dif-
ferent source may be had sometimes checks or cures the disease. In some
patients, the disease ceases to progress or it may recede, after the fiftieth
year. Hygienic treatment has much to offer in most cases with mild
hyperthyroidism.
Rest, both physical and emotional, is essential in treatment. In connec-
382 SURGICAL TREATMENT
tion with rest, an abundance of pure drinking water is, perhaps, the next
most important factor. If there is any doubt about the water, it should be
boiled. Operation should be considered when the above measures fail.
The patient should usually not be subjected to operation during an exacer-
bation of hyper thy roidism. Rest and care should carry her through the
attack, and operation should be done in the interval when her physical
condition is better and her mind more hopeful (see Hyperthyroidism, page
389).
Operation is indicated: (i) in goiter which causes pronounced pressure
symptoms, either from pressure on the trachea or blood-vessels; (2) in nodular
goiter; (3) in goiter which grows rapidly; (4) in painful goiter; (5) in goiter
situated or growing down into the thorax, where compression will be serious
and operation more difficult with the lapse of time; (6) in goiter that is pro-
ducing symptoms of thyreotoxicosis ; (7) in colloidal goiter which does not
improve under treatment; (8) in any goiter which continues to enlarge despite
treatment; and (9) in goiter which causes the patient distress because of its
unsightliness.
Operation is contraindicated by: (i) extreme impairment of the general
health, amounting to a moribund state; (2) greatly damaged heart; (3) the
fact that the goiter is small and receding; or (4) absence of all of the above
indications for operation.
Operative treatment may consist of excision, resection, enucleation of the
thyroid or ligation of vessels. Complete removal of both lobes and the
isthmus should never be done because of the danger of thyreoprivic cachexia.
For excision of simple nontoxic goiter, the patient should lie on the back
with a sand pillow behind the upper thorax to cause the head to fall back and
render the front of the neck prominent. The whole upper end of the table
should be elevated to diminish congestion. The field of operation is best
screened from the face by means of a bow opposite the chin, over which a
sterile cloth is draped, making a screen. Local anesthesia with novocain or
i per cent, cocain with adrenalin may be used. Infiltration anesthesia is
most satisfactory. A preliminary injection of morphin is helpful. If general
anesthesia is employed it is wise to inject the local anesthetic just the same
as though no general anesthesia were to be used.
The important thing about the incision for goiter is that it should be
adequate. A free exposure is essential. If but one side is to be operated
upon, a unilateral incision suffices. This should begin on the side of the neck
posterior to the tumor on a level with the junction of its upper and middle
thirds. It should pass forward and then curve downward to end well below
the tumor, keeping just external to the inner border of the lobe to be removed
(Fig. 1078, AB) . In low-lying unilateral tumors, this incision may be reversed,
and the inner end be above and the outer end below (Fig. 1078, CD}. For
a median-lying tumor of small size, a median incision may be made from a
point well above the tumor down to the sternum. In large tumors, espe-
cially if bilateral, the horizontal incision is to be preferred (Fig. 1078, EF).
This passes transversely between points external to the tumor on either side
of the neck and crosses slightly below the middle of the mass. It should
make a slightly downward curve. An incision following the anterior border
of the sternomastoid or a combination of the above incisions may best be
adapted to smaller tumors. A low transverse curved incision is preferred
by most surgeons.
The skin, fascia, platysma and deep fascia are divided. Vessels are
ligated in two places and cut between. The thinned-out sternothyroid,
sternohyoid and omohyoid muscles should be retracted. If adequate re-
THE NECK 383
traction is difficult, they should be divided. These muscles should be divided
high, because the nerve supply enters at about the middle of the muscle.
By cutting the muscles above the middle, their function is restored after
they have been sutured (Fig. 1079). The underlying fascia should be
similarly treated. Lying close upon the surface of the tumor will be found a
plexus of veins. These should be ligated in a line with the long axis of the
tumor and cut between the ligatures. Uncontrolled bleeding should not be
permitted. Every bleeding point should be clamped or tied. Nothing
should be cut unless the surgeon knows what it is. Occasionally the head
may be lifted forward to permit the filling of veins which may be obscured
by compression.
The surgeon should identify the surface of the goiter, and the dissection
should be made bluntly, between the planes of tissue, with rounded curved
FIG. 1078. — INCISIONS FOR OPERATIONS ON GOITER.
AB, Incision used for unilateral tumor; CD, incision for low unilateral tumor; EF, collar
incision for bilateral exposure; GH, incision for low bilateral tumor.
scissors (Fig. 1080). As the outer margin of the tumor is reached it may be
retracted inward or lifted forward. Careful work is now required because
the sheath of the great vessels is apt to be adherent to the sheath of the
goiter. The superior thyroid artery should be discovered entering the goiter
above and posteriorly. The artery and vein should be ligated in two places
and cut. If the vessels cannot be identified, the pedicle containing them
should be encompassed by a ligature and cut close to the tumor. The
lower lateral border is then retracted inward, upward and forward, and
the inferior thyroid vessels ligated. The surgeon should be familiar with
the anatomy of the two thyroid vessels (see Vol. I, pages 410 and 411), and
should make allowance for the distortion caused by the growth of the
tumor. The search for the two thyroid arteries should be from without
inward.
384 SURGICAL TREATMENT
Some surgeons, after clearing the front of the lobe and tying the superior
thyroid vessels, prefer to divide the isthmus, turn the tumor downward and
then tie the inferior thyroid vessels.
The tumor is lifted forward and retracted inward and bluntly freed from
its posterior attachments (Fig. 1081). If but one side is enlarged sufficiently
to demand removal, the isthmus is ligated 'and the tumor cut away. If
both lobes are to be removed, the dissection is continued on the other side
in a similar manner. The whole of both lobes should not be removed. The
surgeon should attempt to discover a part of the gland that shows the least
evidence of disease, and leave that. If some normal-appearing gland can be
identified, it should be left in amount about equal to the size of the normal
thyroid. When no particular part of the mass can thus be preferred for
ANT. JUGULAR
FIG. 1079. — OPERATION FOR GOITER.
Flap of skin and platysma retracted and deeper muscles exposed. The sternohyoid muscle
is about to be divided between clamps. (After Mayo.)
preservation, one-third or a half of the smaller lobe should be left. It is
best to leave the upper pole of the lobe rather than the lower, because in
the event of recurrence the growth is more difficult to attack and the symp-
toms which it produces are more serious if it is low in the neck. The part
to be left should not be dissected free, but should be left with all its vascular
connections.
In resecting for hyperplasia, it is well to introduce a mattress suture to pre-
vent oozing, and then whip over the edges of the cut gland. A ligature
should be thrown about the lobe, after freeing the part to be removed, and
the gland tissue cut through close to the ligature. If the lobe is thick,
bleeding may be prevented by multiple ligatures instead of one, or the
angiotribe may be used. After resecting from two sides of the thyroid
THE NECK 385
Mayo warns against letting the two stumps fall together at the median line,
lest they unite and the scar contracture later compress the trachea. If
pressure of an old goiter has caused absorption of rings of the trachea, and
the trachea collapses when the goiter is removed, a tracheotomy tube must
be inserted, or a piece of costal cartilage put in to hold the tissues
from collapsing.
Sponging should be most gentle. All bleeding should be controlled.
The muscles and fascial planes should be restored by suture (Fig. 1082).
The wound may be closed without drainage by a subcuticular suture. It is
wise to leave in a drain for a day. A dressing, making even and gentle
pressure, should be applied. The patient should lie quietly in bed, on his
back, with the head and thorax slightly elevated.
FIG. 1080. — OPERATION FOR GOITER.
All muscles retracted and capsule incised. The superior thyroid vessels are seen at the
upper pole of the gland. {After Mayo.)
For enucleation of a nodule, cyst or localized tumor, growing in the
thyroid, the fascia or gland tissue overlying the tumor is incised, and bluntly
dissected back to expose the growth to be enucleated. As the dissection
proceeds, wide retraction should be maintained and vessels passing between
thyroid and tumor should be divided. Sometimes there may be but little
of the gland left outside of the growth; in which case mass ligature of the
main vessels may be required. When the growth to be removed constitutes
most of the thyroid, and there is but little gland outside of it, this remaining
gland tissue should be accorded the greatest deference. It should not be
traumatized, its blood supply should not be harmed, and the raw surface
left after the enucleation should be covered with fascia to protect it.
The double resection of nontoxic goiter, which is called for because of the
VOL. 11—25
386 SURGICAL TREATMENT
mechanical inconvenience of the swelling, is an operation which should have
no mortality. The tumor is best exposed by the horizontal incision extend-
ing from one external jugular vein to the other. The upper flap is dissected
up as far as the thyroid cartilage and the lower flap as far as the interclavic-
ular notch. After separating the muscular structures by a median incision
the thin capsular covering of the gland should be drawn aside. The finger,
under this capsule, sweeps about the gland upon an exploratory tour.
Some lateral veins may require ligation. The sternomastoid muscle on one
or the other sides may have to be divided. If the gland is found uniformly
diseased, colloidal, cystic or adenomatous in both lobes, both should be
resected.
FIG. 1081. — OPERATION FOR GOITER.
The tumor is lifted forward and freed from its posterior attachments. The superior and
inferior thyroid vessels are seen ligated. (After Mayo.)
After dissecting free the two lobes so that they are brought forward and lie
upon the retracted muscles the isthmus should be divided between two forceps
in its narrowest part (Fig. 1083). The gland still has its posterior and
vascular connections. Each side is then dissected away from the trachea.
Complete removal of all gland tissue is not to be considered, but a resection
of part of each lobe should be proceeded with. A row of clamps is placed
about a lobe, catching the larger vessels which are exposed but especially for
the purpose of holding the stump. The part of the gland anterior to these
clamps is resected. This is done in such a manner as to leave a wedge-shaped
excavation in the remaining portion.
A mattress suture of chromicized catgut is then applied behind the clamps,
through the stump, in such a manner as to close the cavity. A second run-.
THE NECK
387
FIG. 1082. — OPERATION FOR GOITER.
Operation completed. The divided muscles have been sewed, a drain has been placed,
and the wound closed with subcuticular suture.
PIG. 1083. — OPERATION FOR DOUBLE GOITER.
Goiter exposed by transverse incision. Isthmus clamped and divided.
388
SURGICAL TREATMENT
ning suture is carried along the edge of the wound (Fig. 1084). The same
operation is done in the other lobe. The amount of gland tissue to be left
in the two lobes must be determined by the judgment of the surgeon. It
should be planned that the patient shall be left an amount of thyroid tissue
capable of satisfying the physiologic needs. The fact that the gland is
diseased should be taken into consideration, as more diseased gland is re-
quired than normal gland.
For operating upon extremely vascular goiter with greatly dilated capsular
veins, preliminary ligation of the arteries facilitates the procedure. The low
transverse collar incision is used. It passes through the platysma. The
sternomastoid is retracted strongly outward until the fascia covering the
small muscles is exposed. This fascia is divided vertically, and the carotid
exposed on its inner side. The inferior thyroid artery is identified as it
FIG. 1084. — OPERATION FOR DOUBLE GOITER.
The two lobes have been resected. The remaining portions of the gland have been sewed
over with mattress sutures.
emerges horizontally from beneath the artery, and tied. The recurrent
laryngeal nerve is separated from the artery by the thyroid fascia. The
artery should be tied so as to avoid the parathyroid.
The goiter is then freed and retracted downward, and the skin upward,
while the superior thyroid artery is tied. How much of these vessels is
ligated depends upon the character of the goiter. In the case of a double-
sided operation requiring resection of both lobes, ligation of the two inferior
arteries and ligation of the anterior branches of the two superior arteries
should suffice. This will be found to control hemorrhage. The operation
of resection may then go on as above, or the isthmus may be left (Fig. 1085).
For controlling bleeding, L. Freeman (Surg., Gyn. and Obst., xix, 1914),
used two pieces of stiff wire, placed on either side of the lobe to be removed,
THE NECK
389
and drawn together by ligatures tied about the ends and passed through
the pedicle.
For resection of a part of a lobe, the preliminary exposure is made as for
excision. The part to be resected is dissected free and cut away after crush-
ing or multiple ligation beyond the line of incision. The friability of
the diseased thyroid sometimes makes suture of its substance difficult or
inadvisable.
The performance of tracheotomy, in a wound through which an excision
of a goiter has been done, is apt to lead to infection and cellulitis reaching
the mediastinum. It is rarely justifiable. When compression of the trachea
is great, division of the isthmus and outward retraction of the compressing
lobes should be the first step of the operation. If an emergency arises which
cannot be met by intubation, and tracheotomy must be done, the great
wound should be left widely open, and the skin of the lower margin pressed
backward so as to leave as small an inferior cellular area as possible.
,5UPEf\lO(\ THYROID
EPITHELIAL BODIE5 f'
"viNF THYROID AfVT5/'
FIG. 1085. — OPERATION FOR DOUBLE GOITER.
Diagram showing segments of thyroid to be resected and result after closure of wounds.
All arteries are tied excepting a large branch of the superior thyroid on either side.
The results of the operation are good, provided adequate thyroid tissue
has been left, the parathyroids have not been removed, the recurrent
laryngeal nerves not damaged, and the operation conducted with surgical
circumspection.
Aberrant goiter, forming in the accessory thyroid glands, should be treated
by removal provided the function of the thyroid is normal. Degenerative
disease of the thyroid gland proper may be followed by a compensatory
hypertrophy of an accessory thyroid. To remove such an organ would be a
serious mistake.
Aberrant goiter in the region of the hyoid bone is removed without great
difficulty. Goiter developing in the lingual thyroid, or other tumor of the
root of the tongue, is difficult to^ reach. Access may be secured by an incision
carried in a horizontal plane under the lower jaw, bisected by the middle line.
The superficial soft tissues are retracted downward, and the tongue muscles
are separated laterally from the middle line. If necessary, temporary median
division of the lower jaw may be done.
Hyperthyroidism (Conditions in which there is a thyrotoxicosis incident
to excessive secretion of [the thyroid or parathyroids, such as in Graves'
390 SURGICAL TREATMENT
disease or exophthalmic goiter). — It should be remembered that this serious
condition often can be prevented by removing simple goiters before they pro-
duce this disease. All cases are benefited by rest in bed, and quieting
influences. The general treatment consists in improvement of hygiene by
fresh air, freedom from worry, rest, baths followed by cold douches, and
systematic non-fatiguing exercise. Carbohydrate and proteid metabolism
is very active and must be met by a generous diet and rest. Iron and
arsenic are often needed and bromids and valerian for nervousness. Stro-
phanthus may be used when the heart symptoms are distressing. But all
drugs should be used carefully and sparingly and not continued unless giving
positive results.
The vascularity may be reduced and the thyroid function improved by
faradism and galvanism. In acute cases, cold may be applied. The x-rays
have a similar effect. A hard tube of 3^ ma. with i6x as the largest
dosage, is used for two or three months. Thyreoprivic serum and thyreodectin,
obtained from the blood of animals from which the thyroid has been removed,
seem of benefit in some cases so long as it is given. The effect does not
last, it seems not to influence the diseased gland, and it has failed in most
hands.
The radium treatment has given results in some cases which have not
responded to other methods. Radiation treatment is given in dosage of 70
to 100 mgm. hours with a large radium plaque applied externally (see Radium
Therapy, Vol. III).
Improvement has been secured by inserting a bit of radium, sealed in
a tube, into the substance of the gland. For this purpose to cgm. of 300,000
strength for twenty-four hours, and 60 mgm. of 1,800,000 strength for eight
hours, are used.
The serum treatment of hyper thy roidism can not be ignored by the
surgeon. Human thyroid glands are finely chopped, suspended in physio-
logic salt solution, and the thyroid protein extracted. This is used as an
antigen. It is injected into the peritoneal cavity of sheep in increasing
doses. The blood of these sheep is used for the preparation of the serum.
This is the serum of S. P. Beebe (Jour. Am. Med. Assoc., Jan. 30, 1915,
vol. 64, No. 5). Its injection in cases of hyperthyroidism in 3000 cases
reported by Beebe gave 50 per cent, of cures; and marked improvement in
30 per cent, of the cases.
The injections of boiling water have given good results in the hands of
M. F. Porter (Annals of Surg., October, 1916). Under local anesthesia
several areas are injected. This may be done in both lobes through one
median puncture. From 3 to 30 c.c. (45 to 450 minims) may be injected at
one sitting. Improvement takes place in twenty-four hours. Several in-
jections may be made at intervals of two weeks. This treatment is of
value in the cases which are too bad for operation. It is capable of giving
quick relief. It is curative in the mild cases. In these mild cases with small
goiter it is best to make a small incision over the isthmus under local anes-
thesia, and inject each lobe with the aid of sight.
The injections of quinin and urea proved effective in the hands of L. F.
Watson (Jour. Am. Med. Assoc., September 25, 1915). The site of the in-
jection is anesthetized. The empty needle is inserted into the body of the
tumor, then the syringe is connected and from i to 4 c.c. of a 30 to 50 per
cent, solution of quinin and urea hydrochlorid are slowly injected. The
injection is repeated about every third day. Eight to fifteen injections must
be made before any marked improvement is noticed.
It is best to precede the drug by a few injections of normal salt solution
THE NECK 391
There is less pain if the same site is used for all injections. The treatment is
not recommended in advanced toxic cases.
The dangers of nonoperative methods should not be lost sight of. Any
of these measures may produce unexpected hyper thyroidism. When the
thyroid gland is in that unbalanced state which is characterized by hyper-
thyroidism, manipulation, traumatism, or the effect of chemical or physical
stimulation may be expressed in hypersecretion which, though destined to be
but temporary and transient, may result fatally before it recedes. P.
Verning (Hospitalstidente, Aug. i, 1917) reported cases of fatal results
following #-ray treatment.
The important features of nonoperative treatment are rest, fresh air
(preferably at an altitude of 2400 to 5400 feet in the mountains), warm
baths, cold rubs, and a liberal diet of simple food. An abundance of pure
water should be drunk. It should not be the water used by the patient
while the goiter was developing. The best foods are milk, eggs, butter, rice,
fish and meat — all slowly eaten and well masticated. Salt should be used
only very sparingly. If the patient is not restored to comfort or efficiency
by the above measures, thyroid activity should be checked by operation on
the gland, aimed to remove some of its substance or diminish its blood
circulation. Patients should not be operated upon until they have had three
months of treatment, unless no improvement is being derived. Operation
should be preceded by two weeks of rest in bed.
Operative treatment has much more to offer than the above-described
measures. Thyroidectomy is indicated in cases which have not yielded
to hygienic and medical treatment after three months of treatment. In
the presence of serious degeneration of the heart, low blood-pressure, ir-
regular heart, periodic attacks of cardiac delirium, ligation of the superior
thyroid arteries and veins on both sides is advised as a preliminary opera-
tion, or the mass ligation of Crile. This operation gives relief in most cases
and may be followed later by thyroidectomy, if necessary. Much of the
benefit of these operations lies in cutting off some of the nerve connection
between the brain and the gland. The operation gives relief for the same
reason that psychic rest does, for undoubtedly the disease is not one primarily
of the thyroid gland.
In cases in which the condition of the patient does not warrant thyroidec-
tomy, the surgeon should only do such an operation as the patient can bear.
Ligation of one, two or three of the thyroid arteries may be done. If the
patient can bear more than that removal of one lobe may be attempted.
The wise surgeon does no more than the patient can safely tolerate.
If ether anesthesia is used the smallest possible amount of ether shouldjbe
employed. By anesthetizing the patient, and then elevating the head of the
table so that the body lies at an angle of 45 degrees, the brain anemia thus
produced permits the operation to be done without any more ether. The
danger of pneumonia is very great if full ether anesthesia is used.
Washing out the stomach with warm water after ether anesthesia helps
reduce the danger of postoperative thyrotoxicosis. Local anesthesia is
always to be preferred.
The injection of boiling water is less dangerous than ligation, and is to
be preferred in the serious cases in which thyroidectomy can not yet be
done.
For extreme exophthalmos, in which the thyroid is not much enlarged but
the nervous symptoms pronounced, removal of the cervical sympathetic
ganglia has given good results. In this operation the superior thyroid vessels
should be ligated at the same time. Each side is operated upon. The in-
392 SURGICAL TREATMENT
cisions lie along the anterior border of the sternomastoid muscle. The
muscle is retracted outward, the sheath of the great vessels is exposed, and
the sympathetic ganglia exposed (see Removal of Sympathetic Ganglia,
Vol. I, page 899). The superior and middle ganglia are removed. This
operation is capable of preventing the corneal ulcerations which are so prone
to complicate extreme exophthalmos. Jaboulay (Bull, de 1'Acad. de Med.,
1897, xxxviii) resected the superior ganglion and 2 or 3 cm. of nerve on either
side. This operation benefits also the nervous symptoms of the disease.
Rapid benefit is first observed, and then a prolonged and progressive im-
provement of all the symptoms extending over a period of years.
Thyroidectomy is done in the cases with pronounced symptoms and
thyroid hypertrophy. Excision of the larger and more vascular lobe, to-
gether, if possible, with the isthmus and pyramidal process, constitutes the
operation. If the other lobe cannot be felt, some of the lobe operated
upon should be left with the isthmus. Not more than half of the gland
should be removed in the cases of small glands. In the ordinary case
about three-fourths of the total gland is removed. The operation is more
difficult than the operation for ordinary goiter because of the extreme vas-
cularity and friability of the gland. Blood should be saved as much as
possible. Every vessel should be clamped. Unnecessary traumatism
should be avoided.
The choice of anesthetic must depend upon circumstances. Local
anesthesia is much to be preferred, but it should be taken into account that
the patient is apt to be in a highly nervous state and unless the surgeon is a
master of local anesthetization, it should be combined with some general
narcosis, or a general anesthetic should be used. Ether, given by the open
or drop method, is satisfactory. General anesthesia has the advantage that
thefcpatient is spared the fear during operation. Morphin should be in-
jected half an hour before the anesthetic.
The parathyroid bodies should neither be traumatized nor removed.
They are best avoided by care in leaving behind the posterior part of the
capsule. This is the same care necessary for the avoidance of the recurrent
laryngeal nerves.
The recurrent laryngeal nerve is greatly endangered when the inferior
thyroid artery is exposed. If an attempt is made to ligate the artery external
to the point where it crosses the nerve, the nerve is bound to be injured more
or less, and at least a certain amount of temporary paralysis is apt to follow.
Ligation external to the nerve is apt also to interfere with the blood supply
ofj the inferior parathyroid gland. For these reasons the artery should
be ligated in front of the posterior capsule of the gland; and that part
of the posterior capsule which lies against the trachea should be left
undisturbed.
The great danger of the operation is in a superadded hyperthyroidism,
occurring before the patient's organism secures the benefits of the removal of
the thyroid. This condition is manifested hi a psychic storm with increase
of pulse-rate; acute cardiac dilatation, tremor and fever. This is partly
due to the use of general anesthesia, and markedly to psychic influence and
trauma. By trauma is meant, not necessarily injury to the thyroid, but any
traumatism capable of causing pain, peripheral irritation, or fear. When
excision is to be practised, Crile proceeds as follows: The effects of small
doses of morphin and scopolamin are ascertained. As the patient lies in
bed, daily inhalations, of volatile oils, presumably for therapeutic purposes
are given by the anesthetist. Ether is experimentally dropped in the inhaler
to observe the patient's reaction to it. It may be carried to the point of
THE NECK 393
anesthesia. Consent to operation is obtained but the patient is not allowed
to know when the operation is to be done. Morphin and scopolamin are
given prior to operation; the patient is kept quiet in her bed; she is then
anesthetized with ether to the second stage as though it were a treatment,
and taken to the operating room and the anesthesia continued with nitrous
oxid. The field of operation is then cocainized as though no general
anesthetic were to be used. The skin and fascia of the opposite side are
incised about 2.5 cm. (i inch), and through this incision a ligature is carried
with a curved needle around the upper pole of the gland and the overlying
tissue and tied. Then the other lobe is excised with the least possible loss
of blood and with painstaking minimization of traumatism to any unco-
cainized area. Pain and psychic stimuli should be controlled. For the
technic of thyroidectomy, see Goiter, page 382.
Ligation is done by Crile as follows: Morphin and scopolamin are given,
and when the patient is comfortably under their influence, she is told what
she will experience. The operation is done with the patient in bed. Cocain
anesthetization of the skin is used. A transverse incision not longer than
2.5 cm. (i inch) is made through the skin and fascia over the upper pole of
each lobe. A well-curved needle is passed from without inward so as to
include in a ligature the upper pole and all of the structures between the in-
cision and the larynx. The ligature should be tied close to the gland or
should include some gland tissue, in order to prevent a reversal of the circula-
tion in the anastomotic branches which communicate with the inferior thy-
roid artery. After the ligature is tied, the wound is closed. The same opera-
tion is done on each side.
Kocher advised ligation of two or three arteries. The easiest to ligate
are the two superior thyroids (see Vol. I, page 411). In struma vasculosa,
ligation is the operation of choice.
Crile says: "The disease may be cured in one or more ways: (i) if the
brain-cells are sufficiently repaired by absolute rest; (2) if the nerve connec-
tion between the brain and thyroid be interrupted in part by tying the upper
thyroid poles, which include half or more of the nerve supply; or (3) if the
secreting structure of the thyroid be diminished by partial excision or by
cytolytic serum. Of these three methods excision is the most effective.
The immediate relief to the patient following excision is one of the most
striking clinical phenomena in surgery." The value of ligation, he believes,
is in the ligation of the nerves rather than the blood-vessels.
Double ligation gives great improvement in early cases. Cases in bad
general condition, with feeble hearts and inanition, may be treated by liga-
tion of the left superior thyroid vessels. This does not cause quite so severe
a reaction as double ligation. The right superior vessels may then be ligated
a week or two later. It will be observed that the second operation causes
much less reaction than the first. If the condition of the patient permits,
at the second operation, the right lobe, and possibly the isthmus and part
of the left lobe may be removed.
The after-treatment, following either thyroidectomy or ligation, should
be rest. Psychic stimuli, worry, responsibility, and pain should be pre-
vented. If, after operation, a patient soon returns to the environment and
conditions in which the disease was contracted, recurrence may be expected.
The case demands psychic treatment, because the disease has an extrathy-
roid origin; the disturbance of the thyroid is only one of its results. The
patient should have much rest and fresh air. Alcohol, tea, coffee, and tobacco
should be avoided. Excess of salt should be avoided; this means broths
as well as table salt. Ripe fruits and vegetables are desirable. An abun-
394 SURGICAL TREATMENT
dance of pure water should be drunk. A cheerful and hopeful state of mind
should be maintained.
The Parathyroid Glands. — Much experimental evidence seems to point
to the parathyroids as having to do with tetany, and to indicate that their
removal or elimination by disease gives rise to that disease. Parathyreopriva
seems to be associated with tetany-like symptoms, and to be benefited
by parathyroid medication. Amelioration of symptoms has been reported
as following the subcutaneous administration of parathyroid extract, and the
ingestion of Beebe's nucleoproteid, and also of calcium lactate.
Transplantation of parathyroid from animals to man has failed always to
give results. Transplantation from man to man has given beneficial results
in some cases. The glands are secured by carefully dissecting out one para-
thyroid in the course of a goiter operation, preferably on a young person.
The implantation may be made in a pocket just external to the peritoneum
in the abdominal wall. The best results have been obtained when the
transplantation was made immediately.
The results of treatment are so uncertain that prophylaxis should
receive every attention. In operations upon the thyroid, not only must
enough thyroid be left to prevent myxedema, but care must be taken not
to remove the parathyroids lest tetany ensue. Even when only one lobe
of the thyroid is operated upon, the parathyroid should be spared. The
sparing of these glands is best secured by making dissections of the thyroid
within the capsule of the gland. The safest plan is to leave the posterior
part of each thyroid lobe, because the two parathyroids lie in contact with
it. The operations which ligate all of the thyroid vessels widely external
to the gland are dangerous because of the possibility of damaging the nutri-
tion of the parathyroids.
Hypothyroidism (Conditions in which there is a Deficiency of Thyroid
or Parathyroid Secretion, such as in Myxedema, Cretinism, Thyreoprivic
Idiocy, Mongolism, Dwarfism, Thyreoprivic Obesity, Tetany, Certain Neuro-
ses, Psychoses, Sexual Disturbances, and Epilepsy). — The treatment of these
hypothyroses consists in supplying the body with the products of the thyroid
gland. The average internal dose of the dried and powdered glands of the
sheep (i part representing about 5 parts of the fresh gland) is 0.25 Gm.
(4 grains), 3 times daily. The patient's diet should be rich in proteids
and carbohydrates. The earlier this treatment is begun, the better the
results. It has not been determined how much these diseases are due to
parathyroid deficiency, excepting that it is known that tetany belongs to
that class. The implantation of normal living thyroid gland tissue taken
from man or from an animal is the physiological method of treatment.
Kocher has made such implantations in the marrow of the long bones.
Christiani made multiple subcutaneous implantations. Kocher's method is
the best. The fresh warm gland tissue should be used at once. The im-
plantation of parathyroid tissue is still experimental.
Implantation should be done only after the internal administration of
thyroid extract has benefited the patient and thus shown the nature of
the disease.
THE THYMUS GLAND
This gland grows until the second or third year of life. At this time it
extends from the thyroid nearly to the pericardium, lying in the middle
line, flattened, pinkish, elastic, bilateral, embracing the trachea and in the
mediastinum lying just behind the sternum. It gradually atrophies, and
has disappeared by puberty. Thymic asthma, the status thymicus, thymic
THE NECK 395
epilepsy, thymic dyspnea, thymic tetany, status lymphaticus associated with
enlarged thymus, and other conditions, due to abnormal thymus activity,
call for treatment. In some cases the #-rays have been of benefit in check-
ing the malign action of the gland. General hygienic treatment should be
applied in all cases.
Thymectomy is indicated when the thymus persists beyond the period
in which it is required, and when its activities are productive of serious dis-
turbances not amenable- to other treatment. Usually it can be reached
by a median incision exposing it in the root of the neck. If the gland is en-
larged, it appears as a pinkish tumor rising behind the sternum. The
cervical portion of the gland is easily removed through this and much of the
thoracic portion can be drawn up and removed.
The curved transverse incision across the front of the neck gives better
access. The inner borders of the sternomastoid muscles are divided and
the sternohyoid muscles are cut across at their insertions.
In a case in which the physical examination had showed the gland to be
wholly poststernal, I secured a very satisfactory exposure of the space,
bounded below by the pericardium, and laterally by the two pleurae, by
turning back an osteoplastic flap. A ID -shaped incision was made in such a
way that the lower transverse arm crossed the sternum on a level with the
second intercostal space and the upper arm on a level with the top of the first
rib. The curved vertical incision, connecting the ends of the two transverse
incisions, passed down across the first and second ribs about 2 cm. (% inch)
from the left border of the sternum. The first and second ribs and the ster-
num were divided in the line of the skin incision and the corresponding
ribs on the right side were divided with little injury to the flap. The flap
containing the section of sternum with the sternal ends of the two ribs was
turned outward upon its base and the mediastinum and its contents exposed.
At the close of the operation the flap was replaced and held by chromicized
catgut sutures and the soft tissues sutured over the bone.
CAROTID GLAND
This small body, varying in size from that of a grain of rice to a grain of
corn, and attached to the wall of the carotid at or near its bifurcation, becomes
the seat of neoplasm, usually perithelioma, which on account of its close
relation to the vessel often pulsates like an aneurism. The growth should be
removed early, otherwise the carotid becomes involved in the neoplasm.
When operation is deferred resection of a part of the common carotid and of the
external and internal carotids may be necessary. When this is done we have
to consider the probability of serious cerebral disturbance which follows in
fully half of the cases and gives a mortality of about 25 per cent. Whenever
it becomes necessary to ligate or resect the common carotid, gradual occlu-
sion of the vessel should have been practiced, if possible, for several days
before the operation. It is the sudden shutting off of the blood supply to
half of the brain that constitutes the danger.
THE THORAX
Anatomy. — The thorax contains the lungs, heart and trunks of the great
vessels (Fig. 1086). Its rigidity is maintained by the ribs which prevent
collapse of the chest wall. A state of negative pressure exists within the
normal thorax. Fluids and air tend to rush into it, and are expelled only by
FIG. 1086. — DIAGRAM OF FRONT OF THORAX.
The dotted lines represent the borders of the pleuras. The heart and its compart-
ments and the great vessels are shown in dark lines, i. Right auricle; 2. right ventricle;
3, left ventricle.
muscular effort. The surgical anatomy of the various organs (Fig. 10860)
of the thorax will be found in connection with each organ.
Contusions of the Thorax. — Without causing discoverable injury of the
thoracic wall, contusions may injure the heart, lungs, or important nerves to
such a degree as to require treatment for cardiac rupture, valvular injury,
pulmonary hemorrhage or shock. Aside from these conditions, contusion may
produce a strain of the ligaments and muscles of the thorax which should be
396
THE THORAX
397
treated by rest. If the respiratory movements are painful, the pain may be
relieved by hot applications or by applying an adhesive strap as for fracture of
the ribs (Vol. I, page 549). Concussion of the thorax, causing serious irrita-
tion to the great sympathetic centers, should receive the treatment described
for shock (see Vol. I, page 213).
Chest Wall. — Non-penetrating wounds, if small should be covered quickly
with a wet antiseptic dressing, and the movements of the chest somewhat
inhibited by the retaining bandage. One of the objects of this dressing is to
exclude air which may be sucked in and produce emphysema. Larger and
gaping wounds should be sutured and dressed as above. No chances should
be taken with the possibilities of retained discharges; thorough cleansing
should be done and drainage should be provided, because of the danger of
infection invading the pleura or pericardium (see Wounds, Vol. I, page 186).
Penetrating wounds of the chest wall are treated the same as other wounds
except that the damage to the special organs of the thorax may require at-
FIG. io86a.-
-DIAGRAM OF TRANSVERSE SECTION OF THORAX SHOWING POSITIONS OF THE
IMPORTANT VISCERA. (After Gray.)
tention (see Wounds of the Pleura, page 399; Lungs, page 413; Pericardium,
page 422; Heart, page 428; Esophagus, page 431). If the symptoms of
serious shock, hemorrhage or injury of important structures are not present,
the wound should be asepticized and covered simply with a protective
dressing. It is usually best that such a wound should not have instruments
introduced into it to discover whether or not it is a penetrating wound.
Suture of the wound need not be done unless the laceration of tissue is ex-
tensive. If the wound is sutured it should not be closed wholly but an opening
should be left for a drain to carry off pleural exudate or other fluids.
The patient should be kept quiet. Rest in bed is most important.
Sedatives and strapping the chest as for fracture of ribs, may be called for
to control cough and pain.
In case of doubt, as to whether a penetrating wound involves one of the
398 SURGICAL TREATMENT
above-mentioned important structures the wound should be enlarged and
treatment conducted under exact information.
Wounds of the diaphragm are best treated by being sutured, if they are
larger than i cm. (% inch) in size. Suture is aimed to prevent hernia.
The diaphragm is best exposed through the thorax. The transpleural
operation is much easier and safer than through the abdomen. Wounds of
the diaphragm lying near the chest wall may sometimes be sutured to the best
advantage by passing the sutures so that the wounded area is sutured to the
chest wall.
The approach to the diaphragm is secured by resecting one or more ribs.
The wound of the diaphragm being exposed, it is best closed with absorbable
sutures. Whether drainage of the pleural sac or peritoneum is required
depends upon the possibilities of infection. Usually drainage of the abdomen
is not required if there is no penetration of the stomach or intestine. If the
wound in the diaphragm cannot be sutured the lips of the diaphragmatic
wound may be sewed to the lips of the wound of the chest wall, thus obviating
hernia and much reducing the possibilities of pleural infection.
Wounds of the internal mammary artery may produce serious hemorrhage
into the mediastinum without much external show of bleeding. Packing the
wound is not to be depended upon. The best treatment consists in com-
pressing the vessel by means of a ligature. If the wound is sufficiently large,
a well-curved needle carrying a ligature should be passed through the tissues
so as to embrace the vessel. The ligature should be passed from within
forward, by means of a needle on either end. If the wound is not large
enough for this it should be enlarged. The vessel passes down behind the
ribs, lying about 1.3 cm. (^ inch) from the edge of the sternum. While
the ligation is proceeding, firm pressure upon the subclavian may be made at
the root of the neck, behind the clavicle, just external to the sternomastoid,
with a small pad held by the fingers. Both proximal and distal ligation
should be done. The operation should be carried out with the utmost
regard for asepsis because of the danger of infection of the anterior
mediastinum.
Wounds of the intercostal artery occur in connection with fractures,
external accidental wounds and in operations, and produced hemothorax
if there is penetration of the pleura. This artery is so small that packing
of the wound will often control it. It lies in the groove on the lower and
inner aspect of the rib. A small firm plug of gauze, pressed outwrard and
upward by means of a retractor or ligature tied about it, will control the
bleeding. The most satisfactory method is to secure the vessel by means of
a ligature passed on a small well-curved needle. Some surgeons have
carried a ligature around the rib.
Inflammations of the Chest Wall. — Caries and necrosis of the ribs and
sternum are amenable to the same treatment as is applied to other bones
(see Inflammations of Bone, Vol. I, page 467). The same may be said of
arthritis of the sternoclavicular joint and of the costal joints (see Arthritides,
Vol. I, page 657). Abscess of the chest wall should be treated with aseptic
care because of the possibility of its communicating with the pleura. Syphilis
and tuberculosis of the ribs and their joints should receive the same treatment
as elsewhere.
Costal chondritis, expressing itself in the form of necrosis of the costal
cartilages, whether following typhoid or other infection, demands radical
treatment. Usually it comes to the surgeon with a sinus or sinuses opening
on the wall of the chest or abdomen, an abscess having opened or been
opened previously. My own experience with this condition leads me to the
THE THORAX 399
conclusion that it should not be temporized with. A wide excision of all of
the diseased cartilage should be done. It is not easy to identify the place
of demarcation between diseased and healthy cartilage. The cases which I
have been able to cure most promptly have been those in which all contiguous
cartilage was removed at the operation. The vitality of this tissue is so
poor that if it is not all removed, infection and continuation of the necrosis
is prone to occur in the rest of the cartilage. The best method of attack is
to inject the sinuses with methylene blue solution and follow them to their
utmost. The sinuses should be freely laid open and the diseased cartilage
excised. If any cartilage is left the sinuses should be sterilized with phenol
and alcohol, and the wound and cut cartilage surface treated the same. The
whole wound tract should then be dried and throughout treated with tincture
of iodin. Unless a complete sterilization of all of the wound can be secured
all cartilage in relation to the wound should be removed.
THE PLEURA
Anatomy. — The pleura is represented by two sacs which line the chest wall and cover
the viscera of the thorax. The parietal layer of the costal pleura covers the inner sides of
the ribs and the sides of the bodies of the vertebrae, and then passes to the side of the peri-
cardium and the root of the lung where it becomes the pulmonary pleura. The visceral
layer covers the lungs, dips between the lobes, and continues with the parietal layer at the
root of the lung. The cervical pleura is that part which covers the apex of the lung and
rises from 1.3 to 4.5 cm. (J£ to i% inches) above the first rib. The subclavian artery
curves over it and grooves its antero- internal surface just below the apex. The scalenus
anticus and scalenus medius muscles are in contact with it externally. The diaphrag-
matic pleura covers the upper surface of the diaphragm, excepting the central part
which is covered by the pericardium and the extreme outer part which lies in contact
with the chest wall.
Anteriorly the margin of the pleura, extending from the apex of the lung to the sterno-
clavicular joint, passes downward behind the sternum and lies in contact with the oppo-
site pleura from the upper end of the sternum to the fifth costal cartilage. The right
pleura continues downward to the xiphoid appendix and thence passes outward. The
left pleura diverges and lies 1.5 cm. (% inch) from the left border of the sternum at the
fifth costal cartilage; 2 cm. (I^{Q inch) at the sternal end of the sixth; and 3.5 cm. (i%
inches) at the level of the sternal end of the seventh cartilage. The lower margin of the
pleura is reflected from chest wall to diaphragm on the right side along a line extending
from the lower end of the gladiolus outward behind the seventh costal cartilage nearly
to the sternal end of the rib; on the left side this line follows the lower border of the sixth
costal cartilage. At the following points the lower border of the pleura corresponds with
the height of the following structures: in the nipple line, with the eighth rib; in the mid-
axillary line, with the ninth rib on the right and the tenth rib on the left; in the poster-
ior scapular line (a line drawn vertically from the inferior angle of the scapula), with the
twelfth rib; and at the spinal column, with the vertebral end of the twelfth rib. In some
cases the pleura is as low as the transverse process of the first lumbar vertebrae.
The lower border of the lung does not extend to the limit of the pleura, but lies about
two ribs higher on each side. This interval of the width of two ribs leaves the two mar-
ginal surfaces of pleura (diaphragmatic and costal) lying in contact or separated by pleural
fluid.
Wounds of the pleura communicating with the outer air cause pneumo-
thorax and collapse of the lung. If aseptic healing of the wound can be
secured, the air becomes absorbed just as in emphysema and the lung
gradually expands to its normal place. For this reason, the first thing that
should be done with a penetrating wound of the chest and pleura is to apply
an occlusive dressing. For this purpose nothing is better than a copious
covering of gauze wet with antiseptic solution. If the wound of the chest
wall is so large that it gaps, the occlusive property of the dressing can be im-
proved by applying first a small dressing, covering this with rubber dam,
extending well beyond its circumference, and then over all applying a larger
mass of gauze. If the wound of the thorax is extensive, of course, it should
400 SURGICAL TREATMENT
be sutured. The question as to whether drainage should be provided or no
must be determined by the probabilities of infection. A small clean-looking
wound need have no treatment but the occlusive antiseptic dressing. In
the case of a larger wound, one that is ragged, or one that is to be sutured,
the surrounding skin should be cleansed after the method described under
the treatment of wounds (Vol. I, page 186). Wounds made by the surgeon,
in the course of an aseptic operation, should be closed by suture, completely
sealing the pleural cavity. Wounds which are known to be infected, it may
be assumed, will be followed by pleuritis, and drainage should be provided.
Emphysema, occurring in connection with these wounds, usually requires
no treatment, even though it spread extensively over the body. The air
which finds its way under the skin will be absorbed, and will cease to enter
as soon as the connective-tissue spaces in the wound become filled with
exudate. If the air gives distress it may be liberated by incisions or
pressure.
Pneumothorax, with collapse of the lung, without infective pleuritis,
requires only the treatment of the wound through which the air entered,
as described above. Associated with infection, its treatment is described
under empyema. The danger of pneumothorax is from infection, and for
this reason the wound should be occluded as quickly as possible. While the
wound is open a gauze pad should cover it to filter the air. For artificially
induced pneumothorax, see page 416.
Hemothorax is best treated by evacuation of the blood. This course
is to be recommended in the cases in which the hemorrhage is from a penetrat-
ing wound and associated with pneumothorax. Then the wound may be
enlarged, if necessary, the bleeding vessel secured, and the blood washed out
with the aid of the blunt curet. If the wound is high in the chest, or ante-
riorly, it is best to make a new opening low down and posteriorly as for
empyema.
Hemothorax without an external wound, as occurs in laceration of the
costal pleura by a fractured rib, may be assumed to be aseptic. If the
amount of blood is small, it need not be removed. If the hemorrhage is
considerable, easily revealed by percussion, and producing a collapse of the
lung, which is clearly manifested by diminished respiratory murmur, the
blood should be evacuated. The time and site of operation must depend
upon the condition of the patient and the hemorrhage. If the bleeding is
not progressing, there is no urgency. If depression, due to some other
conditions than hemorrhage and lung compression, is present, operation may
be deferred. But at the earliest time consistent with the general interests
of the patient, and at once if the bleeding is progressing and the compression
is embarrassing the heart or respiration, the chest should be opened and the
blood removed. Such an opening should be made as for empyema, unless
the bleeding is continuing, in which event the location of the hemorrhage
should be exposed, a rib resected on either side of the fracture, if necessary,
and the vessel tied.
Small collections of uninfected blood in the pleural sac do not require
operation. Rest in bed and a binder to diminish the respiratory movements
suffice. When operation is done the question of drainage must depend upon
infection. If the surgeon is reasonably confident that no infection has been
introduced, and the bleeding has stopped, the wound may be closed through-
out. If there is a probability that infection has been planted upon the
pleura, drainage should be provided. This should be such as is used in
empyema, excepting that but one short tube is necessary. It should be
borne in mind that a small amount of infection can be overcome bv the
THE THORAX
401
pleura, and that the presence of a tube in an uninf ected pleura always threatens
it with infection. Uninfected collections of blood are capable of absorption.
If infection occurs later, the condition may then be treated as for empyema.
Hydrothorax, or non-purulent serum in the pleural sac, usually becomes
absorbed spontaneously. When the amount of fluid is so great as to em-
barrass respiration or the heart, or when, even though causing no distress, it is
not being absorbed it should be evacuated. The treatment of tuberculous
effusions is discussed elsewhere (page 413).
Aspiration of pleuritic fluid should be done with an aspirating needle,
preferably connected by non-collapsible rubber tubing with a vacuum bottle
(Fig. 1087). The operation should be conducted with rigid asepsis. This is
distinctly a surgical operation. A general anesthetic is not required. Accu-
rate percussion and auscultation should have located the level of the fluid.
FIG. 1087. — ASPIRATING CHEST FOR HYDROTHORAX.
Usually the best result is secured by having the patient sitting on a table
with assistants on either side. Or the patient may lie close to the edge of
the table. A little cocain may be used for the skin in a sensitive adult;
it is rarely needed. The arm on the side to be aspirated should be raised
to elevate the ribs.
If the fluid rests on the top of the diaphragm, and is not confined by
adhesions, the needle should be entered in the midaxillary line through the
sixth or seventh intercostal space. If the fluid is encapsulated or confined
by adhesions the needle should be entered about in its center. Unneces-
sary accidents may occur if this operation is not carefully done. The lung,
pericardium or diaphragm may be penetrated. The chest wall is 2 or 3 cm.
thick — less than this in a young child. The needle should be entered nearer
the upper border of a rib than the lower in order to escape the intercostal
VOL. 11—26
402 SURGICAL TREATMENT
vessels. The sensitive hand easily recognizes the cessation of resistance
when the needle has penetrated the costal pleura. The needle need be carried
no farther. The trocar should be withdrawn, and fluid will run. If fluid
does not flow, it may mean that a bit of fibrin has blocked the needle.
This may be removed by reinserting the stilet or by applying suction. If a
needle without a trocar is used it sometimes happens that a bit of tissue
occludes it; this may be cleared in the same way. As the fluid runs out
a dry cough develops as the lung expands. Presently the lung will be felt
to strike the needle with each respiratory motion. When this occurs the
needle should slowly be withdrawn until no more fluid runs, and then re-
moved. A small pad of gauze held by an adhesive strap may be placed on
the puncture. Hydrothorax may be aspirated several times before a cure is
effected or the disease changes to an empyema.
Insufflation of air is of value in cases with a large amount of effusion.
Air is admitted as the fluid is drawn off. This has the advantage that the
compressed lung is not rapidly expanded, cough, dyspnea, and albuminous
expectoration are obviated. Achard (Semaine Medicale, vol. xxviii, No.
38) in a large experience finds that the cases heal more rapidly with this
method. The lung expands as the air is gradually absorbed. The evacua-
tion should be done through sterile apparatus. As the fluid is pumped out,
for about every half liter, some air should be pumped in, simply by changing
the suction syringe for an injection syringe. The air sterilizes itself in
passing through the syringe, tubes and bottle, provided their interior is wet.
The insufflation should be stopped when the pressure of the air produces
the least discomfort.
A still more simple method consists in placing the patient in a comfortable
position across two beds, the chest spanning from one to the other. A
trocar 6 or 8 cm. (2% °r 3 inches) long and 0.4 mm. (^ inch) wide, is
introduced between two ribs at the lower limit of the effusion, and the fluid
allowed to flow into a receptacle between the two beds. As much fluid as
will is allowed to run out. Air naturally enters with inspiration. The
trocar is removed at the end of a deep expiration, and the opening is closed
with a piece of adhesive plaster. It has never been shown that atmospheric
air does harm in the pleural cavity. It is gradually absorbed.
Auto serotherapy is effective is some early cases. Exploratory puncture is
made with a glass syringe. If the aspirated fluid is found to be clear and
free from pus, it is injected immediately into the subcutaneous tissue.
This is done without withdrawing the needle from the chest wall but simply
altering the position of its point. The injections are repeated every second
or third day. From i to 5 c.c. (15 to 75 minims) of serum are injected
each time. This method, introduced by Gilbert of Geneva, has been reported
upon favorably by many surgeons. The injections probably stimulate the
formation of antisubstances. This treatment has proved effective in sero-
fibrinous pleurisy.
Pyothorax, or empyema, demands opening the chest wall and evacua-
tion of the pus contained in the pleural sac. Unless this is done, a fatal
termination may be expected, from prolonged septic absorption; pyemia;
nephritis; embarrassment of the heart and respiration from pressure; rupture
of the abscess into the lung, causing suffocation; or chronic fistula and sepsis,
following rupture through the diaphragm. Some cases have healed by rup-
ture through the chest wall or by spontaneous sterilization and absorption of
the pus. Such an outcome should not be awaited.
The removal of thin pus by aspiration has in some cases been sufficient.
Usually aspiration must be followed by more radical operation. Aspiration
THE THORAX 403
is justified in cases in which operation cannot be done, but relief is demanded
at once. It should not be expected to cure the disease.
Simple intercostal thorocotomy is performed if the case is so urgent that the
operation of 'choice cannot be done. It consists in an incision between the
ribs. It requires only a knife. After the puncture of the chest wall a drain-
age tube may be put in. The operation is accomplished much more quickly
than aspiration. If desired, a more deliberate dissection may be made,
and aspiration done before the pleura is incised. Unless the tube is very
rigid the ribs will compress it and drainage will soon be shut off. A metal
tube may be used to obviate this.
The operation for empyema which should be called the operation of choice
consists in the removal of a section of one or more ribs, opening of the pleura,,
evacuation of the pus, the introduction of a large drainage tube, and subse-
quent protection from external infection. This is the operation of choice for
all conditions in which drainage is required. The patient should lie on the
sound side. Light general narcosis or local anesthesia may be used. For
local [anesthesia, I have found general infiltration of the tissues with weak
FIG. 1088. — RESECTION OF RIB FOR EMPYEMA.
anesthetic solution most satisfactory, combined with an injection of a stronger
cocain solution in the region of the intercostal nerve. The cutting of the
rib is painful unless the periosteum of its whole circumference is cocainized.
The positive presence of pus should be determined by aspiration. Ordi-
narily the excision of one or two ribs is sufficient. If the pus is thin or haste
is required, but one need be excised. Usually the opening should be
made in the midaxillary line, at the seventh rib or in the eighth or ninth inter-
costal space. When the pus is sacculated or confined by adhesions, the
opening should be made at its center.
An incision, about 7 cm. (2^ or 3 inches) long, is made upon the seventh
rib parallel with the rib. The soft tissues are quickly dissected back and
the rib exposed. The periosteum on the outer surface is incised in the middle
of the rib parallel with its long axis, and peeled from the bone with a sharp
elevator.. The periosteum is peeled from the whole circumference of the
rib, carrying with it the vessels which run in the groove on the lower border.
The denuded segment of rib, 3 or 5 cm. long, is then excised by means of
bone-cutting forceps or a wire saw (Fig. 1088). The section of the rib being
cut out, an incision is made into the pleural sac through the periosteum and
pleura. This should not be done by plunging the point of a knife through
the tissues but by strokes of the knife with a decent regard for uncertainties
404 SURGICAL TREATMENT
which may be underneath. As the pleura is penetrated, and pus rushes
forth, the patient should be turned further toward the recumbent position
to permit its free escape. During inspiration a sponge may be held over the
opening.
Strings and lumps of fibrin should be pulled out with forceps. When the
cavity has emptied itself of this material, a large drainage tube should be
introduced. It is only necessary that the tube should pass well through the
chest wall; it need not pass far into the pleural sac. The outer end of the
tube should be secured by a suture or safety pin (Fig. 1089) to prevent its
slipping into the thorax. (I once operated for an apparently incurable
empyemic fistula, and found a drainage tube lying unknown in the pleural
cavity, the removal of which resulted in rapid healing of the opening. The
safety pin prevents this accident.)
Some surgeons remove sections of two ribs, making the incision in the
eighth intercostal space. In most cases one is sufficient. Irrigation of the
cavity is necessary only when masses of coagulated lymph cannot otherwise
be removed. The ends of the wound are
closed by sutures down to the tube. A cop-
ious dressing of gauze and cotton is held on
by a chest binder.
The after-treatment consists in keeping
the wound covered with sterile dressing to
take up the discharge and protect the wound.
Rigid asepsis should be continued without
relaxation until the wound is healed. The
dressings should be changed only when
FIG. 1089.— WOUND AFTER OPERA- soaked with discharge. This is usually once
TION FOR EMPYEMA. daily. Irrigation is not to be used unless the
discharge becomes fetid or the drainage in-
adequate. For irrigation a chlorin solution, a i : 10,000 bichlorid solution,
a 1:1000 tincture of iodin, a 1:500 potassium permanganate, or a saturated
boric acid solution may be used. The fluid should flow in without force.
Delayed healing in empyema may be due to several causes. It often
happens in these cases that a rise of temperature takes place without any
apparent cause. This may be due to the drainage becoming ineffective
because the tube, not reaching the most dependent part of the abscess, and
being surrounded by a wall of fibrin, is prevented from draining the main
cavity; or because of intercurrent infection of the lymphatics. It should
be seen to that the tube lies unobstructed in the suppurating cavity. If the
tube is not well placed a counter opening lower down should be made. Small
collections of pus may become walled off by adhesions. These should be felt
for with a blunt instrument. Suppuration continuing, irrigation of the cavity
may be practised daily to wash out any material which may delay healing.
Careful examination may show that a tubercular pleuritis is present.
Necrosis of the rib may sometimes be found to account for continued
suppuration.
Ordinarily an empyema, provided with adequate drainage, should be
healed in from three to six weeks. Most cases should be healed in a month.
The most common cause of failure to heal is not a persistence of infection but
failure of the lung to expand and occupy the whole pleural cavity. So long
as there is such an unoccupied space, discharge will flow from it.
If the empyema has been of long duration or slow in development before
operation was done, it may be assumed that the plastic deposit on the surface
of the lung will be so great that expansion will be delayed. In such cases the
THE THORAX
405
dressing applied at the time of operation and thereafter should be, not the
simple dressing described above, but such dressing as is described below
for the treatment of non-expansion. The surgeon may as a routine measure
pursue the latter course.
To promote expansion of the collapsed lung is one of the most important
desideratives after operation for empyema. The earlier the operation is done
the less plastic exudate is deposited upon the pleura and the more of its natural
elasticity resides in the lung. Many devices are used to promote expansion.
Sealing the wound in order to prevent the further entrance of air into the
empyemic cavity is not difficult. To do this the wound is snugly closed
about the drainage tube, the surface of which should be smooth. The
tube is then passed through a small hole in a piece of rubber dam about 1 5 cm.
(6 inches) square. An adhesive strip external to the rubber dam, prevents the
tube from slipping (Fig. 1090). A very small bit of gauze is flatly placed on
the wound, the rubber dam lying on the surrounding skin. A long tube is
connected with the drainage tube and carried into a large-mouthed bottle
FIG. 1090. — DIAGRAM OF OCCLUSIVE DRESSING TO SEAL EMPYEMA CAVITY.
Rubber dam pierced by drainage tube and both held in place by adhesive plaster strips.
setting on the floor at the bedside. This bottle should be about three-fourths
filled with bichlorid or other antiseptic solution, and the end of the tube
should be submerged in the fluid. A smooth gauze dressing is placed on the
rubber dam and held in place snugly by adhesive straps and a binder (P'ig.
1091). As the air in the pleural cavity is forced out by expiration and
is absorbed, it can not return; and what the lung gains in expansion, it keeps.
When the fluid in the bottle becomes much soiled, the tube is clamped and
the solution renewed. The rubber dam should be lifted up once daily and
cleaned; and the skin should be dried and rubbed with alcohol. If necessary
for the health of the skin zinc ointment may be used. This method may be
combined with the following.
Increase of intrapulmonary pressure may be secured and expansion of
the lung aided by means of blowing against resistance. Wolff devised a
simple apparatus for this purpose. It consists of two bottles containing a
liter or so of water, connected by a tube, and each bottle provided witlr an
air^tube. By blowing into the air tube the fluid is forced from one bottle
406
SURGICAL TREATMENT
to the other. The patient is required to perform this exercise, once or twice
daily, blowing the fluid over into one bottle and back again. Theoretically
this should be effective; I have never seen much advantage from it.
Suction is applied by means of a glass suction cup and syringe (see
Vol. I, page 228). In children this must be used carefully lest the lung be
sucked into the wound and injured. The suction may be applied once or
twice daily. It serves to remove the air from the pleural cavity and cause the
lung to expand, and it also removes the pus. A rubber bulb may be attached
FIG. 1091. — OCCLUSIVE DRESSING FOR EMPYEMA COMPLETED.
The discharge is conducted into an antiseptic solution hermetically sealing the wound and
the drainage.
to the drainage tube. The tube is provided with a stopcock so that the
bulb may be emptied without admitting air to the cavity. The bulb is com-
pressed and left attached to the drainage tube to exert continuous suction.
When it has been filled with air and pus, it is emptied and the process repeated.
The same object is better attained by conducting the tube through the
cork of a two-mouthed flat bottle. The other mouth is fitted with a cork
carrying a tube to a rubber bulb. The bottle from which the air is exhausted
by the bulb receives the pus. The whole apparatus may be carried suspended
from the opposite shoulder (Fig. 1092).
A valve device for causing the lung to expand is made by fixing a rubber
THE THORAX
407
drainage tube firmly in the wound, holding it securely by passing it through
a shield, cutting the tube off closely and smoothly, and applying a piece of
rubber dam over its mouth. The tube may be fixed to the shield by rubber
cement. A piece of rubber douche bag may be used for the shield, or instead
FIG. 1092. — EMPYEMA TREATED BY CONTINUOUS SUCTION.
The air is removed from the bottle at intervals by means of the suction bulb.
drainage system is hermetically sealed.
The whole
of this, a flanged tube may be used (Fig. 1093). All are held by bandages or
adhesive straps. The rubber, covering the mouth of the tube, acts as a valve,
permitting escape of pus and air with the expiratory movements but closing
with inspiration. This tends to produce a rarefaction of
the air in the cavity and to encourage expansion of the
lung (Fig. 1094).
Ambulatory treatment may be carried out by having
the patient wear a flat bottle suspended from the shoulder.
The end of the tube from the thorax is enclosed in anti-
septic fluid in this bottle. In acute and recent cases, the
tube may be clamped and continuous drainage not
allowed. Every two or three hours the clamp is re-
leased, and not more than 200 c.c. of pus allowed to
escape at a time. This gives gradual dilatation of the
lung.
Rib-trephining for empyema was recommended by S. Robinson (Boston
Med. and Surg. Jour., Oct. 13, 1910). An incision is made upon the rib
under local anesthesia. The outer periosteum is then anesthetized, and the
PIG. 1093.
FLANGED TUBE FOR
AIR-TIGHT SEALING
OF EMPYEMA CAVITY.
408
SURGICAL TREATMENT
rib trephined, leaving a bridge of rib of at least 3 mm. above and below the
opening. As soon as the bone is penetrated the inner periosteum is anesthe-
tized. The button is then removed. An aspirating needle is inserted to
confirm the diagnosis. A metal tube, having a screw-thread externally
at one end, and the other end made to receive a rubber tube, is screwed
snugly into the bone. The inner end should rest against the periosteum;
the outer end should extend but slightly beyond the level of the body. The
wound on either side of this tube is tightly sutured around the tube and
painted with collodion. With a narrow-bladed knife, the circle of peri-
osteum and pleura, closing the inner end of the tube is excised. The pus
gushes forth without soiling the wound. No dressing is used by Robinson.
A short rubber tube is fixed to the outer end of the metal tube and closed
with a clamp. Suction drainage or any other device for treatment may
be used. The sealing of the wound is hermetical. It should be borne in
FIG. 1094. — VALVE DEVICE FOR SEALING EMPYEMA DRAINAGE.
A, Chest wall; B, flanged drainage tube; C, empyema cavity; D, rubber dam; E, lower edge
of dam under which pus escapes; F, adhesive plaster to hold rubber dam.
mind that any metal body fastened to bone causes rarefaction, and this tube
tends soon to become loose.
Operation for empyema without' rib-resection according to the method of
Thiersch is done as follows: A small preliminary puncture-incision is made
down to the pleura, and a trocar and canula inserted between the ribs
into1 the thorax. The trocar is withdrawn and the largest possible rubber
catheter passed through the canula into the chest. The canula is withdrawn
and the catheter left. A large piece of gutta-percha membrane is slipped
over the tube to make an air-tight closure. The rubber membrane is fixed
to the chest with adhesive strips. The catheter is connected with an espe-
cially thin-walled rubber tube which collapses with every inspiration and
prevents the entrance of air. This tube empties into a pus receptacle.
The catheter is prevented from slipping out by a thread tied around it and
fixed by adhesive plaster and a compression dressing. Later, if the drainage
proves inadequate, a rib or two may be resected at the place of puncture,
when the patient has recovered from the primary disease.
Colton (Jour. Am. Med. Assoc., Vol. 54, Nov. 18, 1910) employed a non-
THE THORAX
409
collapsible silver tube (Fig. 1095). He made a short incision in the inter-
costal space down to the pleura. The opening through the pleura is just
large enough to admit the tube. The wound is snugly sutured about it.
A combination trocar and tube has been used by some.
Comment. — It is doubtful whether any of the schemes for valvular pro-
tection and drainage give better ultimate results than the uncomplicated tube.
Operating for empyema through small openings and without resection
of rib fails in cases with fibroplastic exudate which requires a good-sized
opening for its removal. This is so commonly present that, excepting in
extremely sick patients, resection of rib remains the operation of choice.
In desperately ill persons with much compressed lung, it is best not to
place them on the sound side and still further embarrass their breathing, but
they should be brought close to the edge of the table, and operated upon
lying recumbent.
The longer an empyema exists the more does the lung loose its elasticity.
The pleura is much contracted and covered with exudate which becomes
firmer and tougher as time elapses. The cases in which it is found difficult
to secure expansion of the lung are usually the
cases in which evacuation of the pus has been long
delayed.
In making an incision for resection of a rib in
the axillary line, the arm should be abducted not
above a right angle. In doing so the skin is
carried upward, and the surgeon should plan his
incision so that when the arm is brought down
the wound in the skin and muscle shall not slide
down below the level of the pleural opening.
The drainage tube should be well secured lest
it slip in the thorax. At each dressing it should
be looked at the first thing, lest a misdirected
operation later may be done to recover from the
thorax a tube which had been thrown away with
the dressings.
Chronic Non-tuberculous Empyema. — This con-
dition may yield to better drainage. Under all
circumstances the surgeon must assure himself that a large drainage open-
ing has been provided at the lowest part of the cavity. Bismuth-paste in-
jections may cure small cavities. The cases in which thick plastic exudate
covers the contracted lung, in which adequate drainage has failed to bring
about expansion, must come to operation. Operation should be under-
taken deliberately, with a full understanding of the local and general con-
dition, and with the purpose of saving the patient. A fatal outcome may
be avoided by not attempting too much. The formidable bloody thoraco-
plastic operations should not be done or at least not completed in one
stage. The appearance of shock should not be the signal to stop; the pa-
tient should be sent back to bed before the symptoms of shock appear.
Bleeding should be prevented. The least depressing anesthesia should be
administered.
Failure of the lung to expand after empyema, leaves a cavity between the
lung and thoracic wall, which must be cured by expansion of the lung or by
collapse of the chest wall. Unless one or the other of these is accomplished the
patient will succumb to long-continued suppuration. Exercises to expand
the lung and increase the mobility of the chest, and measures to improve
the general health should be exhausted before operation is attempted. The
FIG. 1095. — SILVER TUBE
FOR EMPYEMA DRAINAGE.
410 SURGICAL TREATMENT
parietal pleura in old cases will be found enormously thickened. This con-
dition is best prevented by the early evacuation of the pus in empyema. In
cases which are not of long standing, expansion may be secured by inserting
the finger in the pleural sac and breaking up adhesions. This, of course,
fails if the plastic deposit is thick as it is apt to be in old cases.
Operations upon chronic empyema cavities to accomplish their oblitera-
tion should not be done until a large drainage opening at the lowest level has
been made, and a period of six weeks at least allowed for it to effect a cure.
This opening should represent the resection of at least 2.5 cm. (i inch) of
rib, and should be provided with a large drainage tube. The new drainage
may cure the case. If it does not, then operation may be proceeded with.
No radical operation should be done upon a patient whose toxic state might
have been relieved by better drainage.
Removing plastic deposits from the surface of the lung should be practised
when the material is so thick that it is impossible for the lung to expand.
Access is secured by resecting 4 or 5 cm. (i^ or 2 inches) of five or six ribs.
This may best be done through an incision passing upward from the old
drainage wound. The pleura lying on the lung should be incised vertically
and the index-finger inserted and used to dissect the pleural deposit from the
surface of the lung. A pair of blunt scissors may then pass along with the
finger and cut the thickened deposit as far up as possible. The finger is
then used to dissect this membrane from the surface of the lung. It is
removed as far as possible in every direction. The wound of the chest wall
should be closed with drainage, and expansion should be encouraged by the
same methods of dressing as are used in primary cases of empyema.
Decortication of the lung, first described by G. R. Fowler (Medical
Record, Dec. 30, 1893), is done as follows: The pleural cavity is freely ex-
posed by resecting portions of three or four ribs or by making an osteoplastic
flap. The fibrinous deposit on the surface of the lung is incised and peeled
off with the aid of scissors. If the lung has not undergone fibrous changes,
it will expand. The operation is most successful in children. If more than
five months have clasped since the empyema was first drained, success is
not apt to be secured. In cases in which the fibrous covering of the lung
is intimately connected with interstitial fibrous deposits, the surface mem-
brane cannot be peeled off without tearing the lung tissue, and the operation
is impossible and thoracoplasty must be done.
Thoracoplasty is done to obliterate a pleural cavity which is not filled
by lung. Whatever operation is done, it must be modified to fit the case,
and no operation is complete unless all of the cavity is obliterated. These
operations should be preceded by a thorough determination of the position
and size of the cavity. S. Robinson (Surg. Gyn. and Obst., vol. xxii,
May, 1916) showed how this may be done by packing the cavity with a
narrow bandage or tape, which has been soaked in a cream made of barium
sulphate and water, and taking stereoscopic radiograms.
The operation of Estlander consists in removing portions of several ribs
covering the cavity, and causing the soft chest wall to collapse against the
lung and become adherent to it. Pressure by pads and a bandage holds the
parts together. The ribs may be removed by a U-shaped incision or by one
incision in an intercostal space for every two ribs to be removed. By this
means four ribs can be removed through two incisions. The extent of the
operation must depend upon the size and position of the cavity. A
single vertical incision opposite the middle of the cavity may be made.
Removing the intercostal muscles, deep fascia, the thickened parietal pleura,
and as much of the plastic membrane as possible from the surface of the lung,
THE THORAX
411
was advised by Estlander. Decortication may advantageously be combined
with this operation. The operation fails to obliterate the cavity if imper-
fectly done; and, as a one-stage procedure, it is formidable. By performing
the operation in two, or three or more stages, it has much to recommend it.
An operation devised by Schede is aimed to obliterate larger cavities.
The incision in each case should outline the cavity. It can be used when the
lung is completely retracted and is nowhere in contact with the parietal
pleura. In such a case, for example, an incision is begun at the costal car-
tilage of the second rib, carried downward to the cartilage of the tenth rib,
along the tenth rib as far as its angle, and thence upward along the inner
border of the scapula to the second intercostal space. This large U-shaped
flap is dissected up, carrying with it everything external to the ribs and
intercostal muscles. The scapula is included. Bleeding is controlled at
every point as the operation proceeds.
The costal cartilages and the ribs are
divided; the latter near their tubercles.
The intercostal vessels are tied posteriorly
and anteriorly. The entire chest wall,
encompassed by these incisions, exclusive
of the flap, is removed. This means ribs
(from the second to the tenth or eleventh) ,
intercostal structures, and underlying
parietal pleura. The surface of the lung
is curetted, and the great flap turned down
and placed in contact with the lung. It
is sutured in place with heavy sutures.
The muscles are sutured separately, and
the skin over all. Drainage is provided at
the lower posterior part of the wound.
A smooth dressing of gauze is so applied
as to hold the soft tissues of the flap
against the lung (Fig. 1096).
This operation is formidable, and
should not be undertaken in one stage.
It fails to cure some cases because the
overhanging costal margin leaves an angle
which is not filled.
Combined operations, adapted to the
particular case, are best. The opening of the sinus should be enlarged by re-
moving 7 or 10 cm. (3 or 4 inches) of the adjacent ribs, and an exploration
made. If the cavity leads upward, as is usually the case, an incision is
carried upward, the soft parts retracted, and ribs resected so far as is neces-
sary to remove the rigid covering of the cavity. An incision is then made
in the upper part of the wound, exposing the lung. The thickened deposit
is stripped from the lung 5 or 7 cm. (2 or 3 inches), and the patient allowed
to cough. It will then be seen how much the lung is going to expand. The
wound should be closed with drainage.
Muscle implantation accomplishes filling the cavity and may be combined
with the principles of the operations to induce collapse of part of the chest
wall and expansion of the lung. A curved incision which outlines the base of
the cavity is made, as in the operation of Schede. It represents only the
lower part of the U. To this S. Robinson added a vertical incision, passing
in the midaxillary line to its concavity. The vertical incision should extend
to the top of the cavity. This inverted T-incision passes down to the ribs.
FIG. 1096. — RESFLT AFTER THO-
RACOPLASTY TO OBLITERATE LARGE
CAVITY IN CHEST.
412
SURGICAL TREATMENT
It is possible to do this operation with the U-incision alone (Fig. 1097).
The skin-muscle flap is dissected up, and the underlying ribs resected and
removed with their intercostal muscles, unroofing the cavity. The thick-
ened parietal pleura is removed at the same operation or at the next. The
cavity is thus freely exposed. The latissimus dorsi muscle is dissected free
from the skin flap in the form of two muscular masses, split by a vertical
incision. These two flaps of muscle are turned into the cavity and sutured
in place, one being imposed upon the other. The skin flap is sewed back in
place over the muscle, a large opening for gauze drainage being left at the
bottom (see Operations on the Lung, page 453). The muscle implantation
operation for old unhealed empyema was devised by S. Robinson.
FIG. 1097. — INCISION FOR OBLITERATING CAVITY OF OLD EMPYEMA.
Bismuth Paste in Empyema. — The injection of bismuth paste not only in
the treatment of old empyemic sinuses but also in recent cases of empyema
has been employed. Bismuth subnitrate, 5 to 33 per cent., in vaselin is used.
From 30 to 120 c.c. of the 33 per cent, preparation may be injected. As
much as 250 c.c. are employed. A cavity holding more than this amount
should not be treated by this method. When the large amount is used, it
should be of the 5 per cent, strength. In treating sinuses, the tube is re-
moved, a bacterial examination of the discharge is made, and an injection of
about 100 c.c. thrown into the sinus. The tube is not replaced. A sterile
dressing is placed over the opening. This is changed daily. The paste
THE THORAX 413
comes out with the pus. When all of the paste has been discharged, if the
sinus is not healed, the injection is repeated.
This method has been practised four days after operation for empyema,
during which time tubular drainage had been employed. Treatment by
resection of rib, evacuation of pus and injection of 250 c.c. of 5 per cent,
bismuth- vaselin paste, has been carried out with success; no drainage tube
being used (see Bismuth Paste in Treatment of Sinuses, Vol. I, page 306).
After injecting the bismuth, if the temperature rises above 38°C. (ioi°F.),
if pressure-discomfort is experienced, or toxic symptoms appear, the bismuth
should be drained out and the opening allowed to close. Distention of the
cavity is not necessary. By injecting warm olive oil into the cavity and allow-
ing it to remain for twelve or twenty-four hours, the bismuth enters into
emulsion and may easily be washed out if necessary.
The surgeon should not be too much encouraged in thinking that patients
with chronic cavities have been cured by bismuth injections. The injections
may have sterilized the cavity, but it still remains, and sooner or later is
apt to become infected and the patient overwhelmed with a recurrence.
Tubercular Hydrothorax and Pyothorax. — Most cases of serofibrinous
pleurisy in adults are tubercular; and a large proportion of these cases is
associated with pulmonary tuberculosis. Their treatment from the begin-
ning should be the general treatment of tuberculosis. By no means should
the teaching be promulgated that the treatment should consist in drawing
off the fluid. Particularly in unilateral disease, the effusion may be re-
garded as a salutary and natural manifestation, the tendency of which is to
cure the disease of the lung. Pleuritic effusion complicating pulmonary
tuberculosis is apt to be to the advantage of the patient, who often
has a better chance of recovery with the effusion than without it (see
Surgery of Consumption, page 416).
Tuberculous empyema is a cold abscess. There is little toxemia due to
it. But when it discharges by an opening through the skin or mucous mem-
brane mixed infection is sure to occur and unless good drainage is then se-
cured, pronounced toxemia results. So long as the pressure of the fluid is
not causing serious embarrassment of respiration or of the heart's action and
the pus remains purely tubercular it need not be removed. In the mean-
time the pulmonary disease should be mending. If the pus threatens to
break through the skin, it should be evacuated. This is best done by means
of an aspirator under rigid asepsis (see Tubercular Abscess. Vol. I, page 281).
An antitubercular antiseptic in emulsion may be thrown into the cavity.
For cases with a discharging tubercular sinus, injection of bismuth paste is
recommended by E. G. Beck. As much as 700 c.c. of bismuth paste may
be injected although it is probable that smaller amounts are as effective
(see page 412). Bismuth subnitrate varying from 5 to 33 per cent., in
vaselin, is used (see Vol. I, page 306).
THE LUNGS
Rupture of the lung, not complicated by penetrating wound of the chest
wall, should be treated by rest in bed with the shoulders and head slightly
elevated. The appearance of hemorrhage or infection call for special treat-
ment.
Wounds of the lung with penetration of the chest wall require the treat-
ment described for penetrating wounds of the thorax (page 397). Bleeding
from a wound of the lung usually stops as the lung collapses by reason of the
entrance of air into the pleural cavity through the wound of the thoracic
414
SURGICAL TREATMENT
wall. If the lung has not collapsed and bleeding continues, its collapse
should be secured by admitting air to the pleural cavity. If the bleeding
continues, the lung should be exposed by enlarging or retracting the thoracic
wound (a resection of ribs is usually necessary), and the vessels controlled
by ligature, suture, or packing of the lung wound. When such an operation
FIG. 1098. — CLOSING WOUND OF LUNG WITH SIMPLE SUTURE.
is done, the clot should be removed from the pleura, and drainage provided.
Wounds of the lung of this kind are so commonly followed by infection of
the pleura, that the surgeon is always on the safe side in providing drainage.
This should be through the chest wound; but if there is much effusion,
drainage should also be provided at the lower posterior part of the chest,
as for empyema.
FIG. 1099. — CLOSING WOUND OF LUNG WITH MATTRESS SUTURE.
The suturing of wounds of the lung is best done with chromicized catgut.
Ragged edges should be trimmed evenly. Uninfected wounds, even though
small, should be sutured. An inverting suture or a through-and-through
suture may be used (Figs. 1098 and 1099).
Acute abscess of the lung, which commonly follows operations on the
nose and throat, W. D. Tewksbury has shown (Jour. Am. Med. Assoc., Feb.
THE THORAX 415
2, 1918), may best be treated by inducing artificial pneumo thorax. The mor-
tality in this condition under nonsurgical treatment is very high. Treat-
ment by pneumothorax has given results superior to those attained by any
other method.
Chronic abscess of the lung requires the same treatment as abscess in
other parts. Evacuation of the pus and drainage of the cavity should be
done. Spontaneous healing by absorption of the pus or by rupture into a
bronchus or through the chest wall has occurred but this is rare and delay
is dangerous. The cases following pneumonia and operations on the nose
and throat offer the best prognosis. Brewer states that under surgical
treatment, 60 to 75 per cent, recover.
Two or three ribs should be resected at the point on the chest wall nearest
to the abscess. This should preferably be in the axillary line opposite the
center of the abscess. The pleura should be incised carefully for but a short
distance, in the hope that the incision may fall wholly within a zone of
adhesions between the pulmonary and costal pleurae. Edema of the costal
pleura is a sign that adhesions are present. If the costal pleura is found
adherent to the lung, the abscess should be opened by a narrow incision
followed by blunt scissors or a pair of forceps to dilate the opening. The
adhesions between the pleural surfaces should not be broken. A tube should
be placed in the abscess and the rest of the wound packed with gauze.
If, as the costal pleura is opened, it is found not adherent to the lung,
the opening should be made rather large, a gauze sponge may be rubbed
over two pleural surfaces to excite reaction, and the outer wound packed
with gauze. After two or three days adhesions of the lung to the chest
may be expected. The formation of adhesions may be made sure by re-
moving the soft tissues external to the pleura, and making a short incision
at right angles across either end of the pleural incision; this gives two
rectangular flaps, which may be turned in so that their raw surfaces lie
against the lung. A couple of sutures and some gauze packing hold these
flaps in place.
If the condition of the patient demands immediate evacuation of the'pus,
the wound may be packed all about with gauze, and the pus drawn off
through an aspirator. This may have to be of large- caliber, but by careful
packing the pleural cavity may be spared infection. After a few days the
incision may be made. Infection of the general pleural cavity requires
drainage as for empyema.
In the case of abscesses which have ruptured into a bronchus, the induction
of artificial pneumothorax is of value. The collapse of the lung may be
hoped to obliterate the cavity. If the lung is adherent to the chest wall,
the adhesions may be separated after the resection of two or three ribs.
A pleural opening in these cases should be made if, after collapse of the
lung, septic absorption continues. If a sinus persists, a plastic operation
may have to be done to secure collapse of the chest wall upon the lung
(see Thoracoplasty, page 410).
Gangrene of the lung is associated with infection, and for this reason
drainage is necessary. Non-surgical treatment has a death-rate of about
80 per cent. Under surgical treatment the mortality is about 30 per cent.
The mortality is highest in bilateral cases. The best results are secured in
the circumscribed form. The disease should be exposed by the resection of
ribs, as in abscess (page 456). Infection of the pleura is quite as dangerous.
If adhesions are not present, shutting off the general pleural cavity, an opera-
tion in two stages, as advised for pulmonary abscess, is to be recommended.
The only exception to this is in the cases which are profoundly septic and
416 SURGICAL TREATMENT
in which relief is urgent. It may properly be held, even in these cases, that
if the patient has not vitality to sustain him for two or three days until
adhesions can form, he has not vitality to withstand infection of the pleura.
When the pulmonary and costal pleurae are adherent, the lung should be
incised down to the gangrenous area. Loose necrotic tissue should be re-
moved. The central part of adherent slough may be cut out; but the hazard
of bleeding is too great to warrant cutting free a still attached slough. The
cavity should be packed with gauze, which should be lead out through a good-
sized opening in the chest wall.
Tuberculosis of the Lung. — Resection of the tuberculous lung has given
so high a mortality that the operation has little to recommend it, and pneu-
mectomy for tuberculosis has fallen into disuse.
Drainage of tuberculous cavities by extrenal incision has little value
except, perhaps, the advantage of the induced pneumothorax which collapses
the lung. In certain cases of pulmonary cavities with mixed infection and
constant toxemia, drainage by incision may be of service. This should be
in two stages in order to insure adhesions between the pleural surfaces (see
page 456).
The induction of artificial pneumothorax for pulmonary tuberculosis has
given sufficiently good results to warrant its recognition in cases which fail to
respond to medical treatment.
In pulmonary hemorrhage the operation is of much service in selected
cases. This applies to bleeding into the bronchi and also to bleeding into the
pleural cavity. The hemorrhage from tubercular cavities may often be
checked, and incidentally the tuberculosis checked, by admitting air to the
pleural sac. (It often happens that when the thorax is opened to discover
and control a bleeding point in the lung, the admission of air causes a col-
lapse of the lung which stops the bleeding. Penetration of the lung by a
broken rib may cause a wound of the lung which bleeds until the pleura is
opened and air admitted.)
This operation may be done with a trocar and canula or a hollow needle
about i mm. in diameter. Under strict asepsis, the chest wall is punctured at
about the seventh intercostal space in the scapular or axillary line (see
Aspiration, page 401). The place of puncture should be as far as possible
from the disease in order to avoid adhesions. The patient should lie on the
side, with the lung to be collapsed uppermost. The skin and pleura should
be anesthetized by free injection. The surgeon should be conscious of the
layers of fascia through which the needle passes. Dust-free air may be
admitted. The needle should be connected with a tube about i meter long,
through which all of the air should pass in order to render it sterile. The inside
of the tube should be slightly moist and aseptic. If desired the tube may be
connected with a wash bottle to demonstrate the movement of the air; or with
a meter to measure it and a manometer to control the pressure.
The operation is performed more accurately if the needle is connected with
a manometer. When the needle reaches the pleura, even before it is pierced,
a slight advance in the indicator will be observed, showing slight negative
pressure. When the costal pleura is punctured, if there are no adhesions at
the place of puncture, there will be recorded a negative pressure indicated as
—4 to —12 cm. of water.
Instead of admitting air, which is quickly absorbed, better results are
secured by slowly introducing nitrogen. Usually a desirable dosage is 50 c.c.
of the warmed gas. Nitrogen is more slowly absorbed than oxygen or carbon
dioxide and it is unirritating and inert. The gas is warmed by passing
through a coil in a basin of hot water between the tank and the needle. Then
THE THORAX 417
the manometer is read, and more gas admitted until a slightly negative read-
ing is shown, or a positive pressure of not more than 3 cm. The gas should
not be permitted to enter until the manometer shows by negative pressure
and free oscillation that the pleural sac has been entered. The cases in
which there is serious hemoptysis require that marked positive pressure
should be secured. The gas should be stopped if the patient has pain or
dyspnea. From 200 to 400 c.c. of gas are introduced. Only after several
treatments should the manometer register zero or show positive pressure.
The collapse of the lung is best accomplished by injecting the gas every two
to five days until a total collapse of the lung is secured. This gradual plan
obviates the dangers and discomforts which are sometimes present when the
heart and other organs are suddenly subjected to the unnatural pressure.
After complete collapse has been secured and determined by the fluoroscope,
the next treatment is deferred for ten days or a month.
This operation in selected cases is capable of arresting the disease.
A. Larralde (Gaceta Med. de Caracas, Oct. 15, 1917) reported that in 1 8 of
the 68 cases operated upon the patients were free from symptoms in some
cases as long as two and a half years after the operation; another group of
1 8 cases was much improved.
Pleurisy with effusion occurs in a large proportion of cases thus operated
upon (30 to 50 per cent.). The fluid should not be removed unless there are
strong indications for its removal. If the fluid must be removed nitrogen
should be introduced in its place.
Gas embolism is a less common complication. The gas may come through
the needle and directly enter a pulmonary vein because of faulty technic. If
the needle enters adhesions, this danger is very great.
Pleural shock, with disturbance of the respiratory and circulatory centres,
is to be guarded against by care that the needle does not injure the lung, that
the collapse of the lung is not rapid, and that the psychology and general
physiology of the patient are protected against shock by all means known to
that end (see Shock, Vol. I, page 213).
Pleural infection should be prevented by strict asepsis in the operation.
Tubercle bacilli near the surface of the lung may be liberated into the pleural
sac; this is an accident which can not always be foreseen.
Subcutaneous emphysema calls for discontinuance of treatment until the
gas is absorbed.
The mortality from the operation is being reduced by experience and atten-
tion to details. A report of 2000 punctures made in forty-nine patients by
Sangman showed no serious mishap.
The indications for the use of artificial pneumothorax are steadily being
widened. Many experienced operators now apply it in all progressive cases in
which the general treatment is not checking the disease. This is especially
in unilateral cases. It would be useless in advanced bilateral tuberculosis, or
in cases in which adhesions would prevent collapse of the lung. This leaves
but a small percentage of cases as suitable for this treatment. It is not to be
used in rapidly acute cases, in patients with dyspnea, in cases with pleural
adhesions or superficial cavities, in cases with pronounced tuberculosis in
organs outside of the respiratory tract, in badly prostrated patients, or in
serious cardiovascular disease. It cannot freely be used on both sides; and
is, therefore, not well adapted to bilateral cases. It may be used in chronic
disease. Laryngeal tuberculosis need not contraindicate. In incipient
infiltration it is especially useful. In cases with small cavities, not associated
with pleuritis, it may be used. Its chief value is in hemoptysis; here it is a
VOL. 11—27
418 SURGICAL TREATMENT
positive indication, as nothing offers so much hope in this condition as collapse
of the lung.
Recently, beneficial results are being reported in the bilateral treat-
ment. But a partial collapse of the lungs can be allowed. It is suggested
that the effect is due to a backing up of lymph in the lungs, producing an
autoserotherapy.
The results of the operation in the fortunate cases are seen first in lowering
of temperature by virtue of the immobilization of the infective focus. Expec-
toration and cough are checked, and the general condition improves. Hem-
orrhages are quite invariably stopped. In some cases the benefits do not
appear until after several weeks. Often the disease seems to be made worse
for a period before benefit is observed.
The length of treatment must vary, but it is best to keep the lung collapsed
for six months, a year, or even longer. Good results may be seen in six
months, but often the treatment must be continued for two years. When
the treatment is discontinued the gas is absorbed and the lung again expands,
unless the collapse has been maintained for a long time.
Remarks. — This treatment of tuberculosis should be under the guidance
of an expert phthisiologist, as tuberculosis of the lung is a disease to be stud-
ied by the medical specialist and treated only under his guidance. If adhe-
sions are present it is still possible in some cases to inject salt solution between
the layers of the pleura, and separate them.
Inter pleural pneumolysia was proposed by F. Torek (Surg., Gyn. and
Obst., xix, 1914) for cases in which collapse of the lung is indicated as a
therapeutic measure but is prevented by adhesions. The anesthesia should
be by insufflation or other method of differential pressure to prevent respira-
tory accident. An incision fully 15 cm. (6 inches) long is made down to the
pleura in the sixth or seventh intercostal space at the posterolateral aspect of
the chest. After all bleeding is stopped the pleura is opened. The patient
should then be placed with the head very low so that discharges from the
bronchi will escape through the mouth and not run into the other lung.
The ribs are separated by retractors and first the finger and then the whole
hand are introduced to separate adhesions. This should be done very care-
fully so that no cavity is opened. Dense adhesions should be divided by
scissors. As the lung collapses the cavity is obliterated. If an opening is
torn into the lung, inflation should show its location, and it should be
closed by sutures.
The pleura is closed without drainage. The ribs are held together with
strong sutures. Pain does not follow this operation as occurs from the pull-
ing upon adhesions when gas is introduced. The subsequent treatment is the
same as for artificial pneumothorax. The #-ray should determine when it is
time to inject nitrogen.
Thoracoplasty, such as is done to obliterate old empyemic cavities, is
effective in some cases (see page 410). This permits the lung to collapse,
puts it at rest, and also adds the nourishment conveyed through the costal
circulation. The principle of immobilization of the lung has been worked
out by Brauer, Friedrich, Murphy and others, and promises help in cases
which fail to yield to medical measures. P. L. Friedrich (Arch, f . Klin. Chir.,
August, 1914, cv, No. 2) proposed the term pneumolysis for the operation.
He cut away the ribs, from the second to the tenth inclusive from their
cartilage to the spine. The intercostal nerves should be divided or resected.
Formerly the intercostal muscles were removed. The smallest possible
amount of anesthetic should be used, and the patient should lie on his back to
prevent drainage into the sound lung. Such operations are not to be done
THE THORAX 419
when both lungs are affected, or when there is tuberculosis in other organs.
The operation is advised in cases in which artificial pneumothorax is other-
wise indicated but cannot be done on account of adhesions or some other
condition.
Resection of costal cartilages has been applied especially to the first rib.
The resection of the cartilages of the first ribs seems to be of some value in
early cases of apical tuberculosis, especially in childhood. The mobility of
the upper chest aperture is improved by the operation. Still more mobility
may be had in some cases by carrying the resection down two or three ribs.
Pulmonary Emphysema. — Rib resection has given relief by relaxing the
rigid thorax in primary alveolar emphysema. Freund advocated division of
the costal cartilages. Friedrich practised removal of 4.5 to 6 cm. (i% to
2^ inches) of the cartilage of each rib from the second to the sixth inclusive.
This is done at the chondrocostal junction, and the periosteum also is carefully
removed in order to secure as much permanent relaxation as possible.
Bronchiectasis (Distention of the Bronchi, either Diffuse, Circumscribed,
Cylindrical or Sacculated). — The milder cases should receive medical treat-
ment, and surgery should not be resorted to in any case until medical and
topical treatment have done all they can. In this disease the size of the
bronchial cavities vary from the size of a pea to that of a hen's egg; the loca-
tion most commonly affected is the lower lobes; it may affect the young as
well as the middle aged or old; and in advanced cases medical treatment can
do little more than make a diagnosis and improve the general hygiene.
Bronchiectasis is amenable to surgical treatment. Early cases will not sub-
mit to operation, but well-developed cases will. Putrefaction of secretions
in the cavities makes these patients miserable and offensive, and they are
sooner or later willing to accept surgical treatment.
Treatment should be applied progressively. In the milder cases non-
operative measures should be tried. The thirst cure consists in cutting down
the amount of fluids allowed the patient until it is reduced to 200 c.c. daily.
This reduces the amount of expectoration. On two days a week the patient
is allowed more fluids. Sweat baths and oxygen inhalations are added to
this treatment.
Other measures are the inhalation of superheated air; intravenous injec-
tion of colloidal silver; local application of antiseptic drugs through a catheter
or spray, passed through the trachea.
In the more advanced cases, which do not yield to other measures opera-
tion is indicated. Before operation the patient should be kept in a position
which best empties out the cavities — lying on the well side or in the knee-
chest position. General anesthesia may be produced with ether, or nitrous
oxid. The danger of pneumonia from general anesthesia is so great that
local anesthesia is to be preferred (see Local Anesthesia, Vol. I, page 127).
A few inhalations of alcohol, ether, or chloroform may occasionally be
required. Unless an effective anesthetization of the costal pleural is secured,
the patient should be given enough general anesthetic to prevent the cough
and straining which is caused by its incision. The operation may be advan-
tageously done in the negative pressure apparatus, or with artificial insuffla-
tion of the lung. Insufflation is especially desirable if a general anesthetic
is used. Such differential pressure is especially desirable in cases in which
pleural adhesions are not present.
The operation of pneumotomy is employed in cases in which a circum-
scribed disease has been diagnosed. Two or three ribs are resected near the
cavity; the pleura is incised; if adhesions are not present, the lung should be
palpated, and then sewed to the wound; if the patient is weak, further proced-
420 SURGICAL TREATMENT
ure may be deferred for a second operation. The region of \ disease having
been identified and walled off, the aspirating needle is inserted until pus is
found or air sucked through the needle. The cavity having been tapped,
the cautery is passed along beside the needle, or the cautery and knife may
be used. If the cavity is deep and near the hilus, a blunt instrument (smaller
than the finger) may be pushed in. The cavity may be found as deep as
20 to 26 cm. (8 to 10 inches) from the surface of the chest. Drainage by a
large tube is essential. Unless a free opening is maintained recurrence may
be expected to follow the later contractions of the drainage tract.
For exposing the middle or lower lobe, an incision in the seventh or eighth
intercostal space, extending from the angle of the rib to the anterior axillary
line, and the use of a strong retractor, give adequate exposure in most cases.
More room may be secured if necessary by dividing the ribs above or below
this.
If multiple cavities are present pneumotomy can not meet the situation,
and collapse-therapy must be undertaken. The induction of artificial pneu-
mothorax fails in advanced cases, and is not to be considered. Compression
must be stronger and more durable than can be secured with gas.
The operation of pneumolysis is useful if accompanied by artificial filling
of the chest cavity with transplanted or foreign material. Subperiosteal
resection of 8 or 10 cm. (3 or 4 inches) of one or more ribs is done; the perios-
teum and fascia are then split down to but not through the pleura; the fingers
are then introduced external to the costal pleura which is thus dissected free
from the chest wall; the pleura collapses with the lung; and a large extra-
pleural cavity is created. This cavity should then be filled with fat, omen-
turn, or lipoma, transplanted from the patient or from another, immediately
or after having been kept in cold storage. This operation may be done
without mortality. Most cases will be improved, but not cured.
Multiple resection of ribs (thoracoplasty) offers help in a large proportion
of cases. The operation should be done under regional anesthesia. It can
not be expected to cure advanced cases.
Removal of a piece of the phrenic nerve (phrenic neurectomy) is done in
the neck on the diseased side. This paralyzes half of the diaphragm, and
in some cases, perhaps, is of benefit. Ligation of the pulmonary artery im-
proves the condition but does not cure.
The only operation that can be relied upon to effect a cure in the advanced
cases of multiple foci is pneumectomy (see page 456).
W. Meyer (Annals of Surgery, July, 1914) showed that we have two opera-
tive methods: Artificial collapse entails little risk, and may be done in two
stages; it causes change in the structure of the lung; it improves: but does
not cure the disease. The other operation, removal of the diseased lobe or
lobes, is a dangerous procedure but is capable of curing the disease. It is
best that patients should select the first method. Pneumectomy remains
as a last resort should the first operation fail to give relief.
H. Lilienthal (Annals of Surg., Vol. 64, No. i, July, 1916) favored excision
of the diseased lobe. He usually found adhesions between the lung and the
chest wall. The adhesions must be separated and the diseased lobe isolated
either by blunt dissection or with scissors. Adhesions between healthy lung
and the chest wall should be left unbroken. The diseased lobe being isolated,
its pedicle is crushed at the hilum, with a strong clamp, the lobe cut away,
and the vessels tied. To prevent napping of the mediastinum, Lilienthal
passes a transfixion ligature from the distal side of the stump out through
the costal wound and fastens it outside of the chest. This should not be too
tight. A strip of gauze or wicking, surrounded with rubber tissue to prevent
THE THORAX
421
adhesions, is packed against the stump and brought out through the chest
wall. The wound is sutured except for the opening where the gauze escapes.
Infection and a complicated convalescence should be expected. Lilien-
thal wisely calls attention to the value of open-air treatment in these cases,
and reports great improvement after a few days and nights in the open.
Extirpation of the diseased lobe or lobes is the radical operation, and may
be regarded as the only curative operation. The results of the other pro-
cedures are doubtful and rarely curative.
S. Robinson (Surg. Gyn. and Obst., Feb., 1917) concluded that collapse
therapy is not curative, and that excision of the diseased portion of the lung
is the only curative treatment for advanced cases. The operation should be
done in two or three stages. The intercostal operation is to be preferred.
Rigidity of the Chest (A Condition of Fixedness of the Ribs, Giving Rise to
Asthma and Emphysema, Observed in the Arteriosclerotic, in which the Chest
Becomes Barrel-shaped and Loses its Power of Elastic Contraction). — Medical
treatment has been helpless against this disease. Surgery has much to offer.
FIG. noo. — RESECTION OF COSTAL CARTILAGES IN THE TREATMENT OF RIGIDITY OF THE
CHEST.
The cartilages and perichondrium are removed and the muscles sewed across the gap.
To give mobility to a chest wall which has become rigid and in which the
costal cartilages have become hardened, removal of the cartilages of the sec-
ond, third, fourth, and fifth ribs is most effective. By removing these carti-
lages an interval of 3 or 4 cm. (i^ inch) is provided, in which the ribs not
only develop a hinge action but the free ends of the ribs move backward
and forward and inward and outward with respiration. The perichondrium
must all be removed; if it is not there is a tendency for regeneration of carti-
lage. A unilateral operation gives great relief; a bilateral gives stillrmore
improvement. The resections may be done through short incisions parallel
with each cartilage or through a single vertical incision. The cartilages
should be wholly removed. Some of the bony end of the rib may be in-
cluded in the resection.
422 SURGICAL TREATMENT
The operation to be preferred makes an incision, beginning just below
the clavicle and passing downward, lying about 2 cm. (% inch) from the
sternum (Fig. noo). Through this incision the four costal cartilages are
exposed. As each one is cut through close to the sternum, it will be observed
that the patient's breathing is at once improved. The cartilage should be
lifted up and separated. No perichondrium should be left; the dissection
should be down to the pleura and pericardium. The cartilages may be cut
with bone-cutting forceps. After the cartilages have been removed, the
channels left should be closed by sewing the intercostal structures together,
thus obliterating the spaces and lessening the probability of further cartilage
growth. The internal mammary artery, which passes down parallel with the
border of the sternum and about 1.3 cm. (^ inch) from it, should not be
injured. It lies just behind the cartilages. The operation may be done
with local anesthesia.
The effect of this operation is most satisfactory. The relief is instanta-
neous. It is not applicable to all asthmas or emphysemas, but only to the
rigid chest. The operation is contraindicated by severe cardiac disease,
costovertebral ankylosis, and rigidity due to disease of the respiratory mus-
cles (spasm or paralysis).
The operation is not serious. No mortality should be expected. The
first rib is omitted because experience has shown that it participates but little
in respiratory movements. The technic may be modified by resecting the
cartilage and leaving the perichondrium. The latter is then divided in the
middle by a vertical incision, dissected up as two flaps, one of which is sewed
over the end of the rib and the other over the sternal defect.
In this operation, if the pleura or pericardium is opened, the wound should
at once be closed with a suture. If both sides are operated upon it should be
done in two stages.
Bronchial Strictures. — Strictures, following irritation of a foreign body,
syphilis or tuberculosis, often require treatment. The only treatment which
can be effective is divulsion of the stricture. This is best done by means
of divulsors, applied through the bronchoscope. The instruments of Cheva-
lier Jackson are most useful (see Bronchoscopy, page 239).
THE PERICARDIUM
The pericardium occupies the middle mediastinum. In front are the
sternum and the costal cartilages of the third, fourth, fifth, sixth and seventh
ribs. The pleurag lie against it laterally. Loose areolar tissue separates it
from the sternum. The interpleural anterior pericardial area extends from
the lower border of the left fifth chondrosternal articulation to the seventh.
It is mostly behind the sternum opposite the sixth intercostal space.
Wounds of the pericardium should receive similar treatment to that de-
scribed for wounds of the pleura (page 399). Bleeding should be checked
and blood clots should be removed from the pericardial sac. If necessary to
do this, the wound may be enlarged. A clean wound may be sutured with
fine chromicized catgut. Infected wounds should be treated with antiseptics
and by applying a large occlusive dressing (see Wounds, Vol. I, page 186).
Serous effusion in the pericardium should be removed when the amount
is so great as to embarrass the heart or when the fluid is the seat of a dangerous
infection. Spontaneous absorption takes place in most serous effusions.
Pericardiocentesis is performed for curative and diagnostic purposes. It
may be done through either the fifth or sixth left intercostal space. The
THE THORAX 423
patient lies supine. Local anesthesia is used. An incision is made in the
sternal end of the fifth left intercostal space, from just internal to the left bor-
der of the sternum downward and outward for about 2.5 cm. (i inch). This
passes through the pectoralis major and exposes the intercostal fascia. The
wound is dried and retracted. An aspirating needle is held between the fore-
finger and thumb and passed through the fascia close to the border of the
sternum and near the upper border of the sixth cartilage. The internal
mammary artery lies about 1.3 cm. (% inch) from the sternum. The needle
should pass directly backward about 8 mm. (%g inch), the thickness of the
sternum. Thence it should pass inward and backward toward the pericardial
space behind the sternum for from i to 2 cm. (% to % inch). This brings it
to the pericardium, which should be punctured in a downward and inward
direction. To make the puncture, in the sixth space, the needle should be
entered close to the sternum in the middle of the space, and passed backward
and inward to the pericardium behind the sternum. The heart should not
be permitted to scratch itself upon the point of the needle.
The fifth interspace is wider and is generally preferred for the operation.
The pleura is further from the sternal border at the sixth space, and when this
space is sufficiently wide it is used. The puncture is made internal to the
internal mammary artery. There is less danger of injury to the heart in the
sixth space. A bridge of cartilage connects the sixth and seventh costal car-
tilages. The area between the inner border of this bridge and the sternum
may be very small. In some cases such a bridge is present between the fifth
and sixth.
All of the fluid should be drawn off. The operation may have to be
repeated several times. It may be done without making the skin incision.
The advantage of the incision is that it permits a better estimate of the size
of the spaces and more accurate distance measurements. The needle and
apparatus are the same as employed for aspiration of the pleura (page 401).
Pericardotomy is done for the removal of serous effusions, especially with
plastic exudate, requiring irrigation. It is also done for inspection of the
pericardium, removal of foreign bodies, and for drainage. An incision, 6 or 7
cm. (2^2 inches) long is made from a point just internal to the left border of
the sternum and carried outward and downward along the center of the fifth
intercostal space. This should pass through the intercostal muscle. After
hemostasis and retraction, the internal mammary artery is retracted outward
or divided between two ligatures. The fibres of the triangularis sterni are
separated or divided. If the pleura appears, it may be retracted outward.
The pericardium lies at the bottom of the wound. It may be grasped by
toothed forceps, lifted forward and incised in the direction of the intercostal
space for a distance of 2.5 cm. (i inch). If drainage is to be established the
edges of the pericardium may be sutured to the deep fascia; or the wound
may be closed, the pericardium being sewed with a continuous suture of
chromicized catgut.
Empyema of the pericardium should be treated by evacuation of the pus as
soon as the diagnosis is made. Rarely is the infection of so mild a nature as
to justify simple paracentesis. Most cases should be treated by pericardotomy.
If the simple intercostal operation does not give sufficient room, excision of
costal cartilage should be added to it. The pericardial sac may be washed
out with warm saline solution. The traumatism should be as slight as possible
in order to prevent the formation of adhesions between the heart and the sac
wall. The lips of the wound in the pericardium may be sutured to the inter-
costal fascia, and the wound left gaping, to be covered with a copious
424 SURGICAL TREATMENT
antiseptic occlusive dressing. The introduction of drainage material into
the pericardium is to be deprecated.
Exposure of the pericardium and heart is best done by resection of costal
cartilage. This may be done by removal of the cartilage or by temporary
resection in a plastic flap. The operation is employed for suturing wounds of
the heart, for hemopericardium, for wounds of the pericardium, and for
drainage of pus in cases in which the intercostal operation does not give
enough room.
For exposure by excision of the costal cartilage, an incision about 9 cm.
inches) long, is made from the middle line outward and downward
along the fifth costal cartilage and rib. This passes down to the bone and
cartilage. The latter is isolated by means of a curved periosteal elevator,
divided at its sternal and costal ends with bone-cutting forceps, and removed.
The intercostal vessels are identified and ligated at both ends of the wound.
The internal mammary artery is exposed, by clearing away the tissues in
front of it, ligated in two places, and divided; or it may be retracted outward.
The triangularis sterni should be divided near the sternum or its fibers
separated and retracted. The pleura will appear overlapping the pericar-
dium from without; it should be freed from its anterior attachments, and
carefully retracted outward. At the bottom of the wound when all the parts
are retracted lies the pericardium. If it is desired to open the pericardium,
it is lifted forward by toothed forceps and incised in the direction of the
external wound. Through this opening drainage may be secured or wounds
of the heart be sutured.
More room may be had, if necessary, by adding to the above external
incision a vertical incision at either end, passing upward or downward, or
both, depending upon whether the fourth, sixth, or both costal cartilages are
to be removed in addition to the fifth. Kocher carried an incision down the
median line from a point opposite the third interspace and thence downward
and outward upon the sixth cartilage. This permits excision of the three
cartilages.
A plastic flap may be made if it is known at the beginning that the removal
of one cartilage will not give adequate room. For suture of wounds of the
heart, operations for tumor, and wider exposures in general, a U-shaped inci-
sion may be made with its base at the sternum, embracing the fourth, fifth
and sixth cartilages. These are divided at their costal attachments, the flap
elevated, and reflected inward (for wider exposures, see page 426).
Cardiolysis for pericardial adhesions has been practised successfully by
Brauer. He performed an osteoplastic resection of the chest wall to release
the adherent pericardium (Centralb. f . d. Grenzgebiete der Med. u. Chir., Bd.
9, Nr. 11-14).
THE HEART
The heart lies behind the gladiolus of the sternum. If projects about 6.7 cm. (3 inches)
to the left of the median line, and about 4 cm. (i% inches) to the right of the median line.
Its upper margin is on the level of a line drawn from a point at the lower border of the
second left costal cartilage 2.5 cm. (i inch) from the sternum to a point at the upper
border of the third right costal cartilage 1.3 cm. (^ inch) from the sternum. The apex
is at a point about 2 cm. (% inch) internal and 3.8 cm. (i J^ inches) below the male nipple;
or 9 cm. (3^ inches) to the left of the median line and between the fifth and sixth costal
cartilages. It rests upon the diaphragm, and the level of its lower border may be defined
by a line from the apex to the seventh right chondrosternal articulation.
A triangular area is not covered by pleura, and is represented by the three lines: (i)
a line from the middle of the sternum opposite the fourth costal cartilages downward and
outward to the apex of the heart; (2) the median line of the sternum; and (3) a line from the
bottom of the sixth right chondrosternal articulation to the top of the seventh left chon-
drosternal articulation and thence to the apex.
THE THORAX
425
The right auricle lies behind the right border of the sternum and the sternal ends of the
third, fourth, fifth and sixth right costal cartilages. The right ventricle constitutes the
large anterior chamber of the beart. It lies between the third and the seventh costal
cartilages on the right side of the median line. The left auricle is behind the second left
interspace and the third left costal cartilage. The left ventricle is behind and to the left
of the right verticle (Fig. 1101).
Paracentesis of the right auricle of the heart is done to save life in cases in
which there is obstruction in the pulmonary circulation. An aspirating needle
about i mm. in diameter is used, connected with a vacuum bottle. It is
directed backward and inserted at the third right intercostal space close to
the sternum. It passes through the skin, fascia, pectoralis major, intercostal
muscle, intervening deep fascia, a few fibers of the triangularis sterni, con-
FIG. noi. — THE HEART.
Showing location of the chambers of the heart. The precordial triangle is that area
which is not covered by the pleura and through which the heart may be approached for
operation.
nective tissue of the anterior mediastinum, pleura, margin of the right lung,
and wall of right auricle. The flow of blood announces the entrance of the
needle into the heart. When the requisite amount of blood has been with-
drawn the needle is quickly removed. The auricle is more easily aspirated
than the ventricle because it is not in motion so strongly, its position is more
fixed, and its anteroposterior diameter is greater.
Paracentesis of the right ventricle of the heart is done for the same condi-
tions as aspiration of the auricle. Suction is not necessary because of the
426 SURGICAL TREATMENT
greater pressure in the ventricle. The trocar and canula, or needle, is
entered in the fourth right intercostal space about 2.5 cm. (i inch) from the
right border of the sternum. It should be directed backward and inward, and
passes through the same structures as in auricular aspiration.
Exposure of the heart by a plastic flap, when a wider exposure is desired
than has already been described for the pericardium, it is secured as follows:
The patient should lie supine with a pillow behind the thorax to throw forward
the chest and widen the intercostal spaces. A U-shaped flap lying to the left
is outlined with its base inward. The incision begins at the left border of the
sternum, passes along the lower border of the third rib, curves downward so
that the vertical portion passes just internal to the nipple and thence back to
the sternum along the lower border of the fifth rib (Fig. 1102). The flap
outlined is intended to expose the lung as well as heart, and is especially
adapted to cases in which the pleura has already been injured. It also allows
access to the apex, outer and posterior aspects of the heart.
FIG. 1 1 02. — INCISION FOR OSTEOPLASTIC FLAP FOR EXPOSURE OF HEART.
The heart may be exposed also by a similar flap with its base externally.
The fourth and fifth ribs are exposed by the vertical incision and further
outward retraction of the soft tissues. The ribs are divided. The intercostal
vessels are ligated and cut. The intercostal incisions are carried down to
the pleura and pericardium. The internal mammary artery need not be
divided. A retractor is then hooked under the outer end of each inner rib
fragment and the flap dissected away from the pleura and pericardium (Fig.
1103). The flap should carry with it the ribs, periosteum, intercostal struc-
tures and the superficial tissues. In dissecting between the periosteum of
the ribs and the pleura, the latter may be opened, if it has not already been.
This contingency should be provided for. As the flap is turned forward and
inward upon its sternal base, the cartilages are broken near the sternum.
The pericardium is picked up with forceps and incised from the lower and
outer to the upper and inner aspect of the wound. If need be the incision is
continued on outward into the pleura. Blood may be removed from the
pericardium, and the heart exposed for operative treatment. This operation
may wisely be done under differential pressure.
To prevent irritation of the heart through pericardial stimuli, M. Heitler
THE THORAX
427
has suggested applying cocain to the pericardium when it is to be much hand-
led (Med. Klinik, Bd. 6, Nr. 25, 1910).
See Operations on the Mediastina, page 458, for other methods of exposing
the heart.
Cardiorrhaphy (suture of the heart) is done after exposure of the heart
by one of the above-described operations or by the operations described for
FIG. 1103. — WOUND OF HEART.
Applying first suture. The heart is held in the palm of the hand and steadied by gentle
pressure with the thumb. The needle is passed during the diastolic interval between
pulsations. The heart has been exposed by an osteoplastic flap with its base outward.
exposure of the mediastina (page 458). The procedure adopted must
depend upon the site to be exposed. If necessary to steady the heart a tem-
porary fixation suture of silk may be passed through the musculature of the
apex.
For suturing wounds of the heart the wound should IDC made freely acces-
sible. A full curved needle held in a light needle-holder is used. Fine silk'is
commonly employed. Fine chromicized catgut is, perhaps, preferable. The
needle is quickly inserted only during diastole. The sutures are placed 3 to
4.5 mm. (% to ^f e inch) from the edge of the wound. The needle should
428 SURGICAL TREATMENT
enter the musculature fairly deeply, but not penetrate the endocardium.
Passing the needle, drawing through the thread, and tying the knot should
all be done during the diastolic intervals. As soon as the first suture is tied,
gentle traction upon it serves to steady the heart for the next suture. Suture
of the auricles may be a running or continuous suture. Wounds of the ven-
tricles should be closed by interrupted sutures, or by sutures which are tied
once for at least every two completed stitches (Fig. 1104).
Following suture of the heart the blood should be removed from the peri-
cardium with the least possible traumatism to its lining. The pericardial
wound may be closed in clean cases. Usually it is best to sew its edges to the
intercostal muscle, and carry a drain through the superficial tissues down to it
but not within the sac (see Wounds of the Heart, below).
FIG. 1104. — WOUND OF HEART.
Applying a continuous suture. The heart is exposed by an osteoplastic flap with its base
inward. Note clamps on pericardium.
Wounds of the heart should be exposed unless there is no deviation from
the normal action of the heart or apparent collection of infected blood in the
pericardium. Usually wounds of the heart will require to be exposed, the
indications being the position and direction of the wound, and the cardiac
embarrassment. The exposure may be made by one of the operations
described for exposure of pericardium and heart or mediastina. If there is
a wound of the chest wall, usually no typical operation will be done, but the
wound will serve as the guide, and sufficient ribs and cartilages will be resected
to give the desired exposure. Such wounds should not be probed, as probing
can reveal but little and is capable of doing great harm in the opening of
sealed wounds, in making new channels, in spreading infection, and in mis-
guiding the surgeon. If the pleura has been opened, much time will be
saved by not attempting to spare it.
The operation cannot be begun upon the basis of an accurate diagnosis.
Upon opening the pericardium it may be discovered that there is no wound
of the heart but only of the pericardium. In such an event, the surgeon
should be thankful. He should remove blood clots from the pericardial sac,
THE THORAX 429
partly close it with sutures, and conduct drainage down to but not within
the sac (see Wounds of the Pericardium, page 422).
A non-penetrating, small, superficial wound of the heart does not require
to be sutured. A wound with gaping of the musculature does, because, unless
it is sutured the heart wall is thinned at that place, a patch of scar tissue
will develop in the wall, the heart is more apt to become adherent to the
pericardium, bloody oozing is more apt to supply serum for bacterial growth
in the pericardium, and infection is more apt to occur.
Wounds of the heart which penetrate its chambers should be sutured if
the patient can be brought alive to the operating table. After opening the
pericardium the relief of pressure, following evacuation of the pericardial
blood, may cause overwhelming hemorrhage from the heart wound. This
should be controlled by taking the heart in the hand and stopping the wound
with a finger while the blood is removed and the first suture introduced.
R. Haecker (Archiv fur klin. Chirurgie, Bd. 84, Nr. 4, S. 917) has shown that
in dogs the afferent vessels can be compressed during operation, keeping
the heart practically empty and a bloodless operation done. This was ac-
complished by displacing the heart forward to angulate the vessels, by digital
compression, and by temporary clamping of the venae cavae. Some of these
expedients can probably be employed in man. After the first suture has
been tied it may be used to hold the heart and steady it (see Cardiorrhaphy,
page 427).
Of the cases of suture of the heart which have been reported, drainage
of the pericardium was employed in most of them. There are, perhaps, 300
or 500 such cases in the literature. Salomoni (Archiv Generales de Chirurgie,
vol. iii, Nr. 9, collected reports of 158 cases with recovery in 59. Death
occurred in 21 cases before the operation had been finished.
The heart is not the delicate organ it was once supposed to be. It has
an enormous capacity to withstand mechanical insult. Its chambers may
be tapped and wounded without serious consequence. The location of the
injury is the important factor. A wound of an auricle may be fatal, whereas
an oblique wound of a ventricle may scarcely give rise to leakage because
of the closure effected by each systolic contraction. Wounds near the
essential cardiac motor nerve ganglion (bundle of His) are apt to be fatal at
once.
Foreign bodies in the heart may remain for a long time without producing
serious consequences. A bullet or other blunt object embedded in the heart
wall and not producing serious disturbances may be allowed to remain ; if
the axray examination shows it to be easily accessible, it may be removed.
Pointed objects tend to migrate and provoke trouble; whether they are pro-
ducing serious symptoms or not their removal is always indicated. When
such an operation is attempted, it should be regarded as only an attempt,
for if in the course of the procedure it appears that the removal of the foreign
body means the sacrifice of the patient the completion of the attempt should
be foregone. D. G. Zesas (Fortschritte der Medizin, Bd. 28, Nr. 21, S. 649,
1910) collected records of 118 cases of foreign body in the heart, 96 having
reached the heart through the chest wall, 12 from the alimentary canal, 4
by way of the blood-stream from some other part of the body, and i from
the air passages. The object was a needle in 54 cases and a bullet in 38
cases. Besides these were such objects as a nail, a thorn, an iron peg, a
splinter, and a hair pin. Koch found a large nail embedded completely in
the heart. of a man who had died of an entirely unrelated disease. In the case
of a man operated upon by Manteuffel, after the wound of entrance in the
anterior surface of the right ventricle had been sewed the bullet was removed
430 SURGICAL TREATMENT
from the cavity of the ventricle through an incision made in its posterior
wall. The patient had an uneventful recovery.
Many and marvelous instances of recovery from shrapnel and bullet
wounds and other foreign bodies are found in the surgical reports of the
war.
Air embolism, occurring through a wound of the vena cava, Schoene has
suggested, could be met by temporarily clamping the vena cava or pulmonary
artery close to the heart, and at once aspirating the air through a strong
suction syringe out of the branches of the pulmonary artery as Trendelen-
burg did for pulmonary embolism.
Heart massage for cardiac syncope (reanimation of the heart) has been
referred to under Anesthesia (Vol. I, page 98). This operation can often
be of much service. In cardiac failure of the newborn, the ordinary measures
of resuscitation often fail. Massage of the heart may be applied by placing
the thumb over the precordium and hooking the fingers under the free border
of the ribs, thus grasping the heart in the hand, and making rhythmic pres-
sure upon it.
In the adult several methods are in use. They are required chiefly
after chloroform syncope, embolism and poisoning. Division of ribs and
grasping the heart, while giving the best mechanical control, have not proved
of much value. It is not necessary to take hold of the heart, the important
thing is to compress the ventricles, and stimulate the nerves of the heart
muscle. This can best be done by opening the abdomen above the umbilicus,
passing in the hand to the under surface of the diaphragm, and compressing
the heart upward and forward against the anterior chest wall. The pressure
should aim to squeeze the blood out of the ventricles. It should be rhythmic
and applied about 60 times a minute. ' When spontaneous contractions
occur, the pressure should accompany them as much as possible. If the
ventricles have not filled at the end of a second, the pressure should be made
less frequently. The return of the blood to the heart is important. This
may be facilitated by elevating the legs and pelvis. The latter operation
also has the effect of relaxing the diaphragm and making massage more
effective.
Artificial respiration or tracheal insufflation should be practised at the
same time. Adrenalin or pituitrin may be thrown directly into a vein
or artery. Intravascular injection of serum or salt solution is also of
service. Electric stimulation of the heart is useful. The surface of the
body should be kept warm. Centripetal massage of the extremities and
lowering of the head should be practised. Subdiaphragmatic massage is
most effective when an abdominal opening has already been made, and the
delay and depression of opening the abdomen after the syncope is not neces-
sary. The massage should be continued a while after the heart has begun
to beat spontaneously. The earlier it is begun the better. It should be
started within five minutes. After ten minutes the results are poor. Fifteen
minutes of massage may be required before the heart responds.
THE ESOPHAGUS
The esophagus extends from the pharynx at the level of the lower border of the
cricoid cartilage between the fifth and sixth cervical vertebrae, and, after passing through
the diaphragm at the level of the body of the eighth dorsal vertebra, ends at the stomach
2 or 3 cm. below the diaphragm, opposite the tenth dorsal vertebra. The distance
from the incisor teeth to the esophagus is from 14 to 18 cm. (5^ to 7 inches); the
length of the esophagus is from 24 to 28 cm. (9^ to n inches); the distance from
the incisor teeth to the stomach is from 38 to 46 cm. (15 to 18 inches) (Fig. 1105).
The narrowest part of the esophagus is at its beginning. It is constricted also at the
THE THORAX
431
fourth dorsal vertebra and at the diaphragm. It follows the anteroposterior curves
of the spine. At the root of the neck and at the diaphragm it curves to the left, and is
in the middle line at the fifth cervical and fifth dorsal vertebra. In the neck, it has
in front the trachea, left lobe of thyroid, and left recurrent laryngeal nerve; behind are the
spinal column and its muscles; to the right are the common carotid artery and the right
recurrent laryngeal nerve ; to the left are the carotid artery, left inferior thyroid artery and
vein, left subclavian artery, and thoracic duct. In the thorax, it has in front the lower end
of the trachea, left bronchus, arch of aorta, left common carotid, left subclavian artery,
pericardium; behind are the spinal column, thoracic duct, right intercostal arteries and
veins, left inferior azygos vein, lower part of thoracic aorta; to the right are the pleura and
large azygos vein; to the left is the pleura. The pneumogastric plexus is on either side
(Fig. 1106). j
SUPERIOR
CERVICAL
GANGLION
INTERNAL
CAROTID
ARTERY
THYROID
BODY
COMMON
CAROTID
ARTERY
PLEURA
AORTA
LEFT LUNG
THORACIC DUCT-
VAGUS NERVE
AZYGOS VEIN -
SUPERIOR
LARYNGEAL
NERVE
VAGUS NERVE
NTERNAL
JUGULAR VEIN
TRACHEA
INFERIOR
THYROID ARTERY
RECURRENT
NERVE
SUBCLAVICULAR
ARTERY
RIGHT CEPHALIC
TRUNK
OESOPHAGUS
VAGUS NERVE
AZYGOS VEIN
BRONCHIAL
ARTERY
RIGHT PUL-
MONARY VEIN
RIGHT LUNG
INF. VENA CAVA
-DIAPHRAGM
FIG. 1105. — ESOPHAGUS.
Diagrammatic. Seen from behind. (After Poirier, Charpy and Gray.)
Wounds of the esophagus are always serious because of the danger of
infection extending to the mediastinum. Slight wounds or abrasions of the
mucous membrane should be given every consideration to avoid infection.
Particles of food should be washed out with clean water. Nourishment
should be given per rectum. No food should be taken by the mouth until
protective exudate has sealed the wound. At first the diet should be fluid,
and this gradually increased to solid diet.
Perforating wounds, if inflicted from within, should be cleansed through the
esophagoscope and the wound, if large enough, washed out and packed with
gauze once daily. Perforating wounds inflicted from without, such as
432
SURGICAL TREATMENT
TRACHEA-----
— AORTA
stab wounds, are usually complicated by injury of other important structures.
In the treatment of the other injured structures, the esophageal wound, if
possible, should be exposed and sutured. It is possible in neck wounds for
the esophagus alone to be injured. When this is the case, the wound should
be enlarged, retracted, cleansed and the esophagus sutured with two layers of
chromicized catgut. The wound external to the esophagus should be left
open and drained. In wounds of the thorax, penetrating the esophagus,
opening of the chest under negative pressure or with lung insufflation may be
done. Posterior exposure of the mediastinum may give the best access
(see Cervical Esophagotomy, page 442; and
Thoracic Exposure of Esophagus, pages 459
and 463).
Rupture of the esophagus practically always
means preexisting disease. Its treatment is
the same as that of perforating wound, except-
ing that it is more urgent, because it usually
occurs in the act of vomiting or swallowing,
and food is projected through the rent. Unless
this foreign matter is quickly removed from the
periesophageal connective-tissue spaces, death
from infection should be expected.
Hemorrhage from the esophagus, not severe
enough to prove fatal and too severe to be neg-
lected, may be treated by swallowing bits of
ice, by the local use of styptol or adrenalin.
The bleeding point may be searched for with
the esophagoscope and cauterized or com-
pressed by a gauze packing controlled from
above. An inflated rubber bulb or a dilating
bougie may be used.
Inflammations and Ulceration. — Corrosive
esophagitis, caused by swallowing corrosive
substances such as acids, caustic alkalies, etc.,
often end fatally from their effect on the
stomach before treatment can be applied. The
chemical and physiologic antidotes should be
given at once and the poison diluted. A
stomach tube should be introduced very care-
fully and the substance removed from the
stomach. Emetics should be avoided because
of the danger of mechanical injury to the esoph-
agus. If the corrosion has been so severe as to produce sloughing or oc-
clusive swelling, a gastrotomy should be done. This serves for inspection
of the stomach, and, if the stomach is found not too badly damaged, for
subsequent feeding and for dilatation purposes. If the stomach and pylorus
are badly corroded duodenostomy is to be preferred. In severe cases if a fis-
tula for feeding is not made nourishment should be given by rectum.
Acute catarrhal esophagitis, caused by milder chemical or mechanical irri-
tation, is treated by rest, rectal feeding and the occasional ingestion of mild
astringent solutions.
Abscess of the esophagus, occurring in connection with wounds, esophagitis,
or periesophageal infection, should be discovered by the esophagoscope and
incised through that instrument. It is possible to reach an abscess in the
thorax by performing esophagotomy and dissecting down in the retro-eso-
FlG. I I O6. ESOPHAUGS,
TRACHEA, BRONCHI, AORTA, AND
STOMACH, RELATIONS.
THE THORAX 433
phageal space to the side of the great vessels. On the right side it is possible
to dissect down behind the vessels. These operations are called cervical
mediastinotomy.
Gangrenous esophagitis is an extremely serious condition if primary and
infective in origin. So much septic absorption goes on that, if the disease has
not reached the intestine, the best plan of treatment, perhaps, is gastrotomy,
with washing of the stomach through the fistula before pouring in the food.
I have operated upon such a case too late because the gangrenous process had
extended also to the intestine.
Chronic esophagitis, following the acute form or resulting from chronic irri-
tation or infection, should be treated by removal of the cause if it is known.
Alcohol and tobacco are often causative factors. Following acute infectious
diseases, it subsides with careful feeding and good hygiene. When due to
thrush, the application of borax or boracic acid solution is effective.
Ulcers of the esophagus commonly follow chronic inflammation and are
best treated by the local application of silver nitrate solution through the
esophagoscope. The treatment of pressure ulcers is obvious. Fissures
should be located by careful examination and treated with silver nitrate.
When ulcers or fissures refuse to heal under local applications gentle curettage
should be applied and followed by silver solution and rectal nourishment.
Congenital stenosis (atresia) of the esophagus may close the esophagus.
Such a condition may be determined by passing a catheter or sound from
above and one from below and feeling that a diaphragm separates the two.
This diaphragm may be punctured by an electrocautery point or by a knife
passed through a tube; and a tube left in place.
This operation is rarely the indicated procedure because in most cases each
segment of the esophagus ends in a blind pouch, and the upper end of the
lower segment communicates with the trachea or a bronchus, forming a free
communication between the lungs, the gullet and the stomach. H. M.
Richter (Surg., Gyn. and Obst., xvii, 1913) in such cases used intratracheal
insufflation ether anesthesia. A preliminary gastrostomy was done; a tem-
porary clamp was placed on the jejunum; a sound was passed up the lower
segment of the gullet; an incision was made in the right sixth intercostal
space, the inner end carried upward, and the sixth, fifth, and fourth ribs
divided at their angles; a ligature was tied about the connection between the
gullet and the trachea; the lung was dilated to fill the chest; the chest wall
was closed; and a gastrostomy tube left in the stomach for feeding.
The ideal operation would be closure of the tracheal opening, and end-to-
end anastomosis of the gullet segments.
Stricture of the Esophagus. — Cicatricial stenosis, usually caused by swal-
lowing caustic substances, though it may result from any of the forms of
esophagitis, is treated by dilatation. For at least five or six weeks after a
corrosive chemical has been swallowed, or if there is fever, or blood in the
vomit, dilatation should not be attempted. A sound should not be passed in
the presence of serious cardiac or pulmonary disease, aneurism of the aorta,
or an extremely excited nervous condition. Esophagoscopy should be done
to determine the location and nature of the constriction. If this cannot be
carried out the information should be secured by means of sounds (Fig. 1107).
For dilating strictures, various forms of instruments are used. Sounds made
of fabric, covered with rubber, dilatable rubber bulbs, tents of compressed
sea-sponge, silver balls attached to a string, and olive-tipped sounds are most
commonly employed (Fig. 1108).
The introduction of a sound requires delicacy, some skill, and much judg-
ment. It is best that the patient should sit perfectly erect on a simple chair
VOL. 11—28
434
SURGICAL TREATMENT
with a back. He should be instructed to breathe through the mouth rather
rapidly, to make no resistance, and by no means to touch the sound with his
hands. He should hold a basin and be instructed to allow the saliva to run
out of the mouth. Plates of false teeth should be removed. If preferred, the
patient may lie on the right side with a pillow under the head to prevent lateral
curvature. An extremely sensitive pharynx may be touched with 7 per cent.
cocain solution. In children a gag should be inserted between the teeth. A
sound marked with the various distances is advised. The first sound should
be a soft stomach tube or catheter. A small piece of gauze placed upon the
tongue enables the operator to depress the tongue with his left forefinger, if
necessary.
FlG. HO?. ESOPHAGEAL BOUGIES OF FLEXIBLE RUBBER.
The sound should be lubricated by dipping it in warm water or by oiling
its surface and bent before introducing it (Fig. 1109). The patient should
extend the cervical spine to straighten the canal. As the sound passes from
the back of the pharynx to the esophagus, the head should be bent forward,
the patient instructed to swallow, and with this the sound passes into the
esophagus (Fig. mo). If an obstruction is met, it is probably spasmodic
contraction of the circular fibers of the gullet. This relaxes after a few sec-
onds and the sound passes onward (Fig. mi). A stricture or obstruction
gives a different sensation; it is impassable until a sound is used which is
small enough to pass it. No force should be used either in passing a spas-
modic contracture or an organic stricture. Local pain should not be caused,
FIG. 1 1 08. — OLIVE BOUGIES WITH FLEXIBLE WHALEBONE STEM.
for it means inflammation, ulcer, or tumor, and a dilating sound is best not
used in these conditions. Care should be taken that the wall of a diverticu-
lum is not penetrated.
The preliminary diagnostic examinations should have rendered the
patient accustomed to the sounds. A small opening through the stricture
may be found by twisting the sound and trying it at different positions. The
stricture having been passed, the next larger size should be used, and so on
until the ordinary stomach tube can be passed. If progress is being made,
the surgeon should be satisfied with a moderate degree of dilatation each day.
If bleeding is caused the operation should be discontinued for that day,
Swelling of the mucous membrane, caused by the sounds, subsides in a few
THE THORAX
435
days. Cicatricial strictures should be dilated once or twice a week; can-
cerous strictures daily. The patient soon learns to pass the sound himself.
FIG. 1109. — INTRODUCING ESOPHAGEAL BOUGIE.
The tube has been wet in warm water and bent to a gentle curve.
FIG. i no. — INTRODUCING ESOPHAGEAL BOUGIE.
The head is extended, the bougie enters the pharynx, and as the patient makes a swallowing
motion the tip glides into the esophagus.
The dilatation of esophageal stricture by mercury has much to recommend
it. It may be combined with retrograde dilatation. The mercury finds its
way through the stricture. It does not stick to the wall; and may be re-
436
SURGICAL TREATMENT
covered through the gastrostomy opening. It may be allowed to pass off
through the bowel. Valuable #-ray pictures may be made while it is
passing the stricture.
When efforts at dilatation by sounds, tents, mercury, collections of filiform
bougies and dilators fail, both unguided and by the aid of the esophagoscope,
operative relief is called for.
Operative treatment of stricture of the esophagus is indicated when attempts
at dilatation have failed, when the patient is suffering from lack of nourish-
ment because of inability to swallow sufficient food, when ulceration or inflam-
mation demands that the esophagus should have rest from manipulation or
deglutition, or when an accompanying diverticulum renders the passage of
sounds hazardous. Gastrostomy is the first step for relief. This permits the
patient to be fed and the esophagus to be rested. After a while it may be
possible to pass the stricture with a sound from above.
If this does not succeed, the method of von Hacker may be tried. The
patient swallows a silk thread, one end of which is brought out of the mouth
or nose and fastened around the neck. This thread has passed on to it a
FIG. 1 1 ii. — INTRODUCING ESOPHAGEAL BOUGIE.
As the tip enters the esophagus the head assumes a natural position and the bougie is
moved gently downward.
series of steel beads ranging in size up from that of the head of a pin (2 mm.).
The lower end of the thread is brought out through the gastrostomy opening.
Larger and larger beads are threaded and passed down through the stricture
and recovered below. Henle devised an electromagnet for recovering the
beads from the stomach. Some surgeons have fastened the beads to the
thread 3 or 4 cm. apart and permitted the thread to move downward. This
may be followed by a catheter having a silk thread passed through its apex
(Fig. 1112). The lower end of the silk thread, whether beads are used or not,
may be recovered at the gastrostomy opening by injecting water into the
stomach and allowing it to run out rapidly; or forceps, or a blunt hook may
be employed.
Sometimes when a tube cannot be made to pass the stricture from above,
it may be pulled up from below. Ochsner brought a loop of silk thread out
through the stomach opening. Through this loop a long, small, soft-rubber
drainage tube is passed and doubled back at its middle. This is then pulled
THE THORAX
437
up to the stricture by traction through the mouth. By pulling the string
above and the tube below, the latter may be stretched small enough to
pass the stricture, and then be relaxed. This gives very effective dilatation,
and may be left for both dilating and feeding purposes.
FIG. iii2. — CATHETER WITH SILK THREAD THROUGH THE APEX, USED BY AUTHOR, IN THE
ESOPHAGUS.
After beginning dilatation has been secured a drainage tube may be pulled
down into the stricture and left there for a few days. The size may be in-
creased from week to week. As soon as dilatation, sufficient to admit an 8 or
FIG. 1113. — CUTTING STRICTURE OF ESOPHAGI'S WITH SILK THREAD.
The bougie is engaged in the stricture through a gastrostomy opening while the thread-saw
is operated. (After Gottstein in Keen s Surgery.)
io-mm. sound has been secured, dilatation by sounds may be instituted and
practised twice daily. To prevent recurrence, the passage of sounds must
be kept up faithfully for several months and then the interval gradually
increased.
438 SURGICAL TREATMENT
Mechanical contrivances for affecting rapid dilatation at one sitting are not
as safe or efficacious as the gradual operation. Wounds and fissures easily
become infected, more scar tissue is formed or periesophageal infection may
occur. R. Abbe passed a silk string through the stricture by causing the pa-
tient to swallow a shot on its end or by means of an instrument. The lower
end is brought out through a gastrostomy opening. The upper end is
brought out through the mouth or through an esophagotomy opening above
the stricture. The stricture is then made tense by pressing a conical bougie
into it. By drawing the string up and down with a rapid sawing motion the
stricture is divided (Fig. -1113). After this, sounds are passed regularly to
prevent recurrence. If the operation has passed smoothly, and the sound has
been easily introduced, the stomach opening may be closed at once.
Resection of the stricture through the neck or mediastinum has been prac-
tised. More recently resection and esophagogastro-anastomosis have been
done under negative air pressure (for Mediastinal Operations, see pages 459
and 463).
Dilatation by electrolysis is sometimes useful. The negative pole is
applied to the stricture by an olive-shaped electrode introduced through the
mouth, stomach or esophagotomy opening. The positive pole is placed on
the skin of the chest. The electrocautery has been used with variable results.
Internal esophagotomy is dangerous unless done through the esophagoscope
with the aid of the eye. Because of the closeness of vital organs no deep or
uncontrolled incision should be made. When done through the esophago-
scope in strictures projecting far into the lumen the results are good. About
three incisions should be made. Without the aid of the eye, multiple
incisions may be made about the circumference of the stricture. The opera-
tion should be followed by systematic dilatation with sounds.
Dilatations of the Esophagus. — Dilatation involving the whole circumfer-
ence of the esophagus, when due to stricture or cardiospasm, are treated by
correcting the causative condition.
Chronic dilatation, occurring just above the diaphragm, usually requires
relief of the narrowed cardiac orifice. This may usually be secured by
making a vertical incision through the cardia and closing it as a transverse
incision. But in extreme dilatation of long standing there is often a sagging
of the esophagus so that it lies upon the diaphragm as a pouch. If the
pouch is very large or the sagging causes an S-shaped bend, it may be neces-
sary to make a second esophageal opening in the diaphragm and perform
esophago-gastrostomy.
Usually in chronic dilatation it may be assumed that a more simple opera-
tion will suffice. The esophagus may be drawn down through the dia-
phragm until the relaxation is removed from the thorax and the bulging
pouch lies in the abdomen. The cardiac obstruction may then be treated
(see Cardiac Stenosis, page 715), and the dilated pouch may be plicated
if that step seem necessary (for approach to Cardia, see pages 716 and 756;
approach to Esophagus, pages 459 and 470).
Diverticula should be treated, first by the cure of stricture, if any exists. If
the diverticulum is of such a sort that it catches and retains food, it should
be washed out, and experiments made to find if there is any position in which
the patient can place himself in which food will not pass into it. If the en-
trance of food cannot be prevented, experiment should be made with passing
a tube beyond it and feeding through the tube. The most important thing is
to keep food from becoming lodged in it and undergoing decay. When this
has been accomplished, the sac should be kept washed out and cleansed.
Astringent antiseptics may be employed to promote contraction of its walls.
THE THORAX 439
If there is a pouch which cannot be drained, it may be possible under esoph-
agoscopy to divide the spur between the esophagus and the lower part of
the pouch, in order to bring its outlet on a level with its floor. This may be
done with the electrocautery or the division may be made at the side of a
clamp with a cutting instrument. When the di verticulm has been made clean,
dilatation of the esdphagus at its mouth by means of an inflatable rubber
bulb may help throw its cavity into that of the esophagus and obliterate
its pouch. This method has been advocated by Lotheissen (Muench. med.
Wochenschrift, S. 76, 1906). By these methods the disease may be prevented
from destroying the patient.
If treatment is not undertaken, but food continues to enter the diverticu-
lum, a fatal outcome is only a matter of time. The prognosis is bad, and
the end wretched. Death results from infection of the mediastinum, from
pneumonia caused by regurgitated and aspirated food, abscess or gangrene
of the lung, empyema, or inanition. If treatment does not keep the pouch
empty and clean, or if curative treatment is not undertaken, gastrostomy
should be done and the patient fed through the gastric fistula.
Extirpation of the esophageal diverticulum is the curative operation. It
was first done successfully by von Bergmann in 1890 (Archiv fiir klin. Chir.,
Bd. 43, 1892). Up to 1918 a large number of cases had been operated upon
with about 12 per cent, mortality. Only the disease accessible through the
neck is embraced in these statistics. Before operating in the neck, a pre-
liminary gastrostomy should be done two weeks before the operation. A
straight sound or esophagoscope is passed into the diverticulum through the
mouth. The pouch is then exposed as in cervical esophagotomy (page 442)
the operation being done upon the diseased side. The sound makes the pouch
project into the wound. The diverticulum is dissected free and isolated
down to its mouth or pedicle. The sound is then withdrawn from the pouch
and caused to pass a short distance into the esophagus below the pouch
opening to serve as a guide. The wound being protected with gauze pads,
the diverticulum is cut off, and the wound in the esophagus closed with two
layers of sutures. If the neck of the sac is small, it may be ligated, the stump
cauterized and sewed over. In the case of a larger sac, some of the sac must
be left to close the gap. If the wound cannot be closed it may be packed
and drained. The patient should be fed by the stomach fistula until the
wound is healed.
Invagination into the esophagus of small diverticula has been successfully
practised. It is not as satisfactory as excision.
Diverticula which are too low to be reached by operation in the neck and
which are not amenable to other treatment must be attacked through the
mediastinum (see page 459).
Fistula. — Fistulse of the esophagus, following wounds, operations, ab-
scess, or ulceration require that any causative disease shall first be attacked.
Stricture in the region of the fistula should be cured. A recent fistula, not
yet lined with epithelium, may be treated simply by feeding through the
stomach tube to give the esophagus rest. An older fistula, lined with epi-
thelium, requires removal of the epithelial lining after the normal state of
the inside of the esophagus itself has been assured. A systematic dissection
of the fistula should be made, just as though it were a cyst. No epithelium
should be left. The dissection should be carried down to the esophagus, the
esophageal opening closed with sutures, and the outer wound drained.
Gastrostomy is rarely necessary (see Esophagotomy, page 442; and Fistula,
Vol. I, page 304).
440
SURGICAL TREATMENT
Foreign Bodies in the Esophagus. — Foreign bodies of all kinds taken
through the mouth become lodged in the esophagus. They may be caught
by a stricture or at the naturally narrow places. Usually they are caught
at the inferior constrictor of the pharynx, just above the bronchus, and at
the diaphragm. Although smooth bodies may remain for a long time, their
removal as soon as possible is always desirable because of the danger of
ulceration and infection. Sharp and irregular bodies demand much more
urgently an early removal because of the additional danger of perforation.
Attempts at removal should not be made until the surgeon is satisfied that
FIG. 1114. — FLEXIBLE ESOPHAGEAL FORCEPS.
a foreign body is present. The patient's sensations are no guide. Careful
history, #-ray examination, esophagoscopy, palpation, gentle probing, and
the clinical signs should be the surgeon's reliance. Esophagoscopy is the
most reliable means for both diagnosis and treatment.
Bodies lodged at the beginning of the esophagus may be dislodged by
the'finger passed back through the mouth. They may be caught by flexible
forceps (Fig. 1114), curved forceps (Fig. 1115), or by the bristle probang
(Fig. 1116). Great pressure on the larynx may demand tracheotomy for
relief. Bodies above the bronchus should be brought out through the mouth
FIG. 1115. — CURVED ESOPHAGEAL FORCEPS.
if possible; bodies below the bronchus may be allowed to enter the stomach,
although in all cases it is best to fetch up the foreign body.
Fish bones, pins and other small-pointed things should be handled with
much gentleness, lest they penetrate and be driven into the great vessels.
It is such objects especially that require the esophagoscope. Usually they
will be found penetrating horizontally or with the point directed downward.
The introduction of an instrument is dangerous unless it passes only to the
object or past it.
Angular and irregular bodies may cause tearing of the tissues if not care-
THE THORAX 441
fully handled. Much force should never be used. They may sometimes be
rolled upward by taking hold of one side. Often such bodies may be divided
by the electrocautery.
Rounded objects such as coins are most easily handled. In the absence
of the esophagoscope, they may be removed with other instruments. In the
case of a child with an oval locket for ten days engaged at the bronchus, I
placed her supine on the s-ray table with the light behind her thorax.
Under general anesthesia, flexible forceps were passed down the esophagus,
and with the fluoroscope I could clearly see the locket approached by the
forceps and grasped by the opened jaws. The bristle probang and the coin
catcher are effective instruments for these cases.
Soft materials, such as pieces of meat, may sometimes be caused to con-
tract by pouring equal parts of alcohol and water against them. This may
be done through a catheter. Or they may be dissolved by means of pepsin
and diluted hydrochloric acid.
When edema of the mucous membrane is present from the local irritation
it may be treated with adrenalin.
Foreign bodies caught at a stricture should be removed upward and the
stricture treated. It may happen that a body has passed through one
O
FIG. 1116. — BRISTLE PROBANG.
stricture and is caught by a stricture below, being inaccessible to the esopha-
goscope. In such an event the strictures should be dilated to give access.
Rarely is it justifiable to induce vomiting to remove a foreign body as
great damage to the esophagus may be done. The gagging caused by in-
troducing the finger into the pharynx often dislodges the object. The
method which should take precedence of all others is with the esophagoscope.
Mucus should be aspirated or sponged away. If the body cannot be drawn
into the tube, it may be grasped and withdrawn with the tube. Whatever
method is employed, very commonly the peristalsis which the instrument
excites dislodges the body and causes it to pass downward.
Bodies which have become lodged in the esophagus and cannot be moved
whole, may be cut in two and thus removed. This operation is best done
through the esophagoscope. Thus, a metal pin may be filed; a body of hard
rubber, such as a denture, may be burned by the electrocautery; or a softer
body may be cut by the rongeur forceps which are used with this instrument.
Operation is indicated when efforts at removal through the natural
passages fail, when severe injury has been done to the esophagus, when the
pressure upon surrounding important organs by a sharp object is so great as
to render manipulation dangerous, and when bleeding obscures the esopha-
goscopic view. When the body is above the bronchus, cervical esopha-
gotomy is done (page 442). The opening is made on the left side unless the
body projects more prominently elsewhere or cellulitis is present on the
right side. The opening of the esophagus in the neck gives better access to
442 SURGICAL TREATMENT
the body no matter where it is; if necessary it may be cut with bone forceps
or divided by some other means. Curved forceps are used for the extraction.
When the body is below the bronchus, esophagotomy still improves the
access to it. By dividing the sternal attachment of the sternomastoid
muscle more room is secured. This makes the esophagus easily accessible
as far as the bronchus. There is still a distance of 8 or 10 cm. (3 or 4 inches)
between the bronchus and the diaphragm. A body may be reached from
above, but the constriction caused by the bronchus makes it very difficult.
Better success with the low-lying bodies has been secured through gas-
trotomy. There are several methods of procedure, (i) The stomach may
be drawn out, walled* off, incised and the whole hand entered into it. The
index-finger is then passed into the esophagus, and the body dislodged and
pulled down. (2) An incision 2 cm. long is made down to the mucosa,
a purse-string suture is passed around the edges, the mucosa is incised,
the index-finger admitted, and the suture tied down upon it. The stomach
wall is then invaginated, and the finger passed into the esophagus . (3)
A small opening is made in the stomach, the abdomen well walled off, and
an instrument passed into the esophagus to grasp the foreign body. (4)
A filiform bougie or thin probe is passed from above downward past the ob-
struction. This carries a thread to which a sponge is attached. The
thread is brought out through the stomach opening, and by drawing down the
sponge the body may be brought with it. In this operation, a thread con-
trolling the sponge from above should be used in order to draw it back should
the operation fail. Other expedients to fit the individual case will occur
to the resourceful surgeon. As a last step to be considered is posterior
mediastinotomy (page 459).
Esophagismus. — Spasm of the esophagus demands treatment of the cause.
Fissure, ulcer, stricture, tumor or contracting scar may be the causative
factor to be treated. Constitutional disease, such as hysteria, epilepsy,
chorea, and diseases with increased excitability of the cord, should be dis-
covered and treated. Reflex irritation from other parts of the body require
correction. In cases in which no cause can be found or removed the spasm
may be allayed by rest, simple diet, sedative drugs, and cocain or orthoform
locally. Rectal feeding may be required. Dilating sounds are often of
help. Gastrostomy should rarely be necessary.
External cervical esophagotomy is done for the removal of foreign bodies
which cannot be removed through the mouth. It may be done for tumor or
for stricture. For purposes of feeding, gastrostomy is much to be preferred.
Esophageal bougies, a stomach tube, bristle probang, esophageal forceps,
tracheotomy tube and intubation set should be at hand. The patient lies
on the back, the shoulders should be raised and the head dropped back in
order to make the front of the neck prominent. If there is no other deter-
mining element the incision is best made on the left side; the face should be
rotated to the right.
An incision 7.5 or 10 cm. (3 or 4 inches) long is made along the anterior
border of the sternomastoid muscle from the upper border of the thyroid
cartilage. It should be carried as far toward the clavicle as is necessary.
The communicating veins are doubly ligated and cut between. The sterno-
mastoid is exposed and retracted outward; the sternohyoid and sternothyroid
are retracted inward; and the omohyoid is retracted outward or divided.
The thyroid fascia is exposed. It forms the capsule of the thyroid gland,
and thence covers the great vessels. This should be divided, and the thyroid
gland with the larynx and trachea retracted inward and forward. The sheath
THE THORAX
443
enclosing the great vessels and pneumogastric nerve should be retracted
outward. The inferior thyroid artery will be seen emerging from behind
the common carotid and coursing inward and upward in front of the longus
colli muscle. It should be ligated in two places and cut between. The supe-
rior thyroid vein may also require to be tied and divided. Retraction of the
trachea exposes the esophagus, which appears as a red flat tube. The re-
current laryngeal nerve lies in the angle between the esophagus and trachea.
It should be spared both wounding and traumatism.
The esophagus may be made to appear more prominently in the wound by
passing a bougie into it from the mouth. It may be incised longitudinally
through its lateral wall. By catching the lips of the wound with forceps or
a silk thread it may be held widely open and the interior of the esophagus
exposed for surgical attack (Fig. 1117). After a clean operation, the
FIG. 1117. — EXTERNAL CERVICAL ESOPHAGOTOMY.
A, Omohyoid muscle; B, sternohyoid muscle; C, thyroid gland; D, recurrent laryngeal
nerve; E, sternothyroid muscle; F, trachea; G, superior thyroid artery; H, sternomastoid
muscle; 7, inferior thyroid artery; J, common carotid artery; K, esophagus incised and
lips of wound retracted with fine sutures.
esophagus is closed by two or three rows of sutures, and the outer wound
partly closed and lightly packed with gauze to induce granulation. The
patient should be fed by the rectum for about four or five days and for two or
three days longer by stomach tube. The packing should be renewed daily.
For purposes of feeding, because of disease above the opening, or for
local treatment, the wound in the esophagus may be left open. The opera-
tion then becomes an esophagostomy. The edges of the esophageal wound
are sewed to the skin, the deep fascia or muscle. Through this opening a
tube'.may be passed and food introduced. When it is desired to close the
wound, the esophagus may be dissected free and the opening sutured.
Partial cervical esophagectomy is undertaken for cancer and incurable
stricture. The exposure is made as for esophagotomy, excepting that the
sternomastoid muscle is detached from the sternum. The esophagus is
444 SURGICAL TREATMENT
dissected free from its attachments as far as necessary or possible. The
recurrent laryngeal nerves are most apt to be injured and pains should be
taken to leave them attached to the trachea (see Relations of Esophagus,
page 430). The isolation being completed, the esophagus is divided above
and below the disease. If possible the two ends may be brought together
and sewed by an internal mucous membrane suture and an external suture.
If the ends are further apart than 4 cm. they can not be approximated and the
upper end should be closed to form a pharyngeal cul-de-sac by a mucous
membrane suture and an external suture. The lower end should be brought
into the wound and sutured. Through this opening the patient is fed by
means of a tube. Rectal feeding should be practised for the first few days
after the operation.
The mortality in this operation is high. Its only justification is cancer of
not more than 3 cm. in extent. The best results have been secured in benign
strictures, but in these the mortality (25 per cent, at least) is still too high
to make it preferable to other methods. If the stricture can not be cured
except by excision, gastrostomy is to be preferred. W. A. Lane (British
Med. Jour., Jan. 7, 1911) reported a case of resection for carcinoma involving
the upper 5 cm. (2 inches) of the esophagus, in which he replaced the re-
moved segment by a skin-flap, cut transversely from the neck and left
attached sufficiently to give it blood-supply. This completely filled the gap,
and later it was freed from its pedicle.
THE MEDIASTINA
Infections of the mediastinum commonly are the extensions of infec-
tions of the neck. For this reason cellulitis of the deep tissues of the neck
should be cured before it can spread downward. Cellulitis of the mediasti-
num should be treated by energetic constitutional measures. Usually the
disease involves the anterior portion of the upper mediastinum. Abscess
should be treated by evacuation. Cervical mediastinotomy will some-
times reach the abscess. Usually it is too low for this and the great
vessels shut it off from above. When it is causing pressure or its presence
is strongly suspected, the sternum should be trephined in front of the
abscess, and careful blunt dissection made. The aspirating needle should
not be used. Drainage should be provided. In some cases the abscess
points between the ribs at the edge of the sternum. Wherever it appears
it should be opened, and if necessary the sternum trephined or cartilage
resected to give drainage at its lowest part.
Access to the posterior mediastinum is secured by a vertical incision ex-
posing two or three costovertebral articulations. The transverse processes
and the ends of the ribs are excised, and the mediastinum entered (see
Posterior Mediastinotomy, page 459).
Tumors of the Thorax. — Tumors of the chest wall should be treated accord-
ing to the principles already laid down (see Tumors, Vol. I, page 323). Tumors
of the thoracic viscera are approached by the methods described below
for opening the thorax and exposing its parts. The important structures
of the chest are so closely associated anatomically and physiologically, that a
thorough familiarity with all of them should be possessed by the surgeon
before attacking any one. If necessary, the chest wall should be resected.
It is possible in some cases to remove ribs and intercostal structures and
leave the pleura un wounded. Tumors of the ribs and sternum, growing
into the thoracic cavity, should be removed early. Chondromata of the bones
THE THORAX 445
should be widely removed as though malignant because of the tendency to
recurrence. Resection of the sternum for sarcoma should be performed
with provisions in readiness to do inflation of the lungs by negative or positive
pressure. This is necessary because of the possibility of opening the pleural
sacs. Sarcoma of ribs is more easily removed. Carcinoma invading the
chest wall as a secondary deposit or by extension, especially from the breast,
is a well-nigh hopeless condition, because it is usually associated with invasion
of the deep lymphatics. Attempts at removal of the disease are justified
if the growth does not clearly involve the chest contents.
Tumors may be removed and a flap of soft parts laid directly back upon
the lung. Friedrich removed 160 square centimeters of the right side of the
diaphragm in extirpating a sarcoma of the thorax and secured satisfactory
healing.
Tumors of the pleura usually belong to the endotheliomata and sarcomata,
if primary. The tumors have been recognized so late and come to operation
when so extensive that little success has been met by their treatment. Sec-
ondary sarcoma and carcinoma or extensions from other tissues offer a
bad prognosis. Attempts at removal may be made.
Tumors of the lung which require surgical attention are usually cysts
and malignant neoplasms. Benign tumors rarely require operation.
Echinococcus cysts of the lung are not uncommon, and unless recognized
and properly treated, the possibilities of death from rupture into a bronchus
or from sepsis are serious. Polycythemia is a helpful sign. Aspiration of
the cyst is objectionable because of the danger of infecting the pleura and the
improbability of such a procedure curing the disease. Aspiration raises
the mortality. The best treatment of large cysts consists in exposing
the tumor by rib resection, protecting the pleura and the rest of wound by
gauze pads, evacuating the cyst contents, if possible peeling out its lining,
stitching the edge of the sac to the chest wound, and packing the cavity
for drainage. In smaller cysts the tumor may be exposed by pneumotomy,
and dissected out without rupturing it. This is the ideal treatment (see
Cystomata, Vol. I, page 325).
Malignant tumors of the lung have not been recognized early enough to
be removed. If early diagnosis can be made pneumectomy may embrace
the disease.
Tumors of the pericardium are similar to those of the pleura. Early
removal offers relief.
Tumors of the esophagus amenable to operation are benign and malig-
nant. Benign tumors within the lumen of the gullet are often peduncu-
lated and accessible through the esophagoscope. Polyps may be removed
with the snare. Polyps near the pharynx have been caused to be vomited
into the pharynx, grasped with forceps and the pedicle cut with a snare.
If the growth cannot be reached through the mouth, external esophagotomy
is indicated if a benign tumor is causing serious dysphagia and inanition.
When a tumor causes great pressure upon the larynx or upper trachea, trache-
otomy may be necessary. If removal of the growth is not to be attempted
for dysphagia and inanition, gastrostomy is called for.
Operations for the removal of malignant tumors of the esophagus should
be undertaken early or not at all. At the best the prognosis is unfavorable.
Earlier diagnosis and improved technic are lowering the mortality in this
class of diseases. Carcinoma is a common disease of the esophagus,
and should be looked for at once in suspicious cases, developing often at the
seat of some old inflammatory irritation. The lower segment of the gullet
446 SURGICAL TREATMENT
is usually attacked. When found in the cervical segment, cervical esophagec-
tomy (page 442) may be done. To remove the disease from the thoracic
segment requires operation through the chest (see below).
The palliative treatment, if curative operation is not to be done, consists
in keeping the patient comfortable and providing nourishment (see Pallia-
tive Treatment of Cancer, Vol. I, page 331). If the patient can still take
food it should be largely fluid and semifluid. Peptonized milk, scraped beef,
gruels, jellies, etc. Mucus and septic material from the esophagus may be
washed out of the stomach once or twice a day to the relief of the patient.
Gastrostomy is indicated when dysphagia is causing inanition. This should
not be confused with the cachexia of the disease.
The treatment by sounds usually precedes gastrostomy. By dilating
the constriction the patient may take nourishment throughout the whole
course of the disease. Conical rubber bougies are used. The dilatation
may be done every day or two, depending on the condition. The local appli-
cation of methylene blue helps to keep the diseased surface clean. Curet-
tage of the occluding tumor is feasible. Radium has much to offer. The
radium treatment is applied directly to the inside of the esophagus. As to
the choice between gastrostomy and keeping the passage open with bougies,
in most cases the patient will live longer and be more comfortable with the
latter treatment. In some cases a rubber tube having a funnel at its upper
end, controlled by a string brought out through the mouth may be left in
for several days, the funnel resting upon the stricture (see Resection of
Thoracic Esophagus, pages 459 and 463). Perforation of the great vessels,
perforation of the trachea and extension of the disease to the pleura are
to be anticipated.
Tumors of the mediastinum, if malignant, should be removed if a suffi-
ciently early diagnosis has been made. The benign tumors should be
removed if pressure causes serious disturbance of the vital organs. The
operations are anterior or posterior mediastinotomy (see below).
Intrathoracic goiter requires treatment to relieve the symptoms of pres-
sure and suffocation. Removal of the goiter is necessary when it continues
to cause increasing symptoms. The operation may best be done under
local anesthesia. These tumors can be removed without dividing the bone
(see Thyroid, page 380).
Hypertrophy of thymus gland is a similar condition requiring operative
removal (see Thymus, page 394).
Operations through the Mediastina and Pleurae Which Have Not Been
Described Above and Which Are Preferably Done under Positive Intra-
pulmonary Pressure or Extrapulmonary Rarefaction of the Air. — The
collapse of the lung during operation is a serious accident if the other lung is
ineffective for any reason. The collapse of both lungs is apt to be a fatal
accident. To overcome the disadvantages of throwing the lungs out of use,
two distinct plans have been devised: (i) One consists in forcing air in through
the trachea to expand the lung; (2) the other consists in lowering the atmos-
pheric pressure upon the surface of the exposed lung. Many combinations
of these two principles have been tried.
Increased intrapulmonary pressure (insufflation of the lungs) was worked
out by S. J. Meltzer. A rubber catheter is passed through the larynx down
as far as the bifurcation, and through this air is pumped to give an intra-
tracheal pressure sufficient to overcome the elastic contraction of the lungs
and keep the lungs distended. The escaping air passes out alongside of the
catheter, and respiratory motions are no longer necessary because air is
THE THORAX
447
artificially brought into the lungs. The catheter should be much smaller than
the lumen of the trachea. For the adult a No. 22 or 24 French soft-rubber
or flexible silk woven catheter is used. The air space in the trachea outside
of the catheter should be as great as the caliber of the catheter. Through
this catheter air enters the lungs and thus they are kept dilated and supplied
with a current of air which performs both the function of inspiration and ex-
piration. With this apparatus a person whose respiratory muscles are para-
lyzed may be kept alive. Air may be admitted to both pleural sacs and still
the lungs kept dilated. The dangers of pneumonia are greatly reduced.
Inhalation of foreign substances does not take place. The trachea is kept
cleared because the current is always upward.
The apparatus for insufflation may be of a simple type connected with a
foot bellows. For this purpose a glass-blowers' bellows is used. Meltzer
(Keen's Surgery, Vol. VI, page 972) described a system of connecting tubes
which fulfil all requirements. The air is pumped through a bottle containing
ether. Safety valves protect the patient from accident. A manometer
PIG. 1118. — APPARATUS FOR ANESTHESIA BY INTRATRACHEAL INSUFFLATION OF S. J.
MELTZER. (Keen.)
shows the amount of air pressure in the lungs. By adding a bottle of mercury
a tube may be submerged to the depth to which it is desired to limit the
pressure. This should not be more than 20 mm. (Fig. 1118).
With the bellows the air is driven through the system of tubes. The tube has a bypass
provided with a stopcock (St 3) which may be used for the release of the air at will.
When this cock is opened to release air part of the air pumped in may be allowed to cir-
culate through the other arm of the tube. The amount of air passing through the left
tube may be regulated by the screw clamp (S.C.). The next branching of the tubes is to
control the anesthetic. The ether bottle (E) is introduced in the course of the current, and
is bypassed with a tube having a stopcock (St 2). A stopcock (St i) also controls
the air current going to the ether bottle. The air may pass through the ether bottle or
around depending upon the opening and closing of these cocks. The air then passes to
the tracheal tube (T.T.). Between the ether bottle and the patient the tube is connected
to a manometer (M) to show the air pressure in the lungs, and to a bottle of mercury with a
blow-off opening (S.V.) which serves as a safety valve. A graduated glass tube is submerged
in the mercury to the depth of the maximum mercurial pressure to be allowed. The
ether bottle may rest in a warmed chamber or warm water bath (see Warmed Anesthetics,
Vol. I, page 130).
448
SURGICAL TREATMENT
The apparatus of C. A. Elsberg (Annals of Surg., February, 1911, vol. 53)
is provided with an electric pump as well as a foot bellows (Fig. 1119). It is
contained in a box which may be conveniently transported. It is compact
and dependable. A one-sixth horsepower electric motor drives the blower
(Fig. 1120).
FIG. 1119. — ELSBERG'S APPARATUS FOR INSUFFLATION OF THE LUNGS
The rotary electric pump (X) forces air first through the air receiver and oil separator
(Z) which removes the oil from the air as it comes from the pump. The air is warmed and
moistened by passing through a tank of warm water at G.
An ether regulating valve (R) is designed to shunt the air stream in varying propor-
tions through the ether chamber (M). When the index is over the word "air" on the
Gl
Y W Z X
FIG. 1 1 20. — DIAGRAM OF ELSBERG'S INSUFFLATION APPARATUS.
scale the ether is completely shut off and the apparatus is delivering pure air. For example,
at 50 half of the air is saturated with the anesthetic and at 100 the entire air stream is be-
coming saturated. The intratracheal tube is connected to the apparatus, by a length of
rubber tubing, after it has been introduced the proper distance into the trachea. If the
catheter is too small the return current is so rapid that the anesthetic is not absorbed
properly, consequently the anesthesia is too light. If the catheter is too large it offers too
449
much obstruction to the return current, causing the intratracheal pressure to become too
high, approaching that registered by the manometer. When the catheter has been properly
introduced, the specially designed clamp is slipped over it to hold it in place and prevent its
displacement should the patient cough. It also has projections to prevent its being closed
at any time by the patient biting on it.
A manometer (H) reads in millimeters of mercury, indicating the pressure at which the
apparatus is delivering the etherized air; the intratracheal pressure is usually one-fourth of
this amount. An average safe pressure for ordinary use is 20 mm. (manometer reading), it
may, however, be necessary to increase the pressure to 30 mm. Pressure much higher than
FIG. 1 12 1. — INTRATRACHEAL INSUFFLATION APPARATUS OF ROBINSON.
The apparatus is supported on a shaft through which the electric wire is conducted.
The tube for conducting air and anesthetic vapor to the patient passes off at the right.
this is dangerous. To prevent all danger of rupturing the lung a safety valve (S) is pro-
vided, which if properly adjusted prevents accidents due to excessive pressure. The
safety valve may be adjusted to blow off slightly in excess of the pressure to be used.
The pressure in the entire apparatus is regulated by the stopcock (B) which exhausts the
excess.
To cause momentary interruption in the air stream and allow the lungs to partially
deflate, the stopcock (D) may be opened and closed; this should be done a number of
times a minute. When (D) is opened the pressure falls but is instantly brought back to
the original pressure upon closing it. To make the apparatus absolutely safe, the foot
bellows should always be connected for immediate use should the electric power fail for
VOL. 11—29
450
SURGICAL TREATMENT
any reason; then by simply throwing over the lever of the valve (A) the operation may
proceed without interruption.
If it is desired to use oxygen or nitrous oxid in connection with the apparatus, connection
to the cylinder of compressed gas may be made through the stopcock (C) attached for that
purpose.
The apparatus of S. Robinson (Surg., Gyn. and Obst., December, 1915)
is provided with a supporting shaft upon which it stands (Figs. 1121 and 1122).
It is constructed of metal and glass and is compact and effective.
Ether tu.be cock
Air-tube cock
Air-tube
side track-vug
Pube to etHejr
bottle -'
I'uro-uraij cock
emergency *
Tube to
safety valye
Outlet of
•uiater
jacket.
ii
flercury
safety
valve
ctXer bottle
-Copper water
jacket
-Mercury
manomet Bl-
•water jacket
Electric
Heater
su/itcK
Supporting *Huft
eo^tavnxng air ti1
and electric -uri
.-Tube to
pat vent
FIG. 1122. — INSUFFLATION APPARATUS OF ROBINSON, SHOWING DETAILS.
With the apparatus of Elsberg or Robinson, the percentage of ether is
regulated as the patient requires. Usually the indicator has to be turned
until it shows that half or full ether vapor is being used.
The patient is first etherized in the usual manner, placed on the operating
table, the head extended on the neck, and the intratracheal tube inserted.
This may be done best under the guidance of the eye with the direct laryngo-
scope. The tip of the catheter should lie about 5 cm. (2 inches) above the
bifurcation.
With skill and experience the tube may best be inserted without the aid
THE THORAX
451
of direct vision. A stilet serves to give the necessary curve and act as a
guide (Fig. 1123). The tongue of the anesthetized patient is drawn forward
with forceps. The mouth gag should give wide exposure. The surgeon
lifts the epiglottis with his left forefinger, and passes the tube exactly in the
median line over the finger into the larynx. The tube will be stopped by the
vocal cords unless the patient is deeply anesthetized. Force should not be
used. As the tube slips between the vocal cords respiratory air can be
felt issuing from the free end as the stilet is withdrawn. The tube should
then be passed downward to the bifurcation and then withdrawn 5 cm.
(2 inches).
The catheter should have an opening at or near the end and be at least
30 cm. (12 inches) long. It should have a mark 12 cm. (4% inches) from the
tip and another 26 cm. (io34 inches) from the tip. The adult trachea is
12 to 13 cm. U§4 to 5 inches) long, and the larynx 5 cm. (2 inches). The
FIG. 1123. — INTRATRACHEAL TUBE.
This is a modified urethral catheter (A). A steel stilet with a bulbous end (B) is in-
serted to guide the catheter. The end of the tube, containing the stilet, is shown in (C).
This is the tube apparatus devised by S. Robinson.
distance from the incisor teeth to the glottis is 14 cm. (5^ inches). If the
tip of the intratracheal tube is 26 cm. from the incisor teeth, it will lie 5 cm.
above the bifurcation of the trachea.
The tube is held in place with a special mouth gag. When the pressure
is raised to 30 or 40 mm. breathing movements seem to cease, but the patient's
color remains good and the action of the heart is not disturbed. If the tube
is too close to the bifurcation it causes coughing; if it is too high cyanosis
will be observed. The patient's color should be good throughout the
operation.
This method is not only applicable for thoracic operations but for general
anesthesia in all classes of cases. Post-operative vomiting and the danger of
pneumonia seem to be reduced. As a method of anesthesia intratracheal
insufflation is now well established.
These devices for insufflation of the lungs have superseded the negative
pressure cabinets which served a most useful purpose in the development
of thoracic surgery. S. Robinson, for example, who devised an effective
differential pressure cabinet, has given it up, as he finds that the work can
be done with the intratracheal insufflation apparatus.
The pneumatic cabinet for securing negative and positive atmospheric
pressure in thoracic surgery was perfected by W. Meyer, who improved
upon the methods of Sauerbruch and Brauer. Meyer's apparatus consists
of an outer negative pressure chamber within which is a positive pressure
452
SURGICAL TREATMENT
chamber. The former is used as the operating room, while the patient's
head is in the latter which is the anesthetic room (Fig. 1124). By means
of these air-tight chambers it is possible to operate under either negative
differential pressure or under positive differential pressure, or a combination
of the two. A rubber collar with a guillotine shutter encompasses the
patient's neck. The air pressure is regulated by pumps. The chambers
are large enough to accommodate operator and assistants.
FIG. 1124.
-MEYER'S POSITIVE DIFFERENTIAL PRESSURE CABINET USED IN OPERATIONS
ox THE THORAX. (Keen.)
By the use of the "universal pressure chamber" of Meyer the patient's
pleural cavity may be placed under negative or under positive pressure in the
same place and position. This is accomplished by placing the positive
pressure cabinet within the negative pressure chamber.
The differential pressures required in thoracic surgery does not often
need to be more than 7 or 8 mm. of mercury. This is not so great a deviation
from the normal as to cause discomfort to the operator. It is equivalent to
an elevation in altitude of 250 to 300 feet. The positive pressure to which
the anesthetist is subjected is so slight as to be scarcely noticeable.
THE THORAX
453
OPERATIONS ON THE LUNGS
For Diseases of the Lungs see page 413. The lung may be cut with knife
or scissors, but if a large wound is to be made multiple ligatures should have
been tied on either side to prevent bleeding. Indurated areas may be incised
with less bleeding. Blunt dissection or tearing may be practised for short
distances. A bloodless incision may be made by means of the red hot
cautery knife. When a lung is incised deeply enough to open large bronchi,
the patient should not lie with the sound side down because of the danger
of blood running into the sound lung. Cavities are opened by enlarging a
narrow incision or puncture by blunt dilatation.
The patient may be placed on the ordinary operating table and the posi-
tion controlled by sand-bags, or the special table of Friedrich may be used
FIG. 1125. — SPECIAL TABLE FOR OPERATIONS ON THE THORAX
(Fig. 1125). A necessary instrument for thoracic surgery is the rib spreader
or retractor which permits wide access with a minimum of assistance and
external wound (Fig. 1126).
Exposure of the lungs for pneumotomy, pneumectomy or other operation,
may be made by a simple rib resection, as described for empyema, by resect-
ing two ribs through an incision placed between them, or by making a thoracic
flap (Fig. 1127). Such a flap may retain the divided rib segments, or they
may be sacrificed and the flap consist only of soft tissue (see also Thoraco-
plasty, page 410). In making these thoracic flaps consideration should be
given to the source of blood-supply in order to insure the best nourishment.
Lines of incision running parallel with the ribs are to be preferred (Fig. 1128)
The division of the ribs in a flap having its base at one intercostal space
454 SURGICAL TREATMENT
should be made a short distance (i cm.) to one or the other sides of the
incision in the skin (Figs. 1129 and 1130).
If a flap of soft parts is turned back it should include everything external
to the ribs and external intercostal fascia. The ribs are then divided at the
outer edge of the wound, the intercostal vessels tied, and the ribs with
the intercostal structures and costal pleura removed throughout the extent
of the wound. This operation leaves a raw flap to be replaced against the
lung over a ribless area (Fig. 1131).
If it is desired to retain the ribs and pleura in the flap the resected seg-
ments and pleura are retained in connection with the superficial soft parts.
If before replacing the flap, it is desired to convert it into a boneless flap,
the ribs may be removed by incision over each rib on the pleural side. Or
if it is desired to secure adhesions to the lung but not collapse of the thorax,
the pleura alone may be dissected off or irritated with the curet.
FIG. 1126. — RIB-SPREADER FOR GIVING WIDE ACCESS TO THE THORAX.
The ribs may be removed, and the pleura left. This is done by turning
back the flap of superficial soft tissues, and then removing each rib from its
bed of periosteum. With care this can be done without opening the pleura.
To expose the lung, an incision may be made through the pleura in any
direction. If desired, the intercostal structures may be removed with the
ribs, leaving the pleura alone or with the pleural side of the rib periosteum
attached to it. When the pleura has been thickened by old empyema, it is
easy to separate the ribs with their periosteum from it.
If it is desired to close off the rest of the pleural cavity on account of
infection which is to be exposed in the lung, the parietal pleura may not be
included in the flap; it is incised, and the lung exposed; the edges of the wound
in the parietal pleura are then sewed to an elliptic surface of the lung. This
line of suture may be left for a few days to become sealed before incising the
lung; or, with the aid of a protective packing, the lung may be incised at once.
It is possible to make this suture still tighter by making a superficial incision
through the pulmonary pleura, and sewing the edge of this wound to the
edge of the wound in the costal pleura.
THE THORAX
455
FIG. 1127. FIG. 1128.
FIG. 1127. — INCISIONS FOR EXPOSING LUNG BY VERTICAL FLAPS.
FIG. 1128. — INCISIONS FOR EXPOSING LUNG BY TRANSVERSE FLAPS.
These incisions are so placed that a better blood supply is provided for the flap than
in flaps turned back at right angles to the intercostal spaces.
FIG. 1129. — LUNG EXPOSED BY OSTEOPLASTIC FLAP IN THE DIRECTION" OF THE LONG
AXES OF THE RIBS.
To turn back this flap, the ribs may be broken. It is better to cut with forceps the
two ribs adjacent to the incision and then divide the intervening rib or ribs through a small
incision at the base of the flap.
456
SURGICAL TREATMENT
For exposing the apex of the lung a U-shaped flap is made having its
convexity at the border of the sternum, its base at the anterior axillary line,
its upper arm at the first intercostal space, and its lower arm in the third
intercostal space. If an operation in two stages is done, the flap is placed back.
If the second operation is to be carried out after an interval of more than
three days, a layer of gauze may be left under the flap in order to facilitate
its subsequent separation.
Pneumotomy may be performed through an incision made in the direction
of the pleural incision. If drainage is required it may come out at the lower
edge of the flap which is left unsutured. Incision is made not only for
abscess, gangrene, and tumor, but also for foreign bodies in the bronchi,
FIG. 1130. — METHOD OF DIVIDING RIBS TO TURN BACK FLAP.
The two outer ribs adjacent to sides of the flap may be cut through the flap incision; the
middle rib is cut through a short special incision at the base of the flap.
which cannot be reached by the bronchoscope. In the latter operations
the lung should be exposed and incised at the place nearest to the object
with due regard for the important structures and pleural asepsis (Fig. 1131).
Pneumectomy is done for bronchiectasis, tumor, and rarely for tubercu-
lous disease. There must be one sound lung, and the heart must be normal.
The operation cannot safely be done on a patient past middle life. Young
adults are the patients of choice. The tissue to be removed may consist
of one lobe or one lobe and a part of another. The mortality of the operation
is very high, and it should be undertaken only when every palliative measure
has failed. The operation in stages is to be preferred. Neither differential
positive nor negative pressure is necessary. The convexity of the incision
is downward. It starts at the fifth rib 5 cm. from the vertebral column,
crosses the eighth rib at the scapular line, and ends at the sixth rib in the mam-
mary line. The skin-muscle flap is turned up, and the seventh, eighth, and
THE THORAX
457
ninth ribs subperiosteally resected from their angles to the anterior axillary
line. The flap is then replaced. This ends the first operation.
After a week or so, when the patient has quite recovered from the opera-
tion and is able to clear the bronchi of sputum, the second stage of the
operation is undertaken. The sutures are removed and the skin-muscle
flap again turned back. The pleura is freely retracted, and the separation
of adhesions attempted. This may prove difficult. Adhesions which can
not be separated must be cut. Much force must not be used. If the patient
is not doing well the operation should be
stopped and deferred to a later day.
For amputating the detached lobe, it
is grasped with a long clamp which com-
presses the root of the lobe. The lobe is
cut away about i cm. from the clamp.
Veins, arteries and bronchi are separately
tied with chromic catgut. A ligature
carrier is then passed through the pedicle
behind the clamp and the pedicle tied in
two sections as the clamp is slowly re-
leased.
Pneumectomy may be performed by
an exposure secured by simply resecting
or dividing the ribs. For the removal of
tumors, the pleura may be left unopened,
the flap turned back, and the pulmonary
and parietal pleurae sewed together by a
running suture carried around the cir-
cumference of the wound. The wound is
then covered lightly with gauze and the
flap replaced. Adhesions are formed,
and in two or three days, the lung may
be incised through the two adherent
pleurae without causing pneumothorax or
hemothorax. For tumor, the one-stage
operation is usually done. The lung is
brought out through the wound, trans-
fixed behind the part to be removed with
a needle carrying chromic catgut and tied
off in two or more mass ligatures, mas-
sive clamps may be used. The excision
is then made, the stump whipped over
with a running suture to leave a smooth surface, and dropped back into
the chest. In clean cases drainage is not used, and the chest wound is
snugly closed.
When performing pneumectomy, if a large bronchus is opened, it should
be ligated firmly, its mucous membrane cauterized, and the stump sutured
over with adjacent tissue (see Exposure of Lungs, page 453; Diseases of the
Lungs, page 413).
Pneumectomy for the removal of a lobe or of the whole lung is a serious
operation, and has a mortality of about 50 per cent. There is great danger of
vagus shock from irritation of the vagus at the hilus. The exposure of the
lung by a chest-wall flap is not difficult or dangerous, but the manipulations at
the hilus are. The closing of the bronchus so that it shall be air-tight is one
of the difficult problems. This is best secured by destroying the mucous
FIG. 1131. — FLAP OF SKIN
FASCIA TURNED BACK TO EXPOSE
LUNG.
The ribs and intercostal structures
have been removed. The costal pleura
remains, and is in process of being su-
tured to the pulmonary pleura for the
purpose of closing off the pleural sac
from infection for later incision.
458
SURGICAL TREATMENT
membrane with the cautery and curet, to which may be added tincture of
iodin or phenol. Crushing the bronchial cartilages with heavy clamps is
advisable. The stump should then be sutured, and over the bronchus should
be sewed the remains of lung tissue. If the stump of the bronchus is not
effectively closed leakage of air will take place. There is the danger of pneu-
mothorax developing from this leakage after the costal pleura has been
closed. A valve-action of the leaking bronchial stump may fill the cavity
with air under pressure, and give rise to a condition which requires prompt
tapping of the chest to prevent death from the excessive internal pressure.
Even with the greatest care bronchial fistula may be expected to follow
pneumectomy. For this reason free drainage is necessary. This is best
secured by a copious packing of the cavity. By using gauze the cavity is
kept well drained and no pocketing occurs. A later plastic may be done to
cover any remaining fistula.
OPERATIONS ON THE MEDIASTINA
The superior mediastinum is that part of the thoracic cavity lying above the heart and
between the two pleurae. It is bounded in front by the manubrium of the sternum, and
behind by the bodies of the first, second, third and fourth dorsal vertebrae. The anterior
mediastinum is that part of the thoracic cavity between the superior mediastinum and the
FIG. 1132. — ANTERIOR OSTEOPLASTIC THORACOTOMY, INCISIONS FOR EXPOSING THE
MEDIASTINA.
A, Incision for exposure of anterior and middle mediastina; B, incision for turning up
osteoplastic flap for exposure of superior mediastinum; C, incision for turning back laterally
a thoracoplastic flap for exposure of superior mediastinum.
diaphragm. It is bounded laterally by the pleuras, posteriorly by the pericardium, and
anteriorly by the gladiolus of the sternum and the sternal ends of the left fourth, fifth,
sixth and seventh costal cartilages. The middle mediastinum contains the heart, roots of
the great vessels, roots of lungs, and bifurcation of trachea. It is between the anterior
and posterior mediastina, and laterally is bounded by the pleurae. The posterior medias-
tinum is bounded anteriorly by the roots of the lungs and pericardium, posteriorly by the
bodies of the dorsal vertebrae from the lower border of the fourth dorsal vertebra to the
diaphragm, and laterally by the pleurae.
Anterior exposure of the mediastina is best effected by anterior osteo-
plastic thoracotomy. A flap of sternum is turned back laterally. The hori-
THE THORAX 459
zontal incisions should be placed to include the part of the sternum lying in
front of the region which it is desired to uncover. The attachments of two or
more costal cartilages may be embraced. As a type of the operation, the
following exposes the lower part of the upper mediastinum and the anterior
and middle mediastina: The patient is placed supine with a pillow behind the
dorsal spine to throw the chest forward. The operation should be done in the
presence of appliances for positive or negative differential pressure. The sur-
geon stands on the left of the patient. Two transverse incisions are made
across- the sternum and extending not more than 1.2 cm. (% inch) beyond it
on either side in order not to wound the internal mammary artery. The upper
is on a level with the upper margin of the second costal cartilage, the lower is
on a level with the lower part of the fifth cartilage at its sternal articulation.
The two incisions go down to the bone, and their left extremities are con-
nected by a vertical incision between the border of the sternum and the
internal mammary artery (Fig. 1132). The second, third, fourth, and fifth
costal cartilages are divided with bone forceps. Care should be taken not
to wound the pleura or pericardium or to separate the overlying soft parts,
from the sternum. The intercostal vessels are tied and the structures are
divided. The left margin of the sternum is now lifted slightly forward with a
hooked retractor, and the posterior surface of the bone separated from the
triangularis sterni and connective tissue by means of blunt dissection. The
sternum is divided in the lines of the transverse incisions. This division may
be made with bone-cutting forceps or the wire saw. Whatever method is
used, the instrument should be kept close to the bone. The posterior surface
of the bone is then completely freed from its connections, and the flap turned
back to the right side, the right costal cartilages bending or breaking. The
pleurae move in and out laterally with each respiratory movement. They
may be protected with a pad and held aside by retractors. If a wider ex-
posure is desired the transverse incisions must be longer, and the internal
mammary artery must be ligated and cut.
At the close of the operation the flap is replaced, and held by strong sutures
passed through the periosteal tissues. If necessary the bone may be drilled.
If the perpendicular incision is made further away from the sternum, and the
costal cartilages divided obliquely the flap may be prevented from falling
backward when it is replaced. Drainage may be provided at either side
through the lowest intercostal space exposed.
Exposure of the mediastina may be secured also by median division of the
sternum as far as the xiphoid, and lateral retraction of its two halves. This
operation gives a separation of 6 or 8 cm. (2 ^ or 3 inches) but is more hazardous
than the flap operations. (For other operations on the anterior and middle
mediastina, see Operations on the Heart, page 426.)
Transverse sternothoracotomy, advocated by Friedrich, consists in mak-
ing a transverse incision across the sternum, connecting two intercostal
spaces, dividing the sternum with a wire saw, and retracting the bone frag-
ments. The incision may be carried into the interspaces as far as necessary.
The internal mammary arteries may be tied; and, with proper differential
pressure, the pleurae opened. Access is secured to the great vessels by opera-
tion on a level with the second interspace.
Posterior exposure of the mediastina is best accomplished by posterior
osteoplastic thoracotomy. This gives access to the thoracic esophagus, trachea,
bronchi, thoracic duct, descending aorta, azygos veins, pneumogastric nerves
and posterior mediastinal lymphatics and connective tissue (Fig. 1133). The
area to be exposed must depend upon the site of the disease. This exposure is
usually employed for the removal of foreign bodies in the trachea, bronchi and
460
SURGICAL TREATMENT
esophagus, for the evacuation of abscesses, resection of esophagus, and for
operations on the posterior part of the middle mediastinum. The table of
Friedrich is used, or the patient is placed on the sound side with the upper
shoulder carried somewhat forward and the upper arm thrown over a sand
bag in such a way as to elevate and carry the shoulder outward. The
position should carry the scapula as far away from the spine as possible and
elevate the ribs.
Three ribs are usually resected, the center one being opposite the object of
attack. The esophagus is reached best on the right side below the arch of the
aorta. It is in the middle line at the fifth dorsal vertebra. The bifurcation
of the trachea is usually opposite the fourth dorsal vertebra or the upper part
nterior reflection
of pleuria
Pulmonary
valve
Aortic valve ~
Left phrenic >•
Left bronchus
Thoracic duct
Left vagus —
V. azygos
minor
Sympathetic —
nerve
Lung .-
Pleura
- Sup. vena cava
Esophagus
Right vagus
Azygos vein
_ Sympathetic
nerve
Dorsal muscles
Skin
Approach to aorta
Approach to esophagus
FIG. 1133. — POSTERIOR SURGICAL APPROACH TO THE ESOPHAGUS AND AORTA (POSTERIOR
MEDIASTINAL THORACOTOMY).
The dotted lines show approach on right and left sides. The aorta is reached on the left
side, the esophagus on the right.
of the fifth. The left bronchus is reached with much greater difficulty than
the right. If the object of attack does not call for operation elsewhere,
usually the fourth, fifth and sixth ribs are included in the flap. A square
opening about 10 cm. (4 inches) on either side is made. Two parallel inci-
sions are made from the spinous processes nearly to the border of the scapula.
The upper one is at the interspace between the third and fourth ribs and its
outer end is at the level of the inner extremity of the lower border of the
spinous process of the scapula. The lower incision is at the interspace
between the sixth and seventh ribs. The outer ends of these incisions are con-
nected by a vertical incision running just internal to the scapula. These
three incisions should pass down to the ribs and external intercostal fascia
(Fig. 1134). The flap of superficial tissues and muscles posterior to the ribs
should be dissected up and turned back, and hemostasis secured.
THE THORAX
461
The fifth rib lying across the center of the field is then denuded of perios-
teum by an incision along its uncovered surface, divided at the extreme outer
and inner sides of the wound, and the intervening segment removed. The
FIG. 1134. — POSTERIOR MEDIASTINAL THORACOTOMY.
Lines of incision.
FIG. 1135. — OPERATION FOR EXPOSURE OF THORACIC ESOPHAGUS.
Schede's method of raising a flap of skin and muscle, including the scapula. With the
arm elevated, the scapula may be made to stand out at a right angle to the body.
ribs next above and below this are then divided at the extreme inner and
outer edges of the wound but not detached from their beds. The intercostal
vessels are ligated and divided. The nerves should be spared. An incision
462
SURGICAL TREATMENT
is then carried across the middle of the wound through the periosteum in the
middle of the bed of the resected rib. This incision should go as far as the
pleura but should not wound it. The pleura is then separated by blunt dis-
section from the overlying structure. To the last incision are added two
lateral incisions passing in line with the rib divisions, making an H. One
flap is reflected upward, the other downward, being separated from the
pleura which remains still intact. Each of the flaps contains a resected rib
segment. The unopened pleura is carefully pushed outward with the finger
and protected from being cut or torn. The trachea, bronchi, esophagus, or
thoracic aorta, all of which can be seen and felt, are accessible. This is
called Bryant's operation.
For the removal of foreign bodies from the trachea, bronchi or esophagus,
the structure is incised longitudinally. The opening may be closed with
FIG. 1136. — THORACIC ESOPHAGECTOMY.
The flap has been lifted up, and the whole length of the sixth intercostal space incised.
The rib-spreader gives wide exposure. The thoracic aorta is seen lying next to the esopha-
gus. The esophagus has been resected; the lower stump inserted, and the upper stump
tied. The pneumogastric nerves are seen lying along the esophagus, their communicating
branches passing from one side to the other.
chromic catgut. The great wound is closed by replacing the two rib flaps,
suturing them in place, and then suturing the superficial flap over all. If
infection has been caused, drainage should be brought out at one of the lower
corners of the wound.
For access to the thoracic esophagus, Franz Torek (Surg., Gyn. and Obst.,
June, 1913) incised through the whole length of the seventh intercostal
space, and carried an incision upward from the posterior end of this, cutting
through the angles of the seventh, sixth, fifth and fourth ribs. After ligating
some thoracic branches of the aorta, the arch of the aorta may be lifted
forward, and the esophagus freely exposed. By dissecting up the esophagus,
and bringing it out in front of the sternomastoid muscle, the danger of in-
fection is avoided.
THE THORAX
463
Resection of the Thoracic Esophagus.— This operation is done for cancer.
Operation cannot offer hope unless the resection is wide of the disease. This
means the removal of so much esophagus that anastomosis to close the gap
cannot be hoped for. Therefore the steps must be (i) gastrostomy to feed
the patient, (2) esophagectomy and (3) later an external plastic operation
to connect the upper segment of the esophagus with the stomach.
To secure access to the esophagus, an advantageous approach is that
devised by Schede. An axillary flap is turned up on the left side containing
the scapula, and its attached muscles (Fig. 1135). The thorax is entered by
intercostal incisions and wide separation of the ribs by means of strong re-
tractors. Entrance may be made through the seventh, eighth or any other
FIG. 11360. — ANTERIOR EXPOSURE OF THORACIC ESOPHAGUS, METHOD OF SAUERBRUCH.
A traction suture is passed around the esophagus.
intercostal space. The vagi may be discovered throughout their extent from
beneath the aortic arch down to the diaphragm. The blocking of one of
these nerves by cocain is necessary. They can not be handled roughly.
W. Meyer (Surg., Gyn. andObst., December, 1912 andFebruary, 1915) ad-
vised in cancer of the upper two-thirds of the esophagus to do the operation
in two stages. Incision is to be made in the eighth left intercostal space,
the esophagus divided below the growth, the ends invaginated and closed,
and drainage provided. Seven or ten days later, Schede's incision is made
and the chest entered through the sixth and third intercostal spaces. The
pneumogastric nerves should be carefully dissected away; one should be
cocainized; the esophagus should be brought out from behind the aortic
arch, divided above the growth, and the upper stump invaginated and closed
(Fig. 1136). The growth is then removed. Drainage should be provided:
464
SURGICAL TREATMENT
or, if the condition of the patient will permit, the upper stump of the esoph-
agus should be brought out in the neck.
The operation of Sauerbruch, for securing access to the esophagus in
the upper part of the thorax on the right side, turns back an osteoplastic
flap anteriorly (Fig. 1137). It is a more difficult and dangerous procedure
than that of Schede.
Esophagoplasty. — Plastic operations for wholly or partially restoring a
connection between the mouth and stomach are done after resection of the
esophagus for cancer or in cases of obstruction of the esophagus. If a cancer
FlG. 1137. ROUX'S ESOPHAGOGASTROJEJUNOSTOMY.
A segment of jejunum is detached and the continuity of the bowel restored by anas-
tomosis. The distal end of the segment is implanted in the stomach, and the upper end
is brought out through the abdominal wall.
of the esophagus is inpperable, simple gastrostomy should be done; but if
there is hope of its removal, the preliminary operation on the stomach should
plan a partial restoration of the esophagus.
Many methods for accomplishing this are available. Wallstein (Centralb.
fur Chir., 1904) and Roux (Sem. Med., No. 4, 1907) excluded and trans-
planted under the skin of the anterior chest wall a loop of jejunum. The
upper end was connected with the oral stump of the esophagus, brought out
in the neck, and the lower end with the gastric fistula. Roux resected a
piece of jejunum; the distal end was fastened to the stomach opening, and
the proximal end was brought outside of the abdomen (Fig. 1137). The
skin of the anterior chest wall was tunneled and the loop of gut carried under
THE THORAX
465
it was brought out at the upper end of the sternum. The operation is done
in several stages. The patient may be fed by a funnel or the oral end of
the esophagus may be brought out at the neck later and anastomosed with
the upper end of the jejunal loop. Jejunun thus transposed is liable to
necrosis especially in older persons. The transverse colon has been used
for the same purpose.
A. Jianu (Deutsch. Zeitschr. f. Chir., cxviii, 1912) devised a method
whereby the new esophageal tube is constructed from the greater curvature
of the stomach. This is the superior operation. It has the merit that when
FIG. 1138. — RESULT AFTER PERFORMING Roux's ESOPHAGOJEJUNOSTOMY.
The isolated segment of jejunum has been implanted under the skin of the chest. The
abdominal wound yet remains to be closed.
the tube is made, one end is already connected with the stomach. A median
abdominal section is done above the umbilicus. The great omentum is
doubly ligated from the left inferior epiploic artery to and including the
right inferior epiploic artery. The left artery is preserved. The ligations
are below the gastro-epiploic artery (Fig. 1139). The cardiac end of the
stomach is elevated so that the contents shall flow out. A through-and-
through suture is then passed about 4 cm. (i% inches) above the lower
border of the stomach and parallel with it. Clamps are then placed on the
VOL. 11—30
466
SURGICAL TREATMENT
stomach to prevent the escape of stomach contents when the incision is
made. The division of the stomach should be carried as far up toward the
cardia as the entrance of the left epiploic artery will permit, as every gain
possible in the length of the tube is of advantage (Fig. 1140).
The stomach wall, through both thicknesses, is divided with scissors just
below the line of suture. A piece of cloth is wrapped over the cut edge of
the stomach, and the free edge converted into a tube by suturing the two
free edges together. This is done by continuing the first suture onto the
tube. A second suture, whipping over the free edge is applied to stomach
FIG. 1139. — GASTROESOPHAGOPLASTY, METHOD OF JIANU. FIRST STAGE.
The omentum is tied and cut from the stomach. For the sake of demonstration, the
wound is here shown larger than would be made for surgical purposes.
and tube (Fig. 1141). The open end of the tube is temporarily inverted
with a couple of sutures. This constructs a tube from 18 to 25 cm. (7 to 10
inches) long (Fig. 1142).
The stomach is then placed so that the base of the tube lies at the upper
end of the abdominal wound, where it is made fast by a few sutures and the
tube brought out into the open. The rest of the abdominal wound is closed
about the tube. The tube is then placed on the skin along the left of the
sternum to measure its length, a horizontal cut made, and the skin under-
mined to receive it. The blood supply of the tube is so good that it may be
pulled up on the stretch, and made to reach as high as the third or second rib.
After pulling up the tube beneath the skin, by means of forceps, the mucous
membrane is sutured to the edges of the upper skin wound (Fig. 1143). A
THE THORAX
467
strip of gauze drain may be placed at each side of the tube in the upper wound,
and if necessary in the wound below.
The tube thus constructed has a good blood supply. W. Meyer (Cen-
tralbl. fiir Chir., Feb. 22, 1913, No. 8) has suggested drawing up the tube
into the pleural cavity through an opening in the diaphragm to connect it
with the upper segment of the esophagus.
The tube tends to leak stomach contents because it has no sphincter.
This must be overcome by mechanical pressure or by bringing the tube out
through a split between the bundles of the left rectus muscle.
FIG. 1140. — GASTROESOPHAGOPLASTY. SECOND STAGE.
The omentum has been tied off and cut away from the stomach. The greater curvature
of the stomach is to be cut free just below the curved clamp, along the dotted line.
Patients chew their food and blow it through a tube inserted into the
upper opening. Later after this operation or after esophagojejunostomy, the
upper segment of the esophagus may be brought out at the neck above the
clavicle and connected under the skin with the tube which leads to the
stomach. Or a plastic continuation of the esophagus may be made (Fig.
1144).
Thoracic exposure of the diaphragm may be made below the pleura
beyond the pleura, through the pleura, or through pleural adhesions. It is
done for the evacuation of subdiaphragmatic abscess, for the closure of
wounds, for the treatment of hernia, and the removal of tumors. For sub-
468
SURGICAL TREATMENT
phrenic abscess the lateral thoracic route is to be preferred; about 7.5 or 10
cm. (3 or 4 inches) each of the ninth and tenth ribs between the anterior
axillary and the scapular linesare resected through an incision placed between
FIG. 1141. — GASTROESOPHAGOPLASTY. THIRD STAGE.
The greater curvature of the stomach 'has been converted into a tube. Two rows of
sutures are used to close the stomach. The clamps should be removed as soon as possible.
them. To reach the diaphragm nearer its center, the transpleural root
must be chosen; this is through the excision of costal cartilages in the mam-
mary line.
FIG. 1142. — GASTROESOPHAGOPLASTY. FOURTH STAGE.
Tube completed and ready for transplantation. Note preservation of gastroepiploic
artery.
To reach the diaphragm between its center and posterior part, an
incision of about 13 cm. (5 inches) is made in the interspace between the
ninth and tenth ribs. The center of the incision is midway between the an-
THE THORAX
469
terior axillary and the scapular lines. The wound is retracted to expose the
two ribs and about 9 cm. (3^ inches) of each is resected subperiosteally.
Care is taken not to injure the pleura. An incision is then made along the
middle of the intercostal space down to the pleura. The pleura is not
opened but is bluntly dissected back. This may give sufficient access.
If it is desired to expose more of the diaphragm, the pleura may be still
further separated from it by blunt dissection, being held up by flat retractors
and a gauze pad as the separation proceeds. This is the most satisfactory
procedure.
FIG. 1143. — GASTROESOPHAGOPLASTY. FIFTH STAGE.
The tube has been drawn under the skin of the thorax and the wounds closed.
If the separation of the pleura from the diaphragm cannot be carried out
the two pleural surfaces may be united by suture, the general pleural cavity
thus shut off, and the operation carried out through the eliminated pleura.
In some cases this may already have been accomplished by adhesions. In
other cases it may seem best to pack the wound with gauze, compressing the
two pleurae together and completing the operation after a few days when ad-
hesions have united them.
If none of these expedients can be adopted it may be necessary to open the
470
SURGICAL TREATMENT
pleural cavity, and thence attack the diaphragm through the diaphragmatic
pleura.
By this route, subdiaphragmatic abscess may be opened and drainage
provided; hernia of the diaphragm treated according to the general principles
laid down for the treatment of hernia; tumors of the diaphragm removed; and,
FlG. 1144. ESOPHAGOPLASTY.
Operation for bringing the upper end of the esophagus out of the neck and implanting
it under the skin near the gastroplastic opening. Later an operation may be done to con-
nect the two.
by carrying the resections somewhat farther back on the left side, incision or
resection of the lower end of esophagus accomplished (see Subphrenic
Abscess, page 553).
Resection of the lower segment of the esophagus may be done for 6 or 8 cm.
This requires opening the abdomen through the diaphragm, and bringing up
the stomach for anastomosis with the esophagus after resection.
THE BREAST
Anatomy. — The breast in woman lies upon the deep fascia separating it from the pec-
toralis major, the external oblique muscle of the abdomen, and the serratus magnus. It
is not circular in outline but has a prolongation extending upward and outward into the
axilla as high as the third rib. Other prolongations also occur into the surrounding fat
and pectoral muscles. Gland structure may come up close to the papillary processes of
the skin. The main body of the gland extends from the lower border of the second rib to
the sixth or seventh rib, and laterally from the margin of the sternum at about the fourth
FIG. 1145. — THE FEMALE BREAST.
Showing blood supply and lymphatics. A, Perforating branches of mammary artery;
B, anterior thoracic nerve; C, cephalic vein; D, thoraco-acromial artery; E, axillary vein;
F, lateral cord of brachial plexus; G, median cord of brachial plexus; H, axillary artery; 7,
median nerve; J, brachial vein; K, basilic vein; L, thoraco-epigastric vein; M, lateral
thoracic vessels.
rib to the anterior axillary line at the fifth rib. The gland in the woman consists of fifteen
or twenty lobules each opening at the apex of the nipple through its own separate duct.
The whole gland is suspended between two layers of fascia which is continuous with the
fascia of the neck (Fig. 1145).
The blood supply is (i) from the anterior intercostal arteries of the second, third, fourth
and fifth interspaces, which are branches of the internal mammary; (2) the anterior per-
471
472 SURGICAL TREATMENT
f orating branches of the internal mammary of the same interspaces; (3) anterior branches of
the intercostal arteries which are branches of the thoracic aorta; (4) the superior thoracic
artery, a branch of the axillary; and (5) the external mammary, a branch of the axillary.
The two latter anastomose with the intercostal vessels. The veins form a venous circle
around the gland and join to form trunks which follow the arteries.
The lymphatics of the breast and axilla are most important. It should be borne in mind
that while certain lymphatic chains drain certain areas of the breast, still they all freely
anastomose and are capable of currents to and fro which may carry their contents in any
direction. Cancer cells liberated from the breast usually first become caught in the mesh-
work of the lymphatic glands but they may become engaged in the finer lymphatic radicles.
The lymphatics of the skin are composed of two networks, one superimposed upon the
other. From each network larger trunks lead to the axilla. Other branches communicate
with these trunks and lead again to the skin. Lymph channels follow all of the blood-
vessels. In the muscles, one set of lymph- vessels runs parallel to the muscle fibres toward
the sternum, near the margin of which they perforate the intercostal spaces and empty
into the mediastinal lymphatics, which are rich in glands. The lymphatics of the upper
part of the pectoralis major at its inner part drain over the clavicle and empty into the
supraclavicular glands, and at the clavicular part into the glands lying behind the muscle.
The superficial lymphatics freely anastomose across the median line and with the lym-
phatics of the neck and abdomen. There exists a very intimate connection between the
lower and inner quadrants of the breast and the upper abdomen through lymphatic
channels which pass downward to the epigastrium and thence back to the peritoneum and
through the suspensory ligaments and subperitoneal spaces to the liver.
The lymphatics from the glandular substance of the breast itself pass toward the
surface and communicate with the superficial lymphatics. The main vessels run toward
the axilla. The deep vessels lie upon the fascia of the pectoralis major, and communicate
with the muscular lymphatics. The superficial vessels lie in the layers of the superficial
fascia and accompany the lymphatics of the skin. Some lymphatics from the deep parts
of the breast accompany the perforating branches of the internal mammary vessels, and
lead to the glands of the mediastinum. Others accompany the intercostal vessels into the
chest wall and thence to the posterior mediastinum; and others follow the long thoracic
vessels to the side of the chest and axilla.
A large lymph- vessel passes from the posterior parts of the breast upward and outward,
perforates the pectoralis major muscle to the space between it and the pectoralis minor,
runs between the chest wall and the pectoralis major to the second intercostal space,
through which it passes into the anterior mediastinum.
The lymphatic glands are especially numerous in the axilla. They lie in close relation
to the axillary vein, and follow it over the first rib into the neck and thorax. Four or
five glands lie close to the axillary vein, and rarely have any glands intervening between
them and the breast. They are connected with the chain of eight to twelve glands lying
along the axillary vein, which have other glands intervening between them and the breast.
A group lies under the scapular attachment of the pectoralis minor, close to the upper
ribs. Another group, traversed by the intercostohumeral nerve, lies in the loose connective
tissue in front of the outer border of the scapula, the subscapularis, and the latissimus
dorsi muscles. There is also a midaxillary group, scattered more superficially; in the
lower axilla they are near the skin ; above they lie under the pectoralis major, and com-
municate with the subclavian glands. The supraclavicular triangle contains glands which
receive lymph through vessels passing upward beneath the clavicle. Scattered glands may
occur at different places along the lymph channels. Glands are also found along the
anterior perforating branches of the internal mammary vessels.
Contusions and Wounds of the Breast. — These injuries require the same
treatment as when occurring elsewhere. The same may be said of foreign
bodies.
Congenital Anomalies. — Polymastia is treated by excision of the rudimen-
tary supernumerary breast if the patient desires it for cosmetic reasons, or
if it is in the way or easily becomes irritated. All of the glandular structure
should be removed, but sufficient skin should be left to cover the wound.
The same may be said of polythelia. Inverted nipple may be drawn out by
suction with a cup, massage and alcohol and oil applications.
Hypertrophy of the Breasts. — The surgeon has not to do with the con-
genital or physiologic forms, but diffuse acquired, pathologic hypertrophy
comes within his sphere. In this form, occurring in connection with preg-
nancy, the hypertrophy is apt to subside after confinement. When occur-
THE BREAST 473
ring in the virgin its tendency is to persist, and operation offers the only
assurance of cure. As a palliative measure the breasts may be supported
with slings. The curative operation consists in excision of the breasts.
Enough skin should be left to cover the wound. The operation may be done
upon one breast at a time or both may be removed at one sitting. This
should depend upon the patient's condition.
The surgeon should be sure that he is not dealing with pregnancy before
suggesting operation for this condition, as pregnancy is the most common
cause of hypertrophy of the breasts.
I once, in ignorance, offered operation in the case of a child of fifteen,
whose breasts were so heavy that she was physically unable to carry them,
and was consequently confined to bed; the hypertrophy subsided after
she gave birth to a baby.
Diseases of the Nipple. — Inflammations are painful lesions most common
during lactation, and are to be prevented by cleanliness. Washing with bor-
acic solution is usually sufficient. Covering the nipple with an artificial
nipple permits nursing without interfering with treatment.
Fissures of the nipple which do not yield to this treatment should be
treated with 50 per cent, silver nitrate solution. A single large fissure is best
treated by being touched with the pure drug.
Retracted nipples may be brought forward by suction. Soft flabby
nipples may be massaged forward with boracic acid and alcohol.
Eczema of the nipple requires the ordinary treatment of that disease.
Tumors require the same treatment as elsewhere; the milk ducts should be
damaged as little as possible by operation.
Carcinoma of the nipple (Paget's disease) should not be mistaken for
eczema alone, with which it is associated, but should be promptly extirpated.
Neuralgia of the Breast. — This affection may be so intractable to hygienic
and palliative measures that operation is required. Operative treatment of
neuralgia may be applied to the affected nerves. The breast is supplied
chiefly by the anterior and lateral cutaneous branches of the second, third,
fourth and fifth intercostal nerves, and filaments of the external and internal
anterior thoracic nerves and the posterior thoracic. Amputation of the
breast need not be done. If the disease is so severe as to suggest such an
expedient, an amputation with replacing of the organ is feasible. Through
an incision embracing one-half of the circumference of the base of the breast,
one-half of the gland is dissected up from its posterior connections, replaced,
and the wound closed. After at least three weeks have elapsed the same
operation should be done to the other half of the breast. These two opera-
tions have accomplished division of all of the nerves supplying the organ. If
this does not cure the disease the chances are that complete amputation would
not.
Mastitis. — Acute mastitis occurs usually in connection with lactation and
results in the stoppage of the ducts of one or more lobules. It should be
prevented by cleanliness of the nipples. The treatment to which this condi-
tion has best yielded is the ice-bag and twice daily massage of the engorged
lobules. The massage should be applied with increasing firmness, always
toward the nipple, while the rest of the breast is grasped in the other hand.
During this process milk should be squeezed out of the breast, and the opera-
tion should be continued until the hardened lobule softens. In the mean-
time the breast should be supported by a sling, and should be nursed from or
emptied by a pump. Caked breast (stagnation mastitis, lactation mastitis)
is this form in which the obstruction of the ducts seems to be the main
trouble. They are best emptied by massage and suction.
474 SURGICAL TREATMENT
Chronic mastitis may result from the above form remaining uncured,
and having added to it an infection which does not produce acute suppura-
tion or much temperature. The most effective treatment is hot applications,
massage toward the nipple, and emptying the breast by the pump.
Suppurative mastitis most commonly follows lactation mastitis, although it
may occur independently of lactation. It should be prevented by prompt
treatment of the pre-suppurative stage. When cellulitis of the gland has
developed, two things are necessary: keep the gland empty of milk by means
of the breast pump, and induce hyperemia by hot applications or by a suc-
tion cup big enough to embrace the whole breast. As soon as pus has cen-
tralized in any place, it should be evacuated by an incision in the direction
of radiation from the nipple. This operation should not be deferred; no
matter how small the abscess, it should be opened. It is better to make an
incision and find no abscess than to leave une vacua ted a dram of pus. Large
abscesses should be opened at their center, and another opening may be made
to advantage at the most dependent part to insure good drainage. Drainage
by tubes is best. After opening an abscess, more rapid healing will be
secured by the use of the suction cup (see Hyperemia). Careful asepsis, to
prevent complicating the infection, should be observed. Submammary
abscesses may elude the inexperienced and not receive proper attention until
great damage has been done.
Exiramammary abscess should be opened outside of the gland structure.
It should be borne in mind that an abscess may be located between the gland
and the skin or between the gland and the chest wall ; and in either case the
gland should not be incised.
Chronic fistula of the breast should be treated by cleanliness and suction
hyperemia. In milk fistula, lactation should be terminated if the ordinary
treatment of fistula fails.
Chronic interstitial mastitis is often confused with carcinoma. No treat-
ment except excision is of much avail. On account of the difficulties of
differential diagnosis, the indurated area should be exposed by a simple
incision; if it presents the appearance of carcinoma, it may be dealt with
accordingly; if the disease is inflammatory, the discomfort of the patient and
the danger of malignant degeneration will be eliminated by its excision
(see Chronic Cystic Mastitis).
Chronic Cystic Mastitis. — The surgeon is always confronted with the ques-
tion of diagnosis in these cases. If there is no question as to the diagnosis, it
would seem that the treatment resolves itself into that of the cystic indura-
tion. But the problem is a more complicated one. There usually is some
question about the diagnosis-; and even though the surgeon were satisfied that
the disease is nothing more than chronic cystic mastitis, he can not say how
soon malignancy may appear. Indeed, it is possible that in some of these
cases cancer has already begun, as the primary disease, and has given rise to
the mastitis. A report from the Johns Hopkins Clinic shows that if a simple
operation is done for the removal of such an indurated mass and microscopic
examination shows that it is carcinoma, the patient may be expected not to
live beyond three years, even though a complete secondary operation is done
a few days later. Whereas a report from the Mayo Clinic shows that out of
218 cases, conservative operation was done in 21 1, in none of which was malig-
nancy found. Radical operation was done in the seven doubtful cases.
The course which the surgeon pursues must be regulated by the diagnosis.
If there is doubt, the patient should be given the benefit of radical operation
as for cancer. In case of conservative operation, an immediate pathologic
examination should be made for diagnostic purposes, and if cancer is found,
THE BREAST 475
a radical operation should follow. Patients over thirty-six should usually
have a radical operation unless the diagnosis of mastitis is quite obvious.
As a guide of action in doubtful cases the following rules may be followed:
In women under thirty, partial excision of the breast may be done upon the
assumption that the disease is benign; in women between thirty and forty,
the whole breast and the underlying fascia of the pectoralis should be re-
moved upon the assumption that early malignancy exists; and in women over
forty, the entire gland, the pectoralis muscle, and the lymphatics of the
breast and axilla should be removed. This latter operation, of course, is
upon the assumption that the disease is not mastitis, but positively advanced
cancer. There should be no half-hearted operation for cancer; nor is it pos-
sible to do such a thing as a combined operation for benign and malignant
growth at the same time, as it would seem from the recommendations of
some surgeons in these cases. The operation should be either for one or the
other — benign or malignant disease — it cannot be for both.
Hard and fast rules should not be followed. The location and size of
the induration and other factors may modify the operation. The x-ray,
fulguration, and radium may be added to the above treatments.
In young women, the breast may be separated from the underlying muscle
by a semicircular incision at its lower border. The gland is turned up as a
valve. It may then be dealt with, removing as much as seems necessary
from the rear. In the place of the removed tissue a graft of fat from the
patient's abdomen or thigh may be introduced for cosmetic purposes if
desired. Before beginning such an operation, the surgeon should have the
consent of the patient to do a radical operation should the tissues look
malignant.
Tuberculosis of the breast should be treated by the general measures
already described for tuberculosis. A limited tuberculous area should be
excised under aseptic precautions and care that the wound does not become
reinfected with tuberculosis. Axillary glands should be removed. A tuber-
culous breast, penetrated by sinuses and the disease involving much of the
gland, should be removed. Between these two are many variations.
The cases, as the surgeon usually sees them, can rarely be said to be
limited to a single small area. There is always a strong probability of lym-
phatic infection even when the primary breast focus is small. For most
cases the best treatment consists in removal of the breast, underlying pectoral
fascia, and axillary connective tissue and lymphatics. In early cases, with
apparently one isolated nodule, the surgeon may be satisfied with elliptic
excision of the part of the breast containing the mass, removal of the under-
lying pectoral fascia, and clearing out the axilla (for removal of breast and
axillary lymphatics, see page 480). The prognosis after surgical treatment
is better than in most regions.
Benign Tumors. — (See Tumors, Vol. I, page 323.) All benign tumors of
the breast should be removed. Cysladenoma (senile parenchymatous hyper-
trophy) is important because of its proneness to undergo carcinomatous
degeneration unless extirpated. All of the diseased portion of the breast
should be removed, and as the disease is prone to extend to all parts of the
gland complete excision is the safest course. Cystic adenoma, adenofibroma,
fibre-adenoma, and intracanalicular myxoma are encapsulated tumors which
should be exposed by a radiating incision or by flap incision, and, having
been identified as benign, should be excised, leaving the undiseased gland.
The wound should be snugly closed with buried sutures. Angioma or nevus
is best cured by extirpation. Lipoma and mixed tumors are to be treated as
elsewhere.
476
SURGICAL TREATMENT
Cysts. — Cysts of the breast should be treated as benign tumors. Simple
cysts should be excised. It is not necessary that the excision go beyond the
wall of the cyst. Where there are several cysts, and for cosmetic reasons
FIG. 1146. — INCISION FOR BENIGN TUMOR IN POSTERIOR PART OF BREAST.
FIG. 1147. — BREAST TURNED UP AS A FLAP TO REMOVE BENIGN TUMOR.
it is desired to preserve as much of the breast as possible, the gland may be
dissected away from the pectoral fascia through a crescentic incision and
the cysts removed through its base. A breast containing many scattered
THE BREAST 477
cysts should be removed. Large single cysts over which the gland tissue is
stretched are usually best treated by removal with the gland. Galactocele
is best cured by extirpation of the sac. Dermoid cysts and hydatid cysts
should be treated as elsewhere. Papillomatous cysts, or cysts containing
papillomatous growths, are so prone to undergo carcinomatous degeneration,
that the segment of the breast containing the cyst should be removed; and,
if a part of the wall or the adjacent gland tissue is found infiltrated, the dis-
ease should be treated as carcinoma and a radical operation performed.
There are some simple cysts which are cured simply by aspiration. If
there is no possibility of malignancy, there is no reason why aspiration of a
simple cyst should not first be tried.
Incisions for the removal of benign tumors should generally be straight
incisions in a line radiating from the nipple. A larger tumor requires that
an elliptic incision in this direction should be made. Still larger tumors
require an ellipse embracing the nipple or a racquet-shaped incision. The
milk ducts should only be cut across when necessary. In general it is prefer-
able the incisions should radiate toward the axilla. For tumors of the lower
segment a curved incision (Fig. 1146) may be made about the base of the
gland, and the gland turned up as a flap, the tumor being removed through
the base of the gland (Fig. 1147).
Carcinoma. — The prevention of carcinoma of the breast can be promoted
by (i) preventing and promptly curing mastitis, (2) by removing indurated
areas and benign growths, and (3) by preserving the properties of youth in
the individual (see Malignant Tumors, Vol. I, page 327). The removal of
benign tumor? of the breast or the removal of the whole breast for benign
tumor is always justifiable because of the facts, that no benign tumor ever
becomes more benign, that all such conditions may become malignant, and
that malignancy may already be present though undiagnosticated.
The cure of carcinoma of the breast depends upon the removal of all of the
carcinoma. When all of the disease has been removed, the patient is cured
forever of that particular attack of disease. When but the smallest relic is
left, recurrence may be expected. The disease is originally distinctly local,
but soon begins to spread into the surrounding tissues and to be carried
through the lymphatics; therefore the hope of cure rests upon early and
complete extirpation of the disease while yet it remains localized in one spot.
There is no known treatment which has so much to offer as operation. To
employ any other treatment in an operable case is unjustifiable. When we
realize that, if carcinoma is operated upon as soon as the tumor or induration
can be discovered, it is in the great majority of cases absolutely curable, and
that with the lapse of time the possibility of cure rapidly declines, until in
a few months hope is forever gone, we perceive that to withhold early opera-
tion is to condemn the patient to a wretched an unjustifiable death. To
await an absolutely accurate diagnosis is a surgical crime. There need be
no mortality following the excision of benign tumors of the breast; and the
early removal of a hundred such tumors is better than to deny one woman
deliverance from cancer of the breast. The question for the surgeon to decide
is not, "has this woman cancer?" but, "is there a reasonable possibility that
this may be cancer?" Upon the reasonable possibility he should operate.
One of the reproaches of medicine is this: the vast majority of the cases oper-
ated upon for carcinoma of the breast, are found actually to be suffering
with that disease. It would be much to the credit of medicine were it less
accurate with diagnosis and more timely with the helping hand. Most
cases which come to the surgeon are, alas, too easily diagnosed!
Contraindications to operation should be recognized. There are contra-
478 SURGICAL TREATMENT
indications to the simple operation of extirpation of the breast and adjacent
axillary soft tissues; but the contraindications to most other operations are
fewer. When the disease has spread to the adjacent lymphatics, it is still
possible to remove it all by the simple operation, provided it has not
gone beyond the axilla or the structures of the bony chest wall. The cases
in which operation is contraindicated, as offering no hope, are those (i) in
which there are metastases along the whole length of the subclavian vein
or in the supraclavicular triangle of the neck; (2) those with wide skin
infiltration; (3) those with involvement of the chest wall, as evidenced by
fixedness of the tumor and (4) cases with remote metastases. These are
by no means absolute contraindications, and can be regarded as such only
when the disease has crossed the median line of the body or involves ir-
removable structures. It is difficult often to recognize these conditions.
Swelling of the arm from venous obstruction points to the first; palpation
should reveal the others. Rules cannot be given. Some cases in which
the extent of disease was wide and the case apparently hopeless have
enjoyed long intervals of immunity after operation; and other cases which
seemed hopeful have rapidly perished from recurrence. If it seems possible
to remove all of the disease, operation should be attempted. If the opera-
tion must be so extensive as to threaten the life of the patient, even though
it may seem that all of the disease has been removed, it probably has not.
The necessity for extensive operation means the probability of still wider ex-
tension of the disease. Inoperable cases may have much done for them
by palliative measures (see Extensive and Recurrent Carcinoma, page
494)-
Prognosis influences treatment. Death results in nearly 100 per cent,
of cases not treated surgically. Usually it occurs within two years. Most
patients will be dead inside of three years without operation. Cases oper-
ated upon, but in which recurrence takes place within three years after
operation, live on an average about two years and a half after the discovery
of their original disease. Most recurrences take place within three years after
operation. If recurrence has not taken place within three years after opera-
tion, 90 per cent, need not expect recurrence at all, and may regard them-
selves as permanently cured. Later recurrences do take place, sometimes as
late as ten years or longer. With modern operative technic, notwithstanding
that most cases come to the surgeon weeks and months after the disease
could have been recognized, from 40 to 50 per cent, of cases pass the three-
year period without recurrence, and from 30 to 40 per cent, pass the five-
year period. Local recurrences represent about 10 per cent, of the recur-
rences in cases in which a modern operation had been done. Regional
recurrence is not often seen after the first year. The majority of recur-
rences are within three months after the operation.
Operations done for recurrence of the disease offer a poor prognosis
if a timid and incomplete operation is performed. There is every reason
why they should be done if there is any possibility of removal of the secondary
growth or of relieving the patient from distressing symptoms. Operations
for recurrence have been done repeatedly, and the patients kept alive and
in comfort for many years (see Extensive and Recurrent Carcinoma, page
494)-
Operations in doubtful cases should be so planned that the tumor is ex-
posed as one 'of the first steps in the operation. It has been my practice to
do this through an incision, which, were the disease carcinoma, would be the
part of the incision falling nearest to the growth. The part of the gland,
containing the tumor, having been exposed, the surrounding tissues are walled
THE BREAST 479
off with gauze, and the tumor incised. No surgeon is fully competent
unless he has had sufficient pathologic training to be able to recognize
carcinoma by the gross appearances of the cut surface. If the appearances
are those of benign tumor, the surgeon proceeds accordingly; if the appear-
ances are those of carcinoma, the soiled knife is laid aside, the wound in the
tumor is packed with gauze soaked with tincture of iodin, the wound is kept
covered and the radical operation proceeded with; if there is doubt, the
surgeon should proceed as though the appearances were those of carcinoma.
Tissues to be removed and the extent of their removal in cancer of the breast
depend upon the location and extent of the growth. The skin, it should be
remembered, in places lies upon the gland substance, which is rich in its
lymphatic communications with the skin. As a rule, all of the skin covering
the gland, excepting its outer margin, should be removed with the tumor
in the case of central growths. In cases in which the tumor is near the margin
of the gland, the skin for from 4 to 8 cm. (i^ to 3 inches) beyond the gland
should be removed. In the latter case, skin overlying the gland on the side
opposite the growth may be left, provided the growth is not in the lower and
inner quadrant. In the case of a deep-lying small tumor, the skin covering
much of the breast need not be removed. As a rule, the incision should
not approach the tumor nearer than 5 cm. (2 inches); and at the upper and
outer quadrant of the breast it should be at least 7.5 cm. (3 inches) remote
from the tumor. The skin incision should have as its first aim the circum-
scribing of all of the disease which may possibly reside in the skin. The
subcutaneous fat is more apt to be invaded than the skin. The dissection
should slant away from the skin incision so that more fat than skin is re-
moved. The fat lying between the gland and the axilla, and the axillary
fat should be extirpated.
The mammary gland substance should all be removed. Even the parts
away from the neoplasm may be invaded through the lymphatics. The
pectoral fascia upon which the gland rests is apt to be invaded by the dis-
ease even before the skin. It may contain deposits of cancer cells before
the gland has become adherent to it. All of the fascia underlying the gland
and running up to the axilla should be removed. The muscle is invaded
about as soon as the fascia. I have found, while working with Professor
J. Orth in Gottingen, deposits of carcinoma in the pectoralis major in cases
in which the primary tumor was not adherent to the pectoral fascia and in
which the pectoral fascia was apparently free from disease. Invasions of
the fascia and muscle by metastatic deposits are simultaneous. It is for
these reasons that removal of the fascia alone has little value. The under-
lying muscle should go with it.
The lymph glands were formerly removed only when large enough to be
felt. A high rate of recurrence followed this practice. These glands are
involved very early in the disease. All of the lymphatics of the axilla should
be removed in every case of carcinoma of the breast operated upon which
it is hoped to cure, even though no glands are large enough to be felt. Leav-
ing an impalpable gland with a nest of cancer cells as big as the point of a
pin renders the whole operation of no service to the patient. By removing
all of the fat contained in the axilla, and all of the connective tissue about
the axillary vein, the lymphatics come away with it. The same should be
done with the fat and connective tissue lying beneath the scapular attachment
of the pectoralis minor, the clavicular attachment of the pectoralis major,
and the space between the outer part of the scapula and the serratus magnus.
When the upper axillary glands are found carcinomatous the dissection should
be carried as far over the first rib as possible and then the supraclavicular
480
SURGICAL TREATMENT
space opened in the neck and its fatty contents removed. If glands can be
palpated in this space they should be removed as a routine, though such
cases do not promise well.
The lines of incision for carcinoma of the breast should depend upon the
extent and location of the disease. The incision should be carried further
in one direction or another in order to embrace all of the disease and all of
the probabilities of lymphatic involvement. The incision usually should
begin at the humeral insertion of the pectoralis major, and pass inward
well above the axillary border of the muscle, across the tip of the coracoid
process, and thence curve downward to embrace the breast. Growths
FIG. 1148. — CARCINOMA OF THE BREAST.
Skin incision for disease in upper half of breast.
involving or encroaching upon the upper half of the gland should have a
wedge of skin removed between the breast and axilla (Fig. 1148). In tumors
confined to the lower half of the breast the incision may make a curve about
the upper border of the gland but a wedge of skin should be removed below
the breast (Fig. 1149). Tumors involving both the upper and lower halves
should have a combination of these two (Fig. 1150). For cases of centrally
placed tumor, operated upon early, the breast may be embraced by a circular
incision, and a flap taken from above to cover the defect (Fig. 1151). The
incision recommended by J. E. Jennings (New York Med. Jour., cii, 1916)
is adapted to most cases (Fig. 1152). The special merit of this incision is
that it removes the skin of the axilla which is prone to be the seat of
cancerous deposits.
Steps of the Operation. — The patient should lie supine with the diseased
side close to the edge of the table. The skin preparation should include
the front of the chest, neck, upper abdomen, side of the chest, axilla, shoulder
THE BREAST
481
L
FIG. 1149. — CARCINOMA OF BREAST.
Skin incision for disease of lower half of breast.
FIG. 1150. — CARCINOMA OF BREAST.
Skin incision for disease encroaching upon both upper and lower halves of breast.
VOL. 11—31
482
SURGICAL TREATMENT
FIG. 1151. — CARCINOMA OF BREAST.
Skin incision with axillary flap for cases of early disease in the center of the breast.
FIG. 1152. — CARCINOMA OF BREAST.
Incision of Jennings, removing axillary skin, for cases with central disease of breast.
THE BREAST
483
and upper arm. The preparation of the skin,, and the handling of the tumor
before and during the operation should be so gentle that no cancer-cells are
forcibly dislodged and sent into the lymph-channels. This is one of the dan-
gers of operation. All manipulations should be governed accordingly. The
hand and forearm should be enveloped in towels, and held at a right angle to
the body or rested upon a table. It is well to have 4 protecting screen
between the anesthetists apparatus and the field of operation.
If diagnostic exposure of the tumor is to be made the incision should begin
at the breast; otherwise it should begin at the arm. In the typical case,
the incision should pass from the pectoralis insertion to the inner side of the
breast (Fig. 1153). This should be joined above the axilla by the outer
arm of the incision, extending from the outer side of the breast. These in-
cisions are carried down to the subcutaneous fat, and obliquely away from
FIG. 1153. — INCISION FOR CANCER OF BREAST.
The first part of the incision is shown by the solid lines. The incision indicated by the
dotted lines is made after the axilla has been dissected.
the wound, down to the fascia lying upon the muscles. The skin and sub-
cutaneous tissues are then undermined and dissected free as far as the outer
end of the clavicle and the middle of the sternum; and externally, the axilla
and outer thorax should be uncovered as far as the latissimus dorsi muscle.
Enough tissue should be left so as not to destroy the nutrition of the skin.
In fairly advanced cases the subcutaneous fat in the regions where the
lymphatics run, especially between the tumor and the axilla, should be
removed.
The insertion of the pectoralis major muscle is then exposed, the finger
passed under it, the sternal and costal fibers divided (Fig. 1154), and the
stump reflected inward. This division need not always involve the clavicular
fibers, which may be separated from the costal part by blunt dissection,
and preserved. The removal of the muscle from below the clavicle should
484
SURGICAL TREATMENT
FIG. 1154. — CARCINOMA OF BREAST.
Division of pectoralis major. The incisions have not yet been carried below'the breast.
FIG. 1155. — CARCINOMA OF BREAST.
Pectoralis major has been divided. Division of pectoralis minor is the next step.
THE BREAST
485
extend as far inward as the inner third of the clavicle, where the fibers should
be divided by a vertical incision, exposing the extreme upper limit of the
axilla. The pectoralis minor comes in view and is divided close to its insertion
in the coracoid process, and retracted downward and inward (Fig. 1155).
The thin axillary fascia is now exposed. It should be divided at the
extreme outer limit of the wound parallel with the vessels, reflected inward
and the axillary artery and vein exposed. A clean and complete removal
of the connective-tissue contents of the axilla should then be made. There
are no structures of much consequence requiring to be spared, excepting the
axillary vein and artery and the great nerve trunks. The two superior
subscapular nerves may be preserved. The intercostohumeral nerve, passing
across the center of the axilla need not be spared. The third subscapular
nerve, to the latissimus dorsi, may be saved. None of these nerves should
FIG. 1156. — CARCINOMA OF BREAST.
Contents of axilla have been dissected out. As soon as the lymphatics of the axilla
have been liberated they should be enveloped in a towel to prevent the escape of cancer
cells into the wound.
be preserved if their preservation entails the least amount of risk to the suc-
cess of the operation. The removal of the axillary contents may begin above
at the first rib and follow the vessels downward. The cleaning off of the
axillary vein is most important. The vein should be well in view and clearly
exposed throughout (Fig. 1156). The numerous small arteries and veins,
coming from the main vessels, should be tied in two places and cut between.
Free connective tissue should not be embraced by the ligatures. The dis-
section is best made by anatomic forceps and a small knife. The operation
thus clears out the axilla, extending well into the spaces below the clavicle,
between coracoid process and first rib, and in front of the outer border of
the scapula. The loose tissue is kept attached in one mass. A flat piece
of gauze envelops the tissues as they are loosened.
486
SURGICAL TREATMENT
A towel is pressed into the axilla, and the dissection then passes to the
thorax. The mass of axillary tissue is carried inward. The pectoralis
minor is cut from the ribs, and likewise the upper and outer thoracic attach-
ments of the pectoralis major. The skin incision, which up to this point
had not passed below the level of the nipple, is now completed below the
breast. The same oblique incision through the superficial fascia is made
away from the wound so as to take as much connective tissue from the region
of the disease as possible. The pectoralis major is then cut from the chest.
This is over an area which is much larger than the area embraced by the
skin incision. With the muscle comes the mammary gland, and the axillary
tissue hanging to it (Fig. 1157). The periosteum need not be removed from
the ribs in ordinary cases, and enough of the pectoralis muscle may be left
to afford a hold for the ligatures which the vessels will require (Fig. 1158).
\
FIG. 1157. — CARCINOMA OF BREAST.
The axilla has been dissected and the removal of the breast and pectoral structures is
proceeding. The axillary lymphatics, still attached to the breast, should be enveloped in
a towel.
Next to a wide removal of the disease, the saving of blood is the great desidera-
tum in this operation. Most vessels should be clamped before they are cut.
Skilled assistants are important. The so-called shock following this opera-
tion is largely a matter of hemorrhage. No vessel however small should be
permitted to bleed. The wound should be kept dry. The pressure of the
hemostatic clamp closes most vessels, and not many ligatures are required.
A slow operation with a minimum of hemorrhage gives less depression than a
bloody rapid operation. From a half to three-quarters of an hour should be
consumed up to the completion of the dissection and the beginning of the
closure of the wound. Many surgeons take more than an hour for the fin-
ished operation.
The closure of the wound can not readily be completed without further
THE BREAST
487
FIG. 1158. — CARCINOMA OF BREAST.
Showing wound after removal of the breast, pectoralis major and minor, and contiguous
structures
FIG. 1159. — CARCINOMA OF BREAST.
Wound sutured as far as possible. The uncovered area is left to granulate for later skin-
grafting. Note two mattress sutures of silkworm gut with gauze bolsters.
488
SURGICAL TREATMENT
plastic work if a large amount of skin has been removed. To make a
complete closure, the skin should be dissected free from the chest inward
across the sternum and, if necessary, behind the opposite breast. A similar
freeing of the skin below and externally may also be made. If this does not
permit closure, one or more sliding flaps may be made (see Plastic Operations,
Vol. III). These plastic operations should also be made as free from
hemorrhage as possible. Apposition is facilitated by bringing the arm to
the side and throwing the shoulder forward by a pad placed behind the
upper arm. Tension upon the sutures is objectionable; it is better to
leave an area uncovered. Such an area may be covered at once with skin
grafts or left to granulate (Fig. 1159). A few deep sutures of silkworm-gut,
and the closure of the intervening wound with a continuous suture are most
suitable.
FIG. 1160. — CARCINOMA OF BREAST.
Dressing completed after operation.
The use of drainage must depend upon the possibilities of infection and
the amount of exudate expected. As a rule, it is best to make a small drainage
opening through the flap at the extreme posterior part of the wound, and pass
a rubber tube into the axilla. A separate dressing should be placed over this
tube.
A copious gauze dressing should be applied to the wound. A pad of gauze
should be placed in the axilla. The dressings should be held in place by a
breast binder having straps over the shoulders. A separate bandage may
hold the dressing on the upper arm. An oblong pad of towels or a pillow
should be placed behind the upper arm. It is not necessary to bind it to the
side. The patient is more comfortable if it is left free. The forearm may
be flexed across the abdomen (Fig. 1160).
The after-treatment consists in keeping the patient recumbent for a day or
two. She is then gradually elevated in bed, and allowed to sit up on the
fourth or fifth day. The drainage tube is removed on the second day by
lifting up the back of the dressings, but without removing them. The wound
THE BREAST
489
is dressed on the seventh day, if it was completely closed, and the arm left at
liberty. The patient may walk about as soon after this as she feels able.
Movements of the arm should be begun after the second or fourth day.
The arm should be capable ultimately of making all of the previous motions,
excepting that forward adduction is weak.
Other operations than that described are indicated in peculiar cases.
A small centrally located tumor in the back of the breast does not require
that the elliptic incision for the removal of the breast should include any
more skin than will permit of an easy apposition of the wound. A small
recent tumor on the extreme inner edge of the breast does not require re-
moval of the pectoralis minor muscle. When the supraclavicular glands
contain palpable metastases, if otherwise the case seems hopeful, they /may be
FIG. 1161.- — CARCINOMA OF BREAST.
Operation with preservation of part of pectoralis major. The inner part of the muscle
has been removed with the breast; the outer part, with its nerve-supply intact, is sewed to
the thorax.
removed through a supraclavicular incision. It is not worth while in these
cases to divide the clavicle, as some surgeons have done. When glands are
intimately adherent to the axillary vein, it may be necessary to excise a bit
of its wall. The opening may be closed with suture. Or it may be neces-
sary to remove so much of the vessel as to occlude its lumen. A complete
segment may have to be cut out. The surgeon should stop at nothing but
structures of vital importance. Occlusion of the vein leaves a disagreeable
swelling of the arm.
C. E. Ruth (Am. Jour. Obst. and Dis. Worn, and Chil., vol. Lxix, No. i, 1914)
preserved the distal part of the pectoralis major muscles. The muscle is
divided from the clavicle to the lower and inner part of the axilla. The two
stumps of the muscle are retracted and the axilla exposed and operated upon.
Then the thoracic portion of the muscle is removed along with the contents
of the axilla and the breast. The humeral part of the muscle, at the close
490
SURGICAL TREATMENT
of the operation is turned back and sewed to the chest wall. It is attached
to the latissimus dorsi and teres major muscles (Fig. 1161). The muscle
thus lies in contact with the axillary vessels and nerves, giving them protec-
tion, obliterating the axillary cavity, greatly reducing the amount of scar
formation, and providing a better use of the arm than when the muscle is
wholly destroyed. As this distal part of the muscle is not prone to be in-
volved in the disease, this step may wisely be introduced as a rule in most
operations.
The operation described by Jackson is applicable to small posterior
growths or tumors not encroaching upon the upper half of the breast, but
it should not be employed in anterior central tumors or tumors of the upper
segment, because it does not remove the skin between the gland and the axilla.
FIG. 1162. — COMPLETE CLOSURE OF WOUND POSSIBLE IN PATIENT WHO is NOT LEAN
AND WITH SMALL CENTRAL DISEASE OF BREAST.
This is not a theoretic objection. Before the days of the radical operation
recurrences in just this patch of skin were common.
In tumors of the lower or inner part of the breast, the incision should be
carried to the ensiform appendix; the subcutaneous fatty tissue below the
breast, together with the superficial layer of the deep fascia lying upon the
muscles, should be removed. This operation should remove the fascia
lying upon the upper part of the rectus muscle and the costal attachments of
the external oblique. The dissection should extend as far inward as the
median line, below to the level of the apex of the ensiform, and outward as far
as the outer border of the breast.
To prevent planting cancer-cells in the wound, the greatest care should be
taken not to squeeze or traumatize the breast. So great is this danger that
some surgeons carefully amputate the breast with the pectoral muscle and
THE BREAST
491
FIG. 1163. — PARTIAL CLOSURE OF HIGH WOUND AFTER EXCISION OF BREAST
FIG. 1164. — COMPLETE CLOSURE OF HIGH WOUND BY MEANS OF T\vo LATERAL PLASTIC
FLAPS.
492
SURGICAL TREATMENT
fascia, close the wound; and then two or three weeks later proceed with the
operation in the axilla. Others at the first operation remove the part of the
breast only which contains the disease; and complete the operation at a
second sitting. Others, as has been described above, begin the operation
with the dissection of the axilla, and, keeping all the removed tissue in one
mass, remove last the breast with its underlying structures.
The closure of wounds after these operations is the same as for other wounds.
The surgeon should not have this as a matter of primary concern. The wide
extirpation of the disease comes first. Closure of the wound is a second-
ary matter (Figs. 1162, 1163, 1164, 1165, 1166, 1167, 1168 and 1169).
The radical cautery operation for cancer of the breast was perfected by J. F.
Percy. The cautery knife is used the same as the cold knife. It possesses the
FIG. 1165. — PARTIAL CLOSURE OF Low WOUND AFTER EXCISION OF BREAST.
advantage that it destroys any cancer cells in the line of incision and may be
used to check bleeding at the same time. The operation is free from hemor-
rhage, and the time which is consumed in clamping and tying vessels is saved.
The line of incision should be marked out with the cautery knife. The knife
should not be too hot. The skin should not be cut from without inward as
this causes a necrotic edge. The knife should be caused to puncture the
skin, which is lifted up with tenaculum forceps, and then the skin should
be cut from within outward as the knife follows along the line marked for
the incision. Dissection of all of the structures is done with the red hot
knife. Dissection of tissues around blood-vessels can be made quite as
close as with a cold knife as the blood-stream maintains a constant tempera-
ture hi the wall of the vessel and prevents overheating. In dissecting
about the axillary vessels and brachial plexus the structures should be held
by the fingers of the free hand, encased in a medium-weight rubber glove,
THE BREAST
493
FIG. 1166. — COMPLETE CLOSURE OF Low WOUND BY PLASTIC FLAPS.
FIG. 1167. — PARTIAL CLOSURE OF LARGE WOUND AFTER EXCISION OF BREAST.
494
SURGICAL TREATMENT
and kept close to the cautery knife. By this means the surgeon may judge
the degree of heat which the tissues are sustaining. The heat should be
applied until the tissues that were fixed by the disease have become movable.
Drainage openings should be made by puncturing the skin from within
outward. The sutures should be placed well away from the edges of the
wound. Percy reports good results with this method.
Inoperable cancer of the breast is becoming less common as education
concerning this disease advances . There are few cases for which nothing can be
done. When the disease has progressed so far that the ordinary operation can
not circumscribe it, the re-ray and radium are capable of checking its progress.
The extent to which surgery may go in removing the invaded parts is
only limited by the necessity to leave the organs which are essential to life.
FIG. 1168. — COMPLETE CLOSURE OF LARGE WOUND BY AID OF LATERAL VERTICAL IN-
CISIONS AND UNDERCUTTING OF THE SKIN.
There have been strange recoveries from cancer — strange because the
nature of the disease is not yet known. The disappearance of recurrent
cancer of the breast has been observed by many surgeons after removal of the
ovaries. In some of these cases the disease has returned, but in some per-
manent cures have been reported.
Extensive and Recurrent Carcinoma of the Breast, Axilla, Neck, and
Thorax. — Cases of carcinoma of the breast, which have or have not been
operated upon, which show symptoms of extension along the course of the
axillary vessels and nerves, giving rise to swelling, pain, and numbness in
the arm, have customarily been regarded as inoperable, and condemned
to morphin, x-rays, serums, bacterins, or quackery until the inevitable end.
The suffering of these patients is very great, and death is welcomed as a relief.
Has surgery nothing to offer these unfortunates? I think it has. The
THE BREAST
495
mistake made by the older surgeons has been to think of carcinoma of the
breast as carcinoma of the breast, when as a matter of fact it soon is carci-
noma of the axilla, neck, and thorax, and should be thought of from the
beginning, either in fact or potentially, as such.
In these desperate cases the surgeon must put out of his mind the idea that
he is considering a disease of the breast, lest the psychology of timidity be
stimulated by the observation of the great distance from its origin which the
disease has traversed. When we think of disease of the axillary vessels,
brachial plexus, scapula, humerus, clavicle, lymphatics of the neck, ribs,
pleurae or lungs we are aware that any of these structures may be removed,
FIG 1169. — CLOSURE OF WOUND AFTER OPERATION WITH AXILLARY FLAP.
I, The breast has been removed, and the circular area behind the breast remains
be covered.
II, The axillary flap (A) is swung downward and caused to cover breast area. The skin
at (B) is carried upward, and the wound is closed.
III, Result after suturing wound.
and are every day being attacked with impunity by surgery. Primary cancer
of these structures is unhesitatingly extirpated. Why should the surgeon
withhold his skill from such disease, if perchance it were preceded by a cancer
of the breast?
These patients can be made more comfortable, life in a certain number
prolonged, and in some the disease cured by such radical operations. I have
no hesitation in saying that such operations have more to offer and will
show more cures than the simple amputation of the breast for primary car-
cinoma which was commonly practised thirty years ago.
The operation begins with amputation of the shoulder, a flap being made
from such tissues as are farthest from the disease (see Intrascapulothoracic
Amputation, Vol. III). The scapula and clavicle may be removed with-
out hesitation in order to remove disease or to uncover the vessels and
496
SURGICAL TREATMENT
nerves which are involved. The axillary and subclavian vessels should be
followed up into the neck and thorax, and the vessels together with all sur-
rounding tissues removed. This dissection and excision may be carried
as far as is necessary to reach the limit of the disease. At the same time the
cords of the brachial plexus should be followed up and removed with their
surrounding tissues. Before cutting the nerve-trunks they should be in-
jected with cocain to block impulses and prevent shock (Figs. 1170 and 1171).
This dissection and excision of vessels and nerves may be carried as far
as is necessary. If it is discovered that a rib or ribs are involved in the disease,
they may be removed. Ribs are removed for other conditions; why not to
FIG. 1170. — SHOWING THE POSSIBILITIES OF SURGERY IN CARCINOMA OF THE BREAST,
AXILLA, NECK AND THORAX. FRONT VIEW.
save a patient from cancer? Involvement of the pleura calls for resection of
the disease. Involvement of the lung demands removal at least of the
affected lobe. A lobe or the whole lung is excised for other disease; why not
for carcinoma?
There is no structure in the side of the neck which may not be sacrificed.
Vessels, including the internal jugular and carotids, may be resected. The
brachial plexus, vagus, and phrenic nerves may all be removed. In the
chest the only structures which must be preserved on one side are the heart,
aorta and vena cava. The whole of one lung, the ribs which cover it, clavicle,
scapula, arm, all the vessels and nerves of one side of the neck, and the neigh-
boring and involved connective tissues, muscles, and lymphatics may be
extirpated. This means everything practically on one or the other side of the
spinal column from the base of the skull to the diaphragm.
THE BREAST 497
Noe operation, of course, would involve all of these structures. Cancer
would not involve them all in a single patient. They are enumerated, how-
ever, to show the possibilities of radical operation. Such procedures should
be carried out with due regard for the possibilities of shock. Blood should
be saved; and nerve- trunks should be desensitized. Operations of this sort
may be done in several stages, with intervals of several days for recuperation.
In the hands of the experienced surgeon, who knows how to save blood and
minimize shock, these operations have much to offer. The #-rays and ra-
dium Ijmay^oe used in conjunction with them.
FIG. 1171. — AMPUTATION OF SHOULDER FOR CARCINOMA OF BREAST AND AXILLA. REAR
VIEW.
The experience of surgeons is showing that many patients, otherwise
doomed to a painful exodus, may be made comfortable, may have life pro-
longed, or may be cured by such radical procedures. The literature of sur-
gery is growing rich in the reports of these triumphs. Presumably hopeless
cases have been cured. Many cases have been operated upon repeatedly for
recurrences and life prolonged, or the disease ultimately cured. No patient
should be regarded as beyond the hope of relief unless the general toxemia
and inanition indicate an early conclusion.
The Male Breast. — Chronic mastitis requires the same treatment as
chronic inflammations in other structures. Tumors should be treated as in
other parts. Carcinoma, which is by no means uncommon, should be treated
radically as in the female breast.
VOL 11—32
THE ABDOMEN
GENERAL PRINCIPLES
The peritoneum is the important connecting structure of the abdomen.
It is extremely susceptible to infection; and being infected conveys disorder
from one organ to another. No surgeon is competent to deal with abdom-
inal diseases unless he has an understanding of its pathology. Nor is a sur-
geon competent to invade the peritoneum until he has added to his knowledge
a large experience as assistant and student under a master of the subject. This
is because abdominal surgery can be learned only by experience. To open
the abdomen for even the most simple disease may reveal complications, the
handling of which would try the most skillful surgeon. Conditions within
the abdomen can never fully be revealed by external examinations. Only
when the disease is uncovered to the sight or touch can the surgeon be assured
of its character. In most cases of abdominal disease it is better that the
disease be left to nature than that the peritoneum be invaded by an inexpe-
rienced or unskillful surgeon.
The oft-repeated conventionality that the after-care of surgical cases is as
important as the immediate treatment is not well founded. In abdominal
operations the fate of the patient is usually decided by what the surgeon does
before the abdomen is closed.
Every abdominal disease is serious; and invasion of the peritoneum must
always be regarded as a major operation. The idea should not be promul-
gated that certain operations are trivial affairs; it is unfair to the patient,
and it encourages boldness in the inexperienced. Operations should not be
undertaken to cure conditions which are amenable to less hazardous meas-
ures ; and when undertaken they should promise the possibility of relief, and
the hazard should not be unduly out of proportion to such possibility.
The surgeon should calculate the patient's reserve strength and operate
when possible at the propitious time. The emergencies, such as strangulated
internal hernia, acute perforation of the intestine or gangrene of the bowel,
offer little margin for such calculations. Nor can any of these be diagnosed
positively except when exposed to view. On the other hand an infected ova-
rian cystoma or a bleeding uterine fibroid, which are easily recognized, may
require immediate operation, tentative operative relief, or treatment prelimi-
nary to a deferred operation. The surgeon must also take into account the
relation of the patient's abdominal disease and the operation to disorders of
the heart, kidneys and other organs. Arbitrary routine is not desirable;
each case should be regarded as peculiar and receive the special consideration
which its conditions demand.
Exposure and insult to the peritoneum should be minimized. Operations
should be conducted with speed and precision; and for this reason a well-
organized operating room with experienced assistants offers the best results.
Discourses to bystanders and audiences are best delivered, not by the
operating surgeon but by another surgeon assigned to that special task —
preferably an assistant of the operator. If the operator carries on the dis-
course, an assistant should be performing the operation. For the surgeon to
converse and explain to bystanders, thereby delaying his work, is a crime not
498
THE ABDOMEN
499
forbidden by statute but by a law of higher ethics. Only the competent
should be licensed to perform these serious operations ; and neither the inter-
est of the surgeon nor that of the bystander should be paramount to that of
the unconscious patient.
The preparation of patients for abdominal operations is not essentially
different from that already described (Vol. I, page 176). Measures to mini-
mize the possibility of vomiting should be taken. The intestine should be
well cleaned out by 30 or 60 c.c. (i or 2 ounces) of castor oil; but the prelimi-
naries should not be so strenuous or extraordinary as to unbalance the
patient's physical or mental equipoise (for Preparation for Gastro-intestinal
Operations, see page 564). Means for preventing shock should be employed
(see Shock, Vol. I, page 213). The legs, arms and thorax should be warmly
covered.
FIG. 1172. — LOWERED HEAD, OR ELEVATED PELVIS, POSITION OF TRENDELENBURG.
The position for operation is usually the horizontal dorsal position, but
operations should be conducted upon a table which permits either lowering
or elevation of the head and chest. The lowered-head position (Trendelen-
burg) (Fig. 1172) is employed in operations in the lower abdomen and pelvis,
in order to permit of easier upward retraction of the intestines to give better
exposure of the field of operation. It is much used and greatly facilitates
operation. The elevated head position is employed in some cases of opera-
tion in the upper abdomen to permit of better downward retraction of the
intestines or drainage of the stomach. Either of these positions may be
had simply, by elevating one end of the table. The elevated-head position
is best secured by the employment of a table capable of producing flexion
at the knees. It should be provided with supports to catch the shoulders
and prevent slipping of the patient. The legs may or may not be made fast.
The Regions of the Abdomen. — The abdomen is divided arbitrarily by two horizontal
and two vertical imaginary lines. The upper horizontal line crosses at the lower part
of the tenth costal arch, the lower at the most prominent lateral points of the crests of the
ilia. The two vertical lines pass upward from the centre of Poupart's ligament. Antero-
posterior planes through these lines divide the abdomen into nine arbitrary regions.
The contents of these regions vary greatly, but they will be given as commonly found.
The right hypochondriac region: most of the right lobe of the liver, hepatic flexure of
colon, and part of right kidney. Epigastric: the left lobe of the liver, part of right lobe of
500
SURGICAL TREATMENT
liver, gall-bladder, part of stomach, pyloric and cardiac openings of stomach, first and
second parts of duodenum, duodenojejunal junction, most of the pancreas, upper and
inner part of the spleen, upper and inner part of both kidneys, suprarenal bodies. Left
hypochondriac: part of stomach, most of the spleen, tail of the pancreas, splenic flexure of
colon, part of left kidney, and sometimes extreme left end of left lobe of liver. Right
lumbar: ascending colon, part of right kidney, and sometimes part of ileum. Umbilical:
most of transverse colon, third part of duodenum, parts of coils of jejunum and ileum,
part of mesentery, part of great omentum, part of right kidney, and sometimes part of
RIGHT
HYPOCHON
DRIAC
RIGHT
LUMBAR,
BRIGHT
INGUINAL
EPIGASTRIC
UMBILICAL
LEFT
HYPOCHON-
DRIAC
LEFT
LUMBAR.
HYPOGASTf\IC
LEFT
INGUINAL
FIG. 1173. — REGIONS OF THE ABDOMEN ACCORDING TO THE OLD NOMENCLATURE.
left kidney. Left lumbar: descending colon, part of jejunum, and sometimes part of left
kidney. Right iliac: cecum, vermiform appendix, end of ileum. Hypogastric: loop of
sigmoid, upper part of rectum, convolutions of ileum, part of bladder in children, and part
of distended bladder in adults. Left iliac: sigmoid colon, and parts of coils of jejunum and
ileum (Fig. 1173).
The B.N.A. commission divided the abdomen into regions according to the natural
lines. All of the lines are curved (Fig. 1174).
Structures of Abdominal Wall. — The anterior wall is composed of skin, superficial and
deep layers of superficial fascia, areolar connective tissue overlying external oblique muscle,
THE ABDOMEN
501
external oblique muscle and its aponeurosis, internal oblique muscle and its aponeurosis,
transversalis muscle and its aponeurosis, rectus muscle, pyramidalis muscle, transversalis
fascia, extraperitoneal areolar connective tissue, peritoneum (Figs. 1175 and 1176).
The posterior wall is composed of five lumbar vertebrae and their intervertebral disks,
posterolateral parts of the ilia, and the following soft structures: skin, superficial fascia,
posterior layer of the lumbar fascia, erector spinae muscle, middle layer of lumbar fascia
attached to transverse processes, quadratus lumborum muscle, anterior layer of lumbar
fascia, psoas muscle, crura of diaphragm, kidneys, areolar connective tissue, colon, extra-
peritoneal connective tissue, peritoneum (Fig. 1177).
I^EGIO
INGU1NALI5
FIG. 1174. — REGIONS OF THE ABDOMEN ACCORDING TO BNA (BASLE XOMINA
ANATOMICA).
The blood-supply of the abdominal wall is through the superior epigastric and musculo-
phrenic from the internal mammary artery; lowest two intercostals from the thoracic aorta;
abdominal branches of lumbar arteries from abdominal aorta; iliolumbar from internal
iliac artery; deep circumflex iliac and deep epigastric from external iliac artery; and super-
ficial epigastric, superficial circumflex iliac, and superficial external pudic from the femoral
artery. The veins accompany the arteries. There is a plexus of veins in the lower supra-
pubic region and in front of the inguinal canal.
The nerve supply of the anterolateral wall is largely through the lower intercostal nerves.
These nerves emerge from the intercostal spaces and pass in a general direction forward and
502
SURGICAL TREATMENT
inward and downward between the internal oblique and transversalis. They penetrate
the outer edge of the sheath of the rectus to supply that muscle. Thence they traverse the
substance of the muscle, pass through its anterior sheath and supply the skin. The twelfth
intercostal nerve passes along the lower border of the twelfth rib in front of the quadratus
FIG. 1175. — DIAGRAM OF TRANSVERSE SECTION OF ANTERIOR ABDOMINAL WALL ABOVE
THE SEMILUNAR FOLD OF DOUGLAS.
FIG. 1176. — DIAGRAM OF TRANSVERSE SECTION OF ANTERIOR ABDOMINAL WALL BELOW
THE FOLD OF DOUGLAS.
X \ \5FiriAE >t'O, C
Kx-0^s?^55;3r^4s!^-4* I?
FIG. 1177. — DIAGRAM OF TRANSVERSE SECTION OF WALL OF ABDOMEN IN MIDLUMBAR
REGION.
lumborum and between the internal oblique and transversalis. Its anterior branch pene-
trates the rectus and supplies the skin of the suprapubic region.
The iliohypogastric branch of the first lumbar runs along the crest of the ilium, pierces
the transversalis, and divides between the transversalis and internal oblique, about 6.5
cm. (2^ inches) posterior to the anterior-superior spine into the hypogastric branch and the
THE ABDOMEN
503
iliac branch. The hypogastric branch passes forward between the internal oblique and
transversalis, pierces the internal oblique, then the aponeurosis of the external oblique
about 2.5 cm. (i inch) above the external abdominal ring and just to its outer side, and is
distributed to the skin of the hypogastrium and region of the external inguinal ring. Anes-
thetization of this nerve is easily accomplished for operations in the groin.
The ilio-inguinal branch of the first lumbar nerve passes from the outer border of the
psoas and thence just below the iliohypogastric. It penetrates the transversalis near the
anterior superior spine of the ilium, passes forward between the transversalis and the
internal oblique, and pierces the latter just internal to the anterior superior spine. It passes
inward behind the aponeurosis of the external oblique to the spermatic cord, which it
accompanies through the inguinal canal. Emerging at the external ring, it supplies the
skin of the upper and inner part of the thigh and the scrotum or labium (see Hernia).
Landmarks. — The sheath of the rectus muscle is peculiar. Above, the anterior sheath
is formed by the union of the aponeuroses of the external oblique and anterior layer of that
of the internal oblique. Below, the anterior sheath is
formed by the union of the aponeuroses of the external
oblique, internal oblique, and transversalis.
Above, the posterior sheath is formed by the union of
the posterior layer of the aponeurosis of the internal ob-
lique and the aponeurosis of the transversalis. Behind
these come the transversalis fascia, extraperitoneal connec-
tive tissue, and parietal peritoneum. Below the semilunar
fold of Douglas, the transversalis fascia is the only fascia
passing posterior to the muscle. This fold is at the junc-
tion of the upper three-fourths and the lower fourth of the
recti muscles, about 3 cm. (i J^ inches) below the umbilicus.
The linea alba extends from the ensiform cartilage to
the symphysis pubis, and is formed by the blending of the
aponeuroses of the muscles of the anterior abdominal wall.
It is broad above and narrow below. Below the fold
of Douglas it is not distinct, and the two recti lie close to-
gether. It is most marked just above the umbilicus.
The umbilicus is in the median line 2 to 2.5 cm. (% to i
inch) above the highest points of the crests of the ilia. It is
about 2 cm. (% inch) above the bifurcation of the aorta,
opposite the tip of the spine of the third lumbar verte-
bra or the intervertebral disk between the third and
fourth lumbar vertebrae. The celiac axis is 10 to 12.5 cm.
(4 to 5 inches) above the umbilicus. The renal arteries
arise 7.5 to 10 cm. (3 to 4 inches) above the umbilicus.
At the umbilicus only a thin layer of connective tissue
separates the peritoneum from the skin. When operating
through it or around it, it is well to excise it completely to
prevent hernia — excepting in young women to whom it
possesses a cosmetic advantage. To avoid the round liga-
ment, the incision should be on the left side.
The linecE semilunares are formed by the blending of
the abdominal aponeuroses, and are bounded internally by
the outer borders of the recti muscles. They extend from the seventh costal cartilages
to the pubic spines. At the level of the umbilicus they are from 13 to 15 cm. (5 to 6 in-
ches) apart.
The linea transverse? are tendinous intersections in the substance of the recti muscles.
There are usually three. The lowest is at the umbilicus.
The inguinal landmarks are especially important for hernia (q.v.). The spine of the os
pubis is nearly on the same level with the top of the great trochanter. It may be found by
following up the adductor longus muscle. The inner pillar of the external ring is attached
to it. Poupart's ligament represents the lower border of the external oblique muscle and
the conjoined fascia?. It curves slightly downward and connects the anterior-superior
spine of the ilium and the pubic spine. The internal abdominal ring is situated 1.3 cm.
(% inch) above the centre of Poupart's ligament. The external abdominal ring is situated
above the extreme inner end of Poupart's ligament. It is just above and external to the
crest of the pubic bone.
The external oblique musae becomes aponeurotic anteriorly at a line passing from the
anterior limit of the ninth costal cartilage to the anterior superior spine of the ilium.
The lower limit of the fleshy part of the muscle is represented by a line drawn transversely
between the points on the iliac crests 2.5 or 5 cm. (i or 2 inches) behind the anterior superior
spine. The fibres of the muscle and its aponeurosis run at right angles to a line connecting
the anterior superior spine and the umbilicus.
FIG. 1178. — DIAGRAM OF
MEDIAN SECTION OF THE FE-
MALE BODY, SHOWING EXTENT
AND COMPLEXITIES
PERITONEUM.
OF THE
504 SURGICAL TREATMENT
The internal oblique muscle runs upward and inward. Above, it becomes aponeurotic
at a line passing from the tip of the twelfth rib upward and inward parallel with the costal
border; internally, it becomes aponeurotic at a line extending from the middle of Poupart's
ligament upward and slightly outward.
The transversalis muscle passes to the linea semilunaris further inward above and below
than at the midabdomen. It is further described under hernia.
The peritoneum is the serous membrane which partly covers the viscera within the
abdomen and lines the abdominal walls. It may be thought of as constituting a compli-
cated sac. It communicates with the outer world by the Fallopian tubes. Covering the
intestine, it must needs have a large area (Fig. 1178).
ABDOMINAL SECTION
Instruments used in abdominal operations are: scalpels; scissors,
straight, curved, pointed, blunt; anatomic forceps; mouse- tooth forceps;
nemos tats; hooked retractors; smooth retractors; abdominal retractors;
sponge holders; ligature carrier; needles, curved and straight; needle holder;
long forceps; tenaculum; intestinal clamps; catgut, plain and chromicized;
silk; silkworm-gut; gauze pads; gauze sponges; gauze packing; drainage
tubes. Besides the ordinary retractors, self-retaining abdominal retractors
are useful (see Instruments).
Opening the abdomen for exposure of the abdominal contents, is per-
formed in whatever region required. The nearer the incision is to the middle
line, the greater the number of viscera that can be reached. In general,
incisions should be made so as to give the best possible access through the
smallest opening. For most operations an incision should be from 5 to 9
cm. (2 to $% inches) long. Larger openings are often required; smaller,
rarely. A 5-cm. (2-inch) incision heals as quickly as a 2.5-011. (i-inch)
incision, and permits better access. When not otherwise undesirable the
skin incision should be in the general direction of the nerves and vessels. The
incision through fascia should preferably be in the direction of its fibers.
Openings through muscle should be made by separating the fibers of the
muscle by blunt dissection. This is done with the handle of the scalpel. In
many situations it is possible to uncover the muscle to its edge, and then
retract it without penetrating its substance. When necessary, muscles may
be cut across their fibers ; but when this is done, it is most desirable to sew
together the rent at the close of the operation. Motor nerves should be
spared. They will often be seen traversing the muscle where they may be
isolated and retracted.
Hernia is least apt to occur in wounds which are closed in such a way as to
restore the structures of the abdominal wall to their natural relations. A
wound is strongly protected against hernia if the openings through the several
structures are made at different lateral planes, with strong muscle interven-
ing. The muscle and deep fascia are the main protection. Incisions should
preferably not be made through the umbilicus but to the left side. An
absolutely median incision is rarely made. The so-called median incisions
are made slightly to the side of the middle line (Fig. 1179).
Incisions for Opening the Abdomen. — The median postmuscular incision
has the widest range of usefulness. It has the merit of dividing no motor
nerves or muscles; it is in the thinnest part of the abdominal wall; and by
making the openings of the deep fascia at one side of the median line and
retracting the rectus muscle outward, strong muscular protection is secured
(Fig. 1 1 80). The median incision when carried alongside of the ensiform
cartilage, should be made with care lest the pleura be opened.
Each structure should be identified and cleanly incised, step-by-step —
skin, superficial fascia, deep fascia, muscle, deep layer of deep fascia (trans-
THE ABDOMEN
505
versalis fascia) and peritoneum. A connective-tissue layer with more or less
fat lies between the deep connective tissue and the peritoneum. It is quite
thick in the upper and lower parts of the median region. Behind the rectus
muscle below the level of the umbilicus it is almost absent, and the perito-
neum and fascia lie in close contact. When this connective-tissue layer is
absent, the peritoneum is divided with the fascia. The transversalis fascia
should not be confused with extraperitoneal connective tissue.
FIG. 1179. — ABDOMINAL INCISIONS.
A, Oblique subcostal for liver and gall-bladder; B, median for stomach, and liver; C,
vertical subcostal for gall-bladder; D, right abdominal through rectus; E, right oblique.for
appendix; F, anterior superior spine of ilium; G, right vertical external to rectus; H, oblique
inguinal for hernia and exposure of iliac vessels; /, left oblique subcostal; J, left vertical,
subcostal for cardiac end of stomach; K, left subcostal external to rectus for spleen; L,
median midabdominal ; M, infraumbilical midabdominal; AT, vertical median suprapubic;
O, suprapubic transverse curved. The costal arch in this picture should be just above
the lines A and I as these incisions are to be placed just below and parallel with "the costal
border.
The peritoneum should not be mistaken for intestine. If intestine is
wounded, it should at once receive the necessary attention (page 628).
Extraperitoneal connective tissue should not be confused with omentum.
The peritoneum is opened by picking it up with two pairs of forceps, to hold
it away from the viscera, and making a small opening between (Fig. 1181).
The two edges of the wound are held open by forceps, a finger or other pro-
506
SURGICAL TREATMENT
tector slid beneath the peritoneum, and the opening enlarged with scissors to
the desired extent. Before opening the peritoneum all bleeding should have
been controlled and clamps removed. There are no vessles of consequence
in the anterior abdominal wall. *
FlG. 1 1 8O. POSTMUSCULAR MEDIAN INCISION.
Showing path of entrance to abdomen. The rectus is retracted outward as soon as it is
exposed by the anterior incision.
FIG. 1181. — METHOD OF OPENING THE PERITONEUM.
The skin is shown uncovered to demonstrate location of wound.
The median intramuscular incision, which passes directly down between
the fibers of the rectus muscle, divides the motor nerve and paralyzes a part of
the muscle internal to the incision. In dealing with the oblique muscles it
THE ABDOMEN
507
should be noted that the nerves are not parallel with the fibres of the external
oblique but run somewhat more transversely. Incisions through the skin
may be made as long as desired and in any direction without regard to the
nerves. The same may be said of the fascia lying on the muscles.
Median incisions are used for parts most easily available thereby. Above
the umbilicus they are used to expose the stomach, liver, pancreas and in-
testines. They should be made preferably through the fascia external to
the inner edge of the rectus.
Lateral vertical incisions along the outer border of the rectus are so apt
to damage the motor supply of the rectus as to be decidedly objectionable.
They are used for the gall-bladder, bile ducts, liver, duodenum, spleen, kid-
neys, ascending and descending colon.
Lateral muscle-splitting incisions are made by separating the fibres of
muscles, one after another, identifying and protecting the nerves especially
between the transversalis and internal oblique, and holding the muscles
FIG. 1182. — TRANSVERSE SUPERFICIAL AND VERTICAL DEEP INCISIONS.
The rectus muscle is drawn inward, the oblique and transversalis muscles are split and
retracted, and the transversalis fascia and peritoneum are incised vertically.
apart while the transversalis fascia and peritoneum are incised and the opera-
tion performed. They are used to expose the lateral parts of the abdomen.
Transverse incisions combine the above. Usually they are transverse
through the skin and superficial fascia only. Such incisions are used in
some instances to obviate the vertical scar. For cosmetic purposes it is
possible to place the incision largely within the area of the pubic hair. It
may also be placed in the transverse suprapubic crease which is present in
the fat abdomen. The incision is carried through the skin and fascia down
to the superficial layer of the deep fascia lying upon the muscles. Vertical
retraction is then made and the superficial fascia dissected free from the
deep fascia as far as is necessary to make room for the vertical incision through
the rest of the abdominal wall.
Any modification of this principle may be applied. It simply means
that the opening through the deeper abdominal structures need not be made
508
SURGICAL TREATMENT
in the same line as the opening through the skin. Access to all parts of the
abdomen may be by this method (Fig. 1182).
Another principle in the application of the transverse incision consists in
making the whole opening through the abdominal wall in the transverse
direction. For example, for the freest possible access to the stomach, an
incision is carried across just above the umbilicus. It may be 15 or 18 cm.
(6 or 7 inches) long, or even longer, and passes down to the muscles. A
median opening is then made and the finger inserted into the abdomen.
At this juncture W. Meyer (Annals of Surg., November, 1915) separated the
deep from the superficial fascia for a short distance, and with a curved needle
FIG. 1183. — TRANSVERSE ABDOMINAL INCISION.
Fixing rectus muscle to its sheath after method of W. Meyer.
passed three catgut sutures through each rectus muscle, above and below
the proposed place of division, fixing the muscle to its sheath (Fig. 1183).
Each of these sutures passes down to but not through the peritoneum.
When they have been tied, the incision is carried down transversely through
the bellies of the recti and through the peritoneum (Fig. 1184). These
sutures prevent retraction of the muscle, and make later suturing easy.
The transverse incision may always be modified to suit other conditions.
The above-described division of the recti may be used to involve only one
THE ABDOMEN
509
rectus muscle. It may be modified by continuing another incision upward,
downward, or obliquely from either of its extremities. •
If the rectus muscle has been divided, it is easily sutured with chromi-
cized catgut. A continuous suture is used to unite the peritoneum and
transversalis fascia. A second continuous suture unites the divided muscle
and catches the anterior sheath. The skin and superficial fascia are united
as usual. Such an incision as this does not damage the nerve supply, it
gives remarkably free access, and when the wound is properly closed is
capable of restoring a firm abdominal wall.
FIG. 1184. — TRANSVERSE ABDOMINAL INCISION.
The rectus, having been fastened to its sheath by two rows of sutures, is divided after
method of W. M-eyer. The incision passes through the peritoneum.
The neatest incision for hiding the scar is 10 or 13 cm. (4 or 5 inches) long,
curved with its convexity downward, all within the pubic hair area. This
incision is made in such a way that the edge of the skin flap is very thin,
little more than a skin graft for a width of i or 2 cm. (% or % inch). By
passing obliquely through the superficial fascia, the anterior sheath of the
muscles is exposed 2.5 to 5 cm. (i or 2 inches) above the pubes. The super-
ficial fascia is dissected upward and retracted. The fascia in front of the
recti is divided transversely. From the ends of this latter incision, incisions
510 SURGICAL TREATMENT
are carried upward and outward between the fibers of the external oblique
if it is desired to make a lateral opening. The fibers of the internal oblique
are similarly separated. If only lateral access is desired, but one of these
oblique incisions is made. The recti muscles may be isolated for a distance
of 10 or 13 cm. (4 or 5 inches), strongly retracted outward and the peritoneum
opened vertically in the median line. For a lateral opening one rectus should
be retracted toward the median line.
Transverse postmuscular incisions may be used in connection especially
with the rectus muscle. The muscle is exposed by a vertical or oblique
incision which passes through its anterior sheath. The muscle is than re-
tracted inward, and the posterior sheath, transversalis fascia, and peritoneum
divided transversely. This incision may be used for access to the vermiform
appendix. In closing, the structures behind the muscle are sutured; the
muscle is then allowed to return to its position; and the anterior structures
sewed. This is the most effective entrance to the abdomen for preventing
postoperative hernia (see Appendicitis, Vol. III).
Combined incisions may involve any of the above described methods.
A very useful incision is the flap incision. This consists of a transverse cut
and a vertical cut or an oblique and a vertical cut. If the former is made
through the external oblique and the latter passes down along the outer
border of the rectus muscle a flap is formed which may be turned back
and give wide exposure of the lateral regions of the abdomen. When free
exposure of the sigmoid or cecum is desired, a transverse incision passing
inward and ending at the outer border of the rectus muscle and then con-
tinuing downward just external to the rectus permits turning back a trian-
gular flap which gives larger access than can be secured by a single linear
incision.
Median Abdominal Section. — The incision may be made anywhere be-
tween the ensiform cartilage and the symphysis pubis. If not enough room
is secured by the original incision, it may be continued above or below.
Within 5 cm. (2 inches) above the pubes, the bladder should always be had
in mind. At the umbilicus, the incision should pass preferably to the left
to avoid the round ligament of the liver.
In the upper three-fourths of the linea alba, where the recti muscles are
somewhat separated, the peritoneum is reached through an incision between
the two muscles. If the incision need not be in the middle line, it is best to
incise the anterior sheath of the rectus at one or the other sides. The edge
of the belly of the muscle is then retracted outward and the aponeurosis,
composed of its posterior sheath and transversalis fascia incised. The ab-
domen is then entered behind the muscle; and when the wound is closed, it
is strengthened by the muscle lying over it. If the incision is made in the
lower fourth of the abdomen, it may be made between the two recti; but,
after passing through the skin and subcutaneous fat, it is preferable to incise
the anterior sheath of one or the other recti, about 1.3 or 2.5 cm. (^ or i inch)
from the border of the muscle. The pyramidalis and rectus are then re-
tracted outward and the abdomen entered behind the muscles. The wound
is closed as already described.
Hio-inguinal Abdominal Section (McBurney's Intramuscular Gridiron
Incision). — Incisions in the iliac and inguinal regions for opening the abdomen
may best be made to follow the general direction of the fibers of the ex-
ternal oblique muscle. This is the operation best adapted for exposure of
the cecum and vermiform appendix. A point midway between the anterior
superior spine of the ilium and the umbilicus is located. This is the
so-called McBurney's point. An incision is made about 7.5 cm. (3 inches)
THE ABDOMEN 511
long, from above downward and inward, at an angle of 45 degrees from the
perpendicular, having its center a little external to McBurney's point.
Having incised the skin and superficial fascia, the external oblique
muscle is exposed and its sheath incised in the line with its fibers. The
fibers are then separated bluntly and the separation is continued if necessary
below into its aponeurosis by retracting the outer edge of the rectus inward.
The opening between the fibers of the external oblique is then retracted
at right angles to the incision with curved retractors; and the internal
oblique exposed. The sheath of the latter muscle is divided in the line
with its fibers which is at about a right angle to that of the external ob-
lique. The fibers are separated similarly by blunt dissection and an occa-
sional incision. This separation is about in the line toward the unbilicus
and anterior superior spine, and the opening in the muscle is retracted at
right angles to the retraction of the external oblique. The fascia lying in
front of the transversalis muscle is exposed. The nerves lying between
the internal oblique and the transversalis should be looked for and protected
from injury.
The fibers of the transversalis pass more nearly in the direction of the
internal oblique. They should be separated in the line of their cleavage.
They may be held apart by the retractors which hold the internal oblique.
The transversalis fascia is exposed at the bottom of the wound, becoming
continuous with the aponeurosis into which the muscle is inserted internally.
It is picked up and incised transversely in the line with the muscle fibers,
exposing the extraperitoneal connective tissue. The peritoneum is then
picked up and incised in the same direction.
In closing this wound, a separate suture of the peritoneum is made with
catgut. The transversalis fascia is closed with a continuous suture of chromic
catgut tied at frequent intervals. The transversalis muscle need not be
sutured. The internal oblique and the external oblique may be sutured with
fine running catgut. The subcutaneous fascia, if thick, should be similarly
sutured; and a subcuticular suture applied to the skin.
This represents the ideal approach to the abdomen. Hernia does not
occur when primary union is secured. If drainage is used the peritoneum
is sutured down to the drain, likewise the fascia, muscles, and skin, when
the drain is removed, all of these tend to close the wound; and, if muscle or
nerve have not been cut, the danger of hernia is slight. The incision may
be made longer or shorter; and the operation may be done at a higher or
lower plane than here described.
This wound may be enlarged externally by further separation of muscle
fibers and retraction. It may be enlarged internally by incising the sheaths
of the rectus muscle and retracting the muscle inward.
Oblique Postmuscular Abdominal Section. — This operation may be
carried out as a continuation of the above operation by carrying the incision
still further inward and downward. This is done when it is desired to make
a more internal exposure. The separation of the fibers of the external oblique,
its aponeurosis, the internal oblique, and the transversalis is continued as
far as the outer border of the rectus. The fascia of the external oblique,
already opened with the muscle as far as the rectus, is separated by blunt
dissection from the anterior sheath of the rectus and incised as far as neces-
sary. This opening may be carried to the median line if desired, and the
split fascia retracted. The anterior sheath of the rectus, thus exposed, is
incised in the same direction; although the incision may be made transverse
or even more oblique, if desired. The rectus is then retracted inward by a
retractor applied to its outer border, while it is bluntly separated from its
512
SURGICAL TREATMENT
posterior sheath which consists in the lower abdomen of transversalis fascia.
The deep epigastric artery and vein are exposed, lying upon the posterior
sheath of the rectus. They may be ligated in two places and cut between or
retracted inwardly with the muscle. The transversalis fascia and peritoneum
are then incised in the same line, and the operation proceeded with. The
wound is closed after the method above described. After suturing the peri-
toneum and transversalis fascia the rectus is allowed to spring back into
place, and its anterior sheath sutured. This latter suture may include also
the fascia of the external oblique. This operation may be done through a
small incision, if desired, having its center at the outer border of the rectus.
Vertical Postmuscular Abdominal Section. — This operation is not
unlike the modified median section. It may be used in any part of the rec-
tus muscle. A vertical incision is made about 6.5 to 10 cm. (2% to 4 inches)
long and about 2.5 cm. (i inch) internal to the outer border of the rectus.
The anterior sheath of the rectus is exposed and incised vertically in the
FIG. 1185. — TRANSVERSE INCISION.
The pyramidalis and recti are exposed.
same line. The outer lip of the rectal sheath is retracted outward until the
outer edge of the muscle is exposed. This edge of the muscle is then retracted
inward, being bluntly separated from its posterior sheath. This exposes
the posterior sheath of the muscle which should be incised vertically. In
the lower fourth of the muscle the posterior sheath consists of transversalis
fascia, and the deep epigastric vessels lie upon it. These vessels should be
ligated or retracted. The peritoneum is then incised, and the operation
proceeded with. In closing the wound the peritoneum is sutured separately;
the transversalis and posterior sheath of the rectus are firmly sutured with a
continuous frequently interrupted suture of chromicized catgut; if the muscle
does not readily spring back into place, it should be sutured to the outer
part of its sheath; the anterior sheath is closed with a running suture of
catgut; and the fascia and skin as above described. The objection to this
operation is that some of the nerves to the rectus are destroyed and the
muscle weakened at the point where it is important that it should be strong.
THE ABDOMEN
513
For this reason, the oblique operations or the median operations which retract
the muscle outward are to be preferred.
Low Median Abdominal Section by the Superficial Transverse Incision. —
This incision is of especial value for exposing the lower abdominal structures
such as the rectum, bladder, uterus, tubes, ovaries, and broad ligaments.
It gives ample exposure because the muscle is easily retracted when the fascia
is divided, the obstacle to lateral retraction in vertical operations being the
fascia and not the muscle. The scar is largely concealed by the pubic
hair. The nourishment of the wound is better than in median sections.
A large ellipse of fat may be removed from the obese abdomen. The incision
is not to be preferred to the vertical incision in infected cases. The bladder
must be looked out for.
The superficial incision is placed transversely, with a downward con-
vexity, and passes just above the pubic bone, and the inner halves of Pou-
part's ligaments. It traverses the area of the pubic hair, and begins and
FIG. 1186. — RETRACTION OF PYRAMIDALES AND RECTI TO MAKE A MEDIAN OPENING
BETWEEN THE MUSCLES.
ends at the deep epigastric vessels. The transverse incision divides the skin,
superficial fascia, and anterior sheath of the two recti muscles. Vessels are
ligated. All of these structures are dissected free from the muscle and linea
alba and retracted upward (Fig. 1185). The pyramidalis of one side is
retracted and a median vertical opening into the abdomen is then made
between the two recti just above the symphysis pubis. Upward and lateral
retraction then permits of a very satisfactory exposure of the lower abdomen
(Fig. 1 1 86). The opening is closed, when the operation is completed, by
layer sutures. A continuous suture of chromicized catgut is used for peri-
toneum and fascia forming the posterior sheath of the rectus muscle. The
two recti are approximated with a few sutures of catgut. The transverse
openings in the anterior sheaths are sutured with a continuous suture of fine
chromicized catgut; and the superficial fascia and skin with buried sutures.
Oblique Subcostal Abdominal Section. — This operation is through an
incision parallel to the costochondral margin. It is used to expose the
gall-bladder and liver on the right side, the left lobe of the liver, cardiac end
VOL. 11—33
514
SURGICAL TREATMENT
of stomach and splenic regions on the left side. The incision is made about
2.5 cm. (i inch) from the costal arch on one side. The center of the incision
should be opposite the object of attack. Its length depends upon the
demands of the case. The skin and superficial fascia are incised. The
external oblique is exposed and its fibers (aponeurotic above and muscular
below) are divided in the line of the skin incision. The wound is retracted,
the internal oblique exposed, and its fibers separated by blunt dissection.
This may be done external to the rectus, if the operation is not done too
high. The transversalis is incised the same as the external oblique. Trans-
FIG. 1187. — QUADRUPLE ABDOMINAL RETRACTOR.
A sheet of rubber protective is shown covering the skin around the wound.
versalis fascia and peritoneum are incised in the same line. After the com-
pletion of the operation, the peritoneum and transversalis fascia are sutured
with a running chromicized catgut suture. The divided transversalis and
oblique muscles are sutured with interrupted sutures of the same material.
The external oblique, fascia and skin may all be included in sutures of
silkworm-gut or silk.
If this incision is made so high that the rectus is involved, it is a simple
matter to [incise its anterior sheath, retract the muscle inward, and'continue
the incision through its posterior sheath and the peritoneum (for other in-
cisions for exposing the subcostal abdominal structures see Operations on
the Bile Tract, Vol. III).
THE ABDOMEN 515
Retraction, after opening the abdomen, is best done by smooth short-
bladed retractors (see Retractors). The intestines are kept out of the way
by laying flat pads under these. The self-retaining double retractor saves
at least two hands, and the quadruple retractor takes the place of four
(Fig. 1187). Intestines should not be pinched between retractor and ab-
dominal wall. R. L. Dickinson (Jour. Obst. and Gyn. British Emp., Septem-
ber, 1913) devised a retractor of soft rubber (shield retractor). This consists
of rather stiff rubber, held open in a circle by two springs, one of which is
within the abdomen the other without (Fig. 1188).
Sponging in abdominal operations should be done only with sponges
which are under numerical control. Gauze is the best material. It may
be used dry, but is best moistened with salt solution. It should be free from
lint and loose threads. Flat sponges (see Vol. I, page 42) are used for
keeping coils of intestine out of the way and covered. Such sponges should
be used wet and warm. To prevent the irritation which produces adhesions,
rubber tissue should be interposed between the gauze and peritoneum (see
FIG. 1188. — RUBBER RETRACTOR.
Device of Dickinson shown in position in median abdominal wound.
page 521). Flat sponges may be used for blood. Sponges on clamps are
employed where frequent sponging in deep cavities is required.
Protection of peritoneum from every unnecessary insult is imperative.
This is accomplished by doing no more than is necessary, by gentle handling
of all peritoneum-covered surfaces and by keeping the peritoneum warm.
Coils of intestine coming in the field of operation should be pressed back
and held covered with warm pads. The flat laparotomy pads or small
towels, wrung out in hot water, are best. The experienced surgeon is able
soon to wall off the rest of the abdomen and leave exposed only the site
of operative attack. Minimized peritoneal irritation is the key to the
prevention of adhesions.
The control of bleeding is best accomplished by clamping and ligating,
if necessary, every bleeding vessel. Capillary oozing is checked by pressure
with a gauze tampon.
The toilet of the peritoneum consists in arranging the viscera in their
natural positions and removing foreign material before closing the abdomen.
The great omentum should finally be spread in place. The surgeon should
be sure that bleeding has been arrested. Blood and other fluid should be
removed, especially from pockets such as the prerectal cul-de-sac, and
516
SURGICAL TREATMENT
among the coils of intestines, and in the flanks. If the peritoneum has been
much soiled with material which cannot easily be sponged away, a general
flushing out with warm salt solution is indicated. Blood clots, bits of gauze,
sponges, or instruments should not be left.
The accident of leaving instruments in the abdomen is best prevented
by careful accounting for all materials used. Before the peritoneum is
closed, the nurse should have received back and
counted all sponges and instruments that were em-
ployed in the wound. A deliberate and systemati-
cally carried out operation, rather than a confused
procedure, is free from these accidents. Few in-
struments and no outside distractions characterize
good surgery.
Closure of the abdominal wound should prefer-
ably be by approximation, layer to layer, of the
divided structures, to restore the normal relations.
While suturing the peritoneum, a small flat pad
should be spread out behind the wound to protect
the intestines and prevent them from pressing for-
ward. This is left in place until the closure of the
peritoneum is nearly complete when it is with-
drawn, and a spatula substituted for it. The
suturing of the peritoneum is facilitated by catch-
ing its edges with clamps. These may be lifted
forward by an assistant while the surgeon applies
the suture (Fig. 1189).
For closing the peritoneum the best material
is fairly fine chromicized catgut. If it is desired
to save the time required for tying the first knot,
the thread may be made double, tied together at
the end and when introduced, caught in a loop.
A fairly good-sized curved needle is used — held
in the fingers if the hand is gloved and the wound
not deep, otherwise in a holder. In a thin abdo-
men a straight needle may be used. A continuous
suture is employed. The needle is inserted about
6 mm. (y± inch) from the edge. Both ends of
the suture should be well secured. Care should be
taken that threads of the pad are not caught by the
needle or it will be difficult to remove it. After re-
moval of the pad, care must be taken not to wound
the intestine or include omentum in the suture.
The second tier of sutures is the most important
for securing the strength of the wound. It is the
closing of the post-muscular fascia. It involves the
extraperitoneal connective tissue, transversalis fas-
cia, and posterior aponeurosis of the muscle (rectal sheath in postrectal inci-
sions). It is the suture most concerned with the prevention of hernia. It
is best made with fairly fine chromicized catgut, introduced with a curved
needle, about 5 mm. (%6 inch) from the edge and i cm. (% inch) apart.
An interrupted suture is used, or a continuous one interrupted every second
or third suture. If the apposition is good and infection does not occur, hernia
need not be feared. The fascia rapidly heals and becomes as strong as
ever. When there is danger of hernia or in cases in which it is especially
FIG. 1189. — SEWING THE
PERITONEUM.
The peritoneum is
grasped by two clamps in
such a manner that the
serous surfaces are opposed,
it is lifted forward to make
a fold, and the needle is
rapidly passed through the
two sides of the wound.
THE ABDOMEN
517
desirable to strengthen the abdominal wall, this should be made an overlap-
ping suture. The muscle should not be embraced in this suture.
FIG. 1190. — DIAGRAM OF ABDOMINAL WOUND COMPLETELY SUTURED IN LAYERS.
Peritoneum, transversalis fascia, anterior layer of fascia lata, and skin are each sewed
separately.
The third tier of sutures should embrace the anterior sheath of the muscle
and the superficial fascia with its areolar tissue and fat. If the fat layer is very
thick an extra subcutaneous suture should be used. These are running
sutures of fine chromicized catgut, and are intended to close all open spaces.
FIG. 1191. — CLOSURE OF ABDOMINAL WOUND WITH CONTINUOUS AND INTERRUPTED
SUTURES IN MUSCLE-SPLITTING OPERATION.
Theiperitoneum has been sewed with a continuous suture, which is brought out at the
end of the wound, and deep interrupted sutures of silkworm gut have been introduced
through all' the structures except the peritoneum. The continuous suture is next to be
taken in hand and used to sew the anterior sheath of the muscles. The interrupted sutures
are finally to be tied over the skin. For the sake of better apposition a fine running suture
of silk may be applied to the skin edges.
The fourth tier of sutures closes the skin. A subcuticular suture of par-
affined linen, silk, chromicized catgut, or other material, is used. An ordinary
518
SURGICAL TREATMENT
running stitch, penetrating the skin may be employed. For this purpose,
silk or silkworm-gut are acceptable (Fig. 1190).
The above is the most desirable suture for the smaller wounds of the
abdomen. For larger wounds the best suture is catgut closure of peritoneum
and figure-of-eight silkworm-gut closure of the two fascia layers and skin.
Such a suture may be combined with separate catgut suture of the fascia.
FIG. 1192. — DIAGRAM SHOWING CONTINUOUS AND INTERRUPTED SUTURES IN CLOSURE
OF ABDOMINAL WOUND.
The suture in the peritoneum is continuous and continuous also with that in the anterior
sheath of the muscle. The interrupted suture catches all the structures superficial to the
peritoneum. The skin suture is superficial.
The silkworm-gut suture is essential to protect the wound from the strain of
coughing. When greater haste is demanded, other methods may be em-
ployed. Gaping openings through the muscle may require a separate run-
ning suture if not capable of being closed by the suture of the overlying fas-
cia. It is often wise to introduce a few deep removable sutures to hold the
fascia in connection with the absorbable sutures (Figs. 1191 and 1192). For
this purpose figure-of-eight sutures of silkworm-gut are useful. They may
FIG. 1193. — DIAGRAM OF ABDOMINAL WOUND CLOSED WITH FIGURE-OF-EIGHT SUTURES.
The peritoneum has first been sewed with a continuous suture. The other structures are
closed with the figure-of-eight.
be removed after a few days when the danger of vomiting or other special
strain has passed and the fascia has become united. Some surgeons sew the
peritoneum and transversalis fascia with one running chain-stitch suture, and
the structures superficial to this with interrupted or running sutures pene-
trating the skin. A running suture is desirable for the skin. In situations
where the peritoneum is close to the transversalis fascia the two may be
THE ABDOMEN
519
sutured with the same thread. A few deep interrupted sutures of silkworm-
gut are always desirable to protect the wound from strain.
The figure-of-eight suture may be employed also alone as the permanent
suture. Silkworm-gut is the best material. A needle is placed on each
end of the thread, and the suture passed from behind forward. One loop
embraces the deep fascia; the other embraces the rest of the tissues super-
ficial to ;,it (Fig. 1193). These sutures should be placed about i cm. (% inch)
apart. When there is much haste, the peritoneum also may be embraced
with the transversalis fascia, in the deep loop; and no other suture is required.
When such deep sutures alone are used, the skin may require a separate su-
ture applied between each of the deep sutures.
A triple figure-of-eight suture was devised by E. H. Richardson (Jour.
Am. Med. Assoc., May 7, 1910) (Fig. 1194). To give especial strength the
fascia may be overlapped (Fig. 1195).
FIG. 1194. — TRIPLE FIGURE-OF-EIGHT SU-
TURE USED IN CLOSING THE ABDOMEN.
FIG. 1195. — SUTURE FOR OVER-
LAPPING THE FASCIA.
Removable nonabsorbable sutures may be employed for all of the layers
if 'great temporary firmness is required. For this purpose silver or bronze
wire or silkworm-gut may be used. Each end is brought out through the
skin. By this method a firm and separate suturing of peritoneum, fascia and
skin can be made, and all of the sutures removed when union is secure.
Special operations for entering the abdomen and for closing the abdomi-
nal wall are described under special operations (see also Closure of Wounds,
Vol. I, page 187).
Dressing the wound is a simple matter. The well-apposed skin edges
require but little dressing. Its chief value is to act as a splint. A simple flat
pad of ten layers of gauze is sufficient. This may be fixed by adhesive
straps and an abdominal binder over all. If the wound apposition is not
perfect, if infection is feared, or drainage used, some extra absorbent material
520
SURGICAL TREATMENT
may be added. Otherwise, large dressings are not needed (see Vol. I, page
205).
The abdominal binder should be put on tightly and smoothly. It may
be provided with thigh pieces to prevent its sliding up (Fig. 1196). Its
function is interchangeable with that of the adhesive plaster.
Some surgeons paint the wound with collodion, powder it with antiseptic,
apply a wet dressing, or silver foil. All of these have their place, but as a
routine none is essential.
Snug adhesive strips, 5 cm. (2 inches) broad, are of decided service in
supporting the wound. Two or three of these strips prevent damage from
coughing or other strain (Fig. 1197). H. J. Boldt advocated an especially
strong dressing of broad adhesive plaster, put on so as to embrace the abdo-
FIG. 1196. FIG. 1197.
FIG. 1196. — ABDOMINAL BINDER APPLIED OVER DRESSINGS.
This supplements the adhesive straps in protecting the wound from strain and in retain-
ing the dressings. To prevent upward displacement an adhesive strip may fix the lower
border of the binder to the skin of the trochanteric region.
FIG. 1197. — ADHESIVE PLASTER DRESSING CAPABLE OF GIVING ABSOLUTE AND IMME-
DIATE SUPPORT TO THE ABDOMINAL WOUND.
men for some distance above the scar and to grasp the sides of the abdomen,
the pubes, and crests of the ilia. With this dressing over a transmuscular
incision; well closed, the patient may walk about on the day following the
operation. The dressing is admirable, but the early ambulation of the
patient, except in especial cases, is not to be advised.
Nonabsorbable sutures may be removed on the seventh to the tenth
day. Snug adhesive straps should be applied again. At the end of two weeks
the parts have become strongly agglutinated, and the patient may be allowed
up. The adhesive strips, and binder for support should be continued for
four weeks after the operation.
Methods of Dealing with Adhesions. — The prevention of adhesions has
been referred to in the discussion of protection of the peritoneum (page 515).
THE ABDOMEN 521
Adhesions do not form unless infection or much irritation of the peritoneum
has occurred. It is surprising how little prone the healthy peritoneum is to
produce adhesions. They do not occur for example between the visceral
and parietal peritoneum at the ordinary line of suture. When formed, there is a
natural tendency for them to become absorbed; and later examination of an
abdomen, once with many adhesions, often shows all adhesions gone. Usu-
ally adhesions are salutary, and the surgeon often desires to produce them.
This is done by the use of gauze packing, the irritation of which will cause an
adhesive plastic exudate to be thrown out in a few minutes, and adhesions
of the apposed surfaces in a few hours.
Adhesions may be separated with knife and scissors. Those which can
be separated by blunt dissection are the sort which might be expected to
dissolve and disappear in the course of time. After dividing adhesions with
knife or scissors they will inevitably form again; that is, the raw surfaces left
will either adhere to one another or to some other surface unless some of the
expedients to prevent adhesions are successfully applied. Wherever possible
the wound left by dividing peritoneal adhesions should be sutured. This
may be done with fine catgut.
The prevention of adhesions should be constantly in the surgeon's mind
while operating in the abdomen. While the formation, or absence, of adhe-
sions depends much upon the presence and character of infection, or its
absence, and upon the fibrogenetic or fibrolytic action of the patient's fluids,
still they may be much influenced by the mechanical and chemical irritations
of the peritoneum which the surgeon can control. Chemical irritants, such
as bichlorid of mercury solution or alcohol, coming into contact with perito-
neum, may be expected to cause adhesions. The surgeon who paints the
skin with iodin and then permits the iodin-stained towels or gauze to touch
the intestines invites adhesions. Rough handling, sponging, instrumenta-
tion, infection, exposure to heat and cold, long exposure to the air, and con-
tact with non-endothelial surfaces are all to be avoided if adhesions would be
prevented.
W. B. Brinsmade (Jour. Am. Med. Assoc., vol. Ixv, No. n, Sept. n,
1915) showed by experiment that for holding and packing off coils of intes-
tines, dry gauze sponges provoke more adhesions than moist sponges, and
that smooth rubber dam is the least provocative of adhesions. He accord-
ingly recommended that this latter material be placed against the peritoneum
instead of the gauze pads which surgeons are wont to use. Gauze and pads
may be employed freely so long as the layer of rubber dam intervenes between
them and the peritoneal surfaces. When it is desired to prevent the agglu-
tination of two surfaces which may become adherent, much can be done.
Keeping surfaces protected with pads wrung out in warm salt solution is,
perhaps, not so effective as wringing the pads in warm petrolatum. Rubber
protective is still better than gauze. Any surface which is not covered by
endothelium will become adherent to the peritoneum which falls against it.
Raw surfaces may be covered with peritoneum slid over it and sutured. This
can be done in most parts of the abdomen but is especially facile in the
parietal peritoneum and region of the broad ligaments of the pelvis.
The use of sterilized olive oil to prevent adhesions has satisfied many
surgeons that it has the power to keep the surfaces apart until the endo-
thelium has become healthy. Petrolatum has less value. From 120 to
1 80 c.c. (4 to 6 ounces) of oil are poured into the peritoneal cavity, and the
patient placed in such a position as to encourage its retention between the
irritated surfaces.
Camphorated oil is used for the purpose of preventing adhesions. As
522 SURGICAL TREATMENT
much as 200 or 300 c.c. (7 or 10 ounces) of a i per cent, solution may be left
in the abdomen.
Vogel (Deutsche Zeitschr. fur Chirurg., Bd. 63, S. 296) found that i
part gum arabic in 2 parts of normal salt solution, filtered and sterilized
is of value in preventing adhesions. After the abdomen has been nearly
closed, a tube is passed down to the area to be treated and the fluid injected.
The tube is then removed and the rest of the wound closed.
The method of Cargile, applying thin gold-beater's skin (ox peritoneum),
has not been found effective.
The introduction into the peritoneal cavity of the vitreous material from
the eyes of animals has a decided influence in the prevention of adhesions.
It coats the intestines with a synovial-like unguent which distributes itself
throughout the peritoneum.
S. Pope (Annals of Surg., February, 1916) after experimenting with many
substances, found that 2 per cent, solution of citrate of soda in 2 per cent
chlorid of sodium solution was the most effective agent. All sponges and
gauze are moistened with this solution, and 125 to 500 c.c. (4 to 16 ounces), or
more, are left in the abdomen. The solution should bathe the whole peri-
toneum. The solution remains in the peritoneal sac long unabsorbed.
It takes up the plastic material poured out by the peritoneum. This solu-
tion will not prevent the adhesion of denuded surfaces; probably nothing but
peritoneal grafts will. It is well to add i or 2 per cent, of citrate of soda to
the ordinary operating-room salt solution (for the prevention of adhesions
on wounded surfaces, see Wounds of the Peritoneum, page 542; and Wounds
of Intestine, page 565).
For the treatment of adhesions after they have formed several methods are
at the surgeon's command. They require to be divided when their presence
hampers the actions of an organ, when they prevent access to some other
region, when they attach some structure which is to be removed, or when
they strangulate or distort some viscus. Adhesions which are harmless
should not be disturbed. Bands or strings should be divided because of the
danger of their causing strangulation of the bowel. Blunt dissection may be
carried out if the adhesions are not firm and especially if a line of cleavage
can be found. The soft friable adhesions of recent origin may be separated
by the tip of the finger or a blunt instrument. It is surprising how the
surfaces left by such an operation will in later years be found covered with
apparently normal peritoneum. Older adhesions which are thin and weblike
can not be torn through so easily without tearing off the endothelial surface,
but they may be cut with scissors, and require no ligatures. Adhesions
which have become organized require to have their vessels liga ted. If the
adhesions are but slightly vascular, they may be divided, and any bleeding
vessel ligated. If they are very vascular, multiple mass ligatures may be
applied before division of the adhesions (Fig. 1198).
Adhesions of the amentum, if not readily separated, are easily treated
by ligating the omentum close to the adhesions and cutting it free. As
much as is necessary of the omentum may be removed. Adhesions to the
anterior abdominal wall of viscera which it is not desired to open should be
approached with much care if they involve the area of the abdominal section.
When such adhesions are suspected, each structure of the abdominal wall
should be recognized before it is divided, and after the transversalis fascia
has been entered, the peritoneum should be penetrated with caution. It is
best, if the interperitoneal line of cleavage is not found, to dissect laterally
until the peritoneum is opened and recognized, and then from that standpoint
the adhesions may be dealt with. Inter intestinal adhesions may be separated
THE ABDOMEN
523
by careful dissection. By keeping the same thickness of tissue on each side
perforation of the bowel may be avoided. Mucous membrane may be recog-
nized before it is cut. When such adhesions are associated with ulceration
of the mucous membrane, perforation of the bowel is very apt to be caused;
it is sutured at once, or, if extensive disease demands it, resection of the bowel
is done.
Adhesions to the bowel of a part which is removable, such as benign
tumor or Fallopian tube, should be divided with the operation leaning
away from the bowel. If some part of the structure is left adherent to the
intestine no great harm is done.
In the case of extensive adhesions which interfere with the functions of
viscera, these may often be broken up or divided, the organs placed in normal
FIG. 1198. — OPERATION FOR THE SEPARATION OF PERITONEAL ADHESIONS AND THE
REMOVAL OF ADHERENT OMENTUM.
The handle of a scalpel is passed beneath the adhesions and the scissors applied.
position, and the patient much benefited by the procedure (see Intestinal
Adhesions, pages 520, 557 and 599).
Methods of Dealing with Hemorrhage. — Bleeding is to be dealt with
according to methods already described (Vol I, page 334). It is important
that every bleeding point shall be controlled, because, while in other parts
of the body hemorrhage stops itself when the clot becomes large enough to
create sufficient pressure, the abdomen may easily entertain a fatal amount
of hemorrhage without material increase of the intra-abdominal pressure.
The control of bleeding is imperative (i) to spare the patient the immediate
depressing effects of steadily increasing anemia in the presence of a shocking
524 SURGICAL TREATMENT
operation, and (2) to prevent the occurrence of concealed postoperative
bleeding.
Bleeding should be controlled at once as the operation progresses.
Vessels of some size, which spurt, should be ligated. It is not well to trust
to a clamp and a clot, for after the abdomen has been closed and the patient's
blood-pressure rises, the clot may be forced out and intra-abdominal bleeding
take place. Oozing surfaces may be treated by packing with gauze or a
sponge. It is such packing, which becomes impregnated with clot and takes
on the appearance of living tissue, that is sometimes overlooked and left
behind when the abdomen is closed. .
Fine ligatures carried through the tissues with a needle are useful. The
cautery is rarely necessary. Adrenalin sometimes may be used. When deep
vessels are caught with long clamps in positions where ligation cannot be
done, it may be necessary to leave the clamps in place, surrounded by gauze
and rubber protective, and the wound partially closed around them as for
drainage. After forty-eight hours the forceps may be removed with care,
while the surgeon is ready with the necessary measures if hemorrhage recurs.
Gauze packing upon a bleeding area may likewise be brought out through
the wound just as a drain. It may be removed a day or two later, and re-
placed if necessary. When drainage communicates with a source of bleeding
the danger of hemorrhage is not great; it is no longer concealed.
Postoperative intra-abdominal hemorrhage demands that the abdomen
shall be exposed, preferably by reopening the abdominal wound, and the
bleeding point found and secured. This is a rule which should not be neg-
lected. When such hemorrhage is enough to be revealed by its unmistak-
able signs it is already serious enough to demand radical attention. When
the bleeding has increased the pulse-rate from 100 to 120, then is the time
to attack it, and not wait until it is 150 or 160. If for any reason it is in-
expedient to reopen the abdomen, the palliative measures may be tried.
Blood may be confined in the legs and arms by means of a constricting
bandage, close to the trunk and light enough to constrict the veins but not
the arteries. A tight bandage about all of the abdomen to increase the
intra-abdominal pressure, and some morphin to insure quiet may be of
service.
It seems almost wrong to describe these temporizing measures where in
the presence of hemorrhage the one best thing to do is to close the bleeding
opening. The thing that is doing the patient greatest harm is the loss of
blood, and fifteen minutes of light anesthesia is not so harmful as five minutes
of bleeding. It is surprising how the picture changes as soon as the abdomen
is opened, the bleeding effectually and finally stopped, the clots removed,
the wound closed, and the patient put back in bed; both the patient and
the surgeon take on a better color.
To avoid these unpleasant experiences there is one rule: never dose the
abdomen when there is even the slightest uncontrolled bleeding.
Methods for Securing Drainage. — Drainage of the peritoneal cavity is
often needed. It is called for when there is infection, the products of which
if not given egress will either be retained or spread to other parts. It is
used when it is desired to wall off by adhesions an area of peritoneum, for
the irritating presence of any drainage material causes an exudation of
plastic fibrin not only where it impinges but also for some distance about
its periphery, where peritoneum lies apposed to peritoneum. These latter
surfaces adhere, and when the drainage is withdrawn it leaves a pocket which
is excluded from the general peritoneal cavity. This is the principle of
drainage. It is practically constant.
THE ABDOMEN
525
When an infected area is drained, it is desirable that it should all be
drained. If some part of the area becomes excluded from the drainage
pocket an infection is excluded, and this septic focus may progress away
from the drain and invade other tissues.
The objection to drainage is that it covers an area of peritoneum with
plastic lymph. If this area is the intestine, the inflammatory infiltration
of its wall inhibits peristalsis; and the inhibition of peristalisis by peritonitis
is one of the greatest dangers in abdominal diseases. I discussed this many
years ago (see Peritonitis, page 546), and the danger is being more and
more realized. A small area of drainage is not bad, but to attempt the
drainage of large areas may do greater harm than no drainage at all. The
peritoneum can take care of a large amount of fluid and infection. If the
primary center of infection and reinfection is removed, it is surprising how
well the peritoneum can clean up the situation without drainage.
The introduction of drainage in the peritoneal cavity marked a great
improvement in treatment. The rule was, to drain when in doubt. Now the
FIG. 1199. — ABDOMINAL DRAINAGE.
Rubber tubing surrounded by gauze enveloped in an outer drainage tube.
dispensing with drainage is marking a still greater improvement. The ex-
perienced surgeon is not now using much drainage, provided that the primary
source of infection is removed; and he is developing the rule, not to drain
when in doubt. The inexperienced surgeon should still drain when in doubt.
Where collections of septic material are focalized it is usually best to
evacuate them. Drainage of a septic focus may be lead out through an area
of healthy peritoneum with the assurance that it will become walled off.
When a peritoneal abscess is evacuated the focus should be drained. This
is best done by a good-sized rubber tube surrounded by gauze or wick drain,
and all enclosed in rubber protective. The latter is always desirable as an
outer covering because, while it excites plastic adhesions, the peritoneum
does not become adherent to it. Gauze, on the other hand, while admirable
for all other purposes, has the disadvantage that the plastic fibrin enters
its meshes and causes it to adhere to the peritoneum so that it is withdrawn
with difficulty, and when pulled out often leaves a bleeding peritoneal surface.
In the presence of much pus, however, gauze does not become adherent.
526
SURGICAL TREATMENT
The packing about the tube is desirable, not so much for the sake of its
capillary drainage as for the purpose of enlarging the caliber of the drainage
canal. Through the rubber tube removable wick may be passed, or the
tube may be emptied by aspiration at frequent intervals. Aspiration is
done with a small rubber tube, connected with a syringe, and passed down
inside of the larger tube. Aspiration may be done once daily or a capillary
wicking may be changed once daily (Fig. 1199).
The cigarette drain is useful. Glass drainage tubes are employed in
cases in which soft drains would collapse or become disarranged. The
glass tube may be placed alone. It may contain wick or be aspirated.
FIG. 1200. — GLASS DRAINAGE TUBE IN PLACE IN ABDOMEN.
Showing syringe for aspiration of fluid.
It quickly forms a canal and is easily removed. It is especially useful for
draining a deep focus out through normal intestinal coils, as is sometimes
required in the pelvis or flank (Fig. 1200).
The gauze envelope drain advocated by Mikulicz is often convenient,
especially where some pressure packing for bleeding is also desired. The
parts are retracted and a square of gauze is pressed into the wound, the.edges
of the gauze all remaining outside of the body. Packing is pressed into the
centre of the square gauze. The packing is all inside of the gauze square;
the latter alone comes into contact with the tissues (Fig. 1201). When it is
desired to remove the drain, the gauze is easily withdrawn. The packing
may be renewed or the square may be taken out. The removal of the latter
THE ABDOMEN
527
is facilitated by having a silk thread fixed to its center before it is introduced.
By pulling on the thread the gauze is brought up from the bottom.
In all this work it should be remembered that plastic adhesions are excited
by the drain in a few hours, and after that the only area drained is the drain-
age tract. The exciting of adhesions by such methods is often of advantage
when there is no infection, simply for purposes of sealing a peritoneal
wound or strengthening a weak place.
After two days the adhesions have become so firm that the drainage may
be removed without fear of their giving way. Two mistakes can be obvi-
ated only by experience: (i) removing a drain too soon; and (2) leaving a
drain in too long. As soon as a drain is withdrawn, the intestines close its
path. If it is removed while infection still exists at the bottom of the cavity,
the tissues may destroy the germs or they may multiply and reform a septic
focus. This septic focus may require to be reached and drained again,
or it may rupture into a viscus or be otherwise disposed of. It often happens
FIG. 1201. — ABDOMINAL DRAINAGE.
Mikulicz drain, consisting of a square of gauze with a gauze strip packed within.
in the hands of the inexperienced that a drainage tube is left in while the
discharge which it is draining is that produced by its own invitation. It
there is no constant source of infection at the bottom of a drainage tract,
such as a perforated intestine, gangrenous material, or a foreign body, the
tube usually may be withdrawn i cm. (j^ to ^ inch) every day after the
second day. It is a clinical fact that pus left behind tends to follow the
course of the drainage tract and reach the surface.
The longer a drain is left, the longer it is needed. In most instances, the
drain may be removed entirely at the end of two days. Often it is better
to remove it at the end of twenty-four hours when the peritoneum is less
damaged.
Harm may come from drainage not only by the irritative periton tis
which it produces, but by its causing angulation of the bowel which should
be eventuating in intestinal obstruction.
When drainage is used, the abdominal wound is closed down to the drain
which should usually be at the lower end of the wound. In drained cases
it is most convenient to sew the peritoneum separately, and close the trans-
versalis fascia, muscle and skin with a figure-of-eight silkworm-gut suture.
528 SURGICAL TREATMENT
It is well at the time these sutures are introduced to insert also the sutures
into the tissues of the drain opening. These may be isolated and covered
by the dressings, and when the drain is removed they are ready to be tied.
This leaves less probability of hernia than when the wound is left to granulate.
Drainage should be at the lowest part of a cavity to be most effective. This
is true in ordinary abscesses, in the drainage of hollow viscera, and in the
drainage of the peritoneum. There are two ways of securing such drainage:
either by making the exit at the lowest part of the cavity, or by changing the
position of the cavity so that the opening is at the lowest point. Posture
may be made an important factor in drainage of the abdomen.
So far as the use of drains is concerned, it must be borne in mind that
plastic lymph shuts off the average drain in less than a day, and therefore
if the drain is to accomplish much it must be soon after it is placed in position.
If drains were not used, abscesses would develop deeply among the intestines,
and would be reached with difficulty. With the use of drains, the abscess
develops at or near the drain and pus more easily finds its way to the surface.
An abscess or a collection of infected fluid being present it should be
opened at the lowest place, or if the place at which it can be opened to the
best advantage is not the lowest place it should be made so if possible.
The pelvic pocket is the lowest part of the peritoneal sac. If it is the seat
of infection, it may be drained through the vagina (see Vaginal Drainage,
Vol. Ill) ; or, by raising the pelvis, its drainage may be successfully secured
above the pubes. The peritoneal cisterns on either side of the spine in
the lumbar regions are the lowest points in the abdomen with the patient
in the supine position. By turning the patient on the diseased side these
lateral cisterns may best be drained.
Bode (Centralb. f. Chir., xxvii, 1900, s. 33) and G. R. Fowler (Med.
Rec., Ivii, 1900, page 617) advocated elevating the upper part of the trunk to
facilitate drainage. This position has proved most valuable in many con-
ditions. One of its chief values, however, has not to do with peritoneal
drainage at all, but depends upon the better downward movements of the
gastrointestinal contents which the semi-sitting posture guarantees.
Rectal drainage . has proved most useful in pelvic abscesses, especially
of appendical origin. It may be used in either the male or female. The
bladder should be emptied by catheter. The exaggerated perineal position
with the knees held high is the best position for operation. A posterior
retractor and a long-bladed anterior retractor are inserted. The rectum
should be irrigated until fecal matter is removed. The bulging place on the
anterior wall where the abscess presses should be cleansed with equal parts
of alcohol and water. A knife should incise the rectal wall in the anterior
median line. This incision should be above the bladder. The pus should
be allowed to run out and a soft-rubber tube, having T-wings at the upper
end to prevent its escape, should be introduced into the abscess cavity. The
sphincter should then be dilated, and the operation is done. Of course,
peritonitis should have been treated so that pelvic abscess does not develop,
but not all cases are seen early enough by the surgeon to meet this demand.
Drainage by counter opening is to be recommended. In the flanks and
in the pelvis, the benefit of gravity may be added to the draining forces.
Ordinarily drainage through an anterior abdominal wound, as above described
is against gravity. Having dealt with an infective focus which requires
drainage, say in the region of the cecum, a stab wound is made outward
and slightly backward from the outer side of the mesocolon through
the flank. A pair of forceps are passed in through this wound, to dilate it
and pull out through it a large drainage tube. The drainage tube has passed
THE ABDOMEN 529
through it a rope of wick. The inner end lies at the site of disease; the outer
end emerges through the skin. The anterior abdominal wound may then
be closed entirely without drainage; or if it has been infected temporary
light drainage may be used in it. This method of counter drainage is much
used through the posterior fornix of the vagina for draining the retrouterine
cul-de-sac; and above and in front of the kidneys for higher abdominal
drainage through the abdominal wall.
Nonadhering gauze for abdominal drainage is desirable because ordinary
gauze becomes so fixed to the peritoneum that its removal causes pain and
bleeding; and often such strong traction is required to remove it at the first
dressing that serious drainage may be done. To meet this need, the rubber
and glass tube and the gauze or wick enveloped in rubber or other non-porous
material should be used instead of plain gauze in most cases requiring
drainage. There are situations in which naked gauze is required. To
prevent it becoming penetrated by plastic tissue various expedients may
be used. The finer the mesh the less does it adhere. Gauze which has been
impregnated with equal parts of paraffin and petrolatum adheres less than
plain gauze. A still less adherent gauze is impregnated with a mixture made
by melting together 7 parts of paraffin and 3 parts of petrolatum.
French surgeons use oiled gauze. This is gauze impregnated with a
mixture composed of 2 parts petrolatum, 2 parts castor oil, and i part yellow
wax. Descour advised the addition of a little balsam-of-Peru which gives
it a pleasant odor. This gauze may be used for dressing any kind of a
wound and will be found nonadherent (Archiv. de Med. et de Pharm. Milit.,
No. 4, Apr., 1917).
The best for this purpose is paraffined gauze, impregnated with a
sterilized mixture composed of equal parts of paraffin and stearic acid.
Gauze which has been soaked in this heated mixture, and stretched out to
dry, forms a sieve which is flexible and non-adherent, and may be used most
effectively for peritoneal drainage. This is the method devised by H. E.
Fisher (see Dressing and Drainage Materials, Vol. I, pages 39 and 45).
Postoperative Treatment of Abdominal Cases. — The less treatment the
patient receives after laparotomy the better. The ordinary case with an
uncomplicated operation goes from the operating table in good condition.
There is a slight degree of depression, scarcely worth being called shock,
which requires only that the surface of the body shall not become cold.
The patient should be taken to a quiet, not too light room, and laid supine
until the anesthetic depression has subsided. Then the head may be elevated.
There will be some abdominal pain, some thirst, some nausea, and some
insomnia the first night. These usually are of so little consequence as to
require no treatment.
As soon as the nausea has subsided, which should be by the day after
the operation, the patient may be given fluids by mouth and the elevated head
position should be instituted. Fluids mean water, albumin water, broth,
glucose solution, whey, orange juice, grape juice, lemonade, or dried proteid
powders in water. The head may be elevated so that the trunk inclines at
an angle 45 degrees above the horizontal. By the second day milk may be
taken if all nausea has subsided. After this the diet may be slowly increased
(see Nourishment and Care of the Patient, Vol. I, pages 19 to 27).
The elevated-head position may be maintained as much as the patient de-
sires through the day. For sleep be should prefer to lie supine with a pillow
for the head. For maintaining the elevated-head position the head of the
bed may be raised or an inclined plane placed behind the back. To prevent
the patient from sliding down in bed a second inclined plane may be con-
VOL 11—34
530
SURGICAL TREATMENT
nected with the first. The second plane should accommodate itself to the
thighs and legs the apex being at the knees (Figs. 1202 and 1203). An exag-
gerated position is not called for. The elevation should be about 45 degrees
above the horizontal. It need not be more than this. Raising the head of
FIG. 1202. — ELEVATED-HEAD POSITION AFTER ABDOMINAL OPERATION.
This position may be secured by means of a special bed frame or by means of props and
pillows.
the bed 45 or 50 cm. (18 or 20 inches) on two chairs suffices. A pair of pillows
below the buttocks may be fixed with a bandage to prevent the patient sliding
downward.
The patient may be allowed out of bed in a chair on the eighth or tenth
day; at the end of two weeks he may be allowed to help himself out of bed;
FIG. 1203. — SHOWING RECUMBENT POSITION SECURED BY THE SAME BED THAT is USED
FOR THE ELEVATED-HEAD POSITION.
and in twenty-one days he may be permitted to go about his business. In
the case of wounds which have been drained, the patient should not be al-
lowed to walk until the wound is entirely healed.
THE ABDOMEN 531
Special treatments are advocated by many surgeons. In some hospitals
certain routine measures are followed in all cases. This is necessary only in
such institutions as cannot guarantee intelligent supervision over post-
operative cases. In the presence of discriminating supervision, each case
should receive the treatment indicated for that particular case.
The placing of a rectal tube after the patient has been put to bed gives
comfort in many cases. It may be left in for two days. If it causes dis-
comfort, some olive oil injected through it will sooth the bowel. The tube
permits the escape of gas without muscular effort. It does no harm and may
be of great benefit.
J. A. Sampson conceived the idea of increasing abdominal pressure by
means of sand- bags placed on the abdomen. Sand-bags measuring 15 by 30
cm. and weighing 2 to 3 kilos (5 pounds) are used. These sand-bags are
made flat and sewed through to keep their shape. Two bags are placed on
the abdomen, one on either side of the median line, and held by the binder.
The weight of the bags increases the intra-abdominal pressure. This pre-
vents overfilling of the abdominal blood-vessels, distention of the intestine
is counteracted, gas is caused to move onward toward the anus, and the
patient has a sense of comfort and security. After the removal of large
tumors or large amounts of fluid, this treatment is especially indicated.
The use of morphin after abdominal operations requires discrimination.
If a patient is not going to have pain or shock it is not necessary. Some
surgeons give it as a routine in doses of 0.005 Gm. (^2 gram) every three
hours while the patient is awake during the first two days. As a rule the
patient is better off without it; but as a rule morphin will do less harm than
pain, restlessness, and sleeplessness.
It is not necessary that most patients should have a bowel movement on
the second or third day, after the operation. Usually if left alone the bowels
will move by the fourth day. If the patient is doing well, there is no harm
if the bowels do not move till the fifth or sixth day. A dose of paraffin oil
may be given if necessary. A particularly effective cathartic at this juncture
is a dose of 45 c.c. (i^ ounces) of castor oil and 4 c.c. (i dram) of compound
tincture of cardamom.
The postoperative administration of oxygen, begun immediately, has-
tens recovery from ether and diminishes the liability to vomiting. The
inhalation of the fumes from vinegar relieves the ether nausea.
Postoperative complications, requiring treatment, arise in many cases.
They may be mild or so severe as to threaten life. None of the measures,
described below are needed in the ordinary uncomplicated case.
Vomiting and nausea have already been discussed from the standpoint
of the anesthetic (Vol. I, page 104). It is possible to employ anesthesia
that will not cause vomiting. Taking fluids too early into the stomach should
be guarded against. Vomiting is easily excited after ether anesthesia.
Commonly it is due to the reflex or direct mechanical disturbances incident
to the operation. Vomiting is least apt to occur if the bowel has been well
emptied before operation, and if the minimum of damage has been done to it
during the operation. If the vomiting is anticipated in a patient who has
had ether, it may be prevented by passing the stomach tube before the
patient regains consciousness, and washing out the stomach. This may be
repeated if nausea develops.
Nausea due to abnormal peristalsis may be serious. By placing the
patient in the elevated-head position downward drainage may be established.
An evacuation of the bowels, secured by enema, will often stop the nausea.
When vomiting of the contents of the small intestine is troublesome, lavage
532 SURGICAL TREATMENT
of the stomach is essential. This should be repeated as many times daily
as necessary.
The surgeon should assure himself that there is no intra-abdominal con-
dition which should be relieved. Gauze or other drainage material may cause
irritation to the bowel and reflex vomiting; or it may be responsible for actual
mechanical obstruction. A collection of pus may have been overlooked.
Very commonly persistent vomiting is due to a spreading peritonitis, and will
not subside except by direct treatment of that condition. Vomiting which
is intractable is usually due to peritonitis or intestinal obstruction, and the
surgeon should address his attentions to these conditions rather than to the
stomach (q.v).
It is rarely worth while attempting internal medication for nausea.
Counterirritation of the skin of the epigastrium by mustard is of help in some
nervous cases. Fresh cool air admitted to the lungs, or the inhalation of
oxygen, sometimes give relief. Gastric lavage should always be regarded as
the main reliance of treatment.
Meteorism, or gaseous inflation of localized segments of bowel, should be
prevented by the precautions already described to minimize the damage to
the peritoneum and bowel. Hot water by mouth in 4-c.c. (i-dram) doses,
as hot as the patient can bear it, will bring up gas. By elevating the upper
part of the trunk, placing the patient in the semi-upright position the expul-
sion of gas is facilitated. The relaxed abdominal muscles may be caused
to contract and press out the gas by applying heat. This may be in the form
of hot stupes, or dry heat. The latter may be applied by means of the hot-
air box.
A distended large intestine requires relief by an enema and the restoration
of peristalsis. If the ordinary enema of soap and water does not accomplish
it, a more stimulating one should be used. Turpentine, 4 c.c. (i dram) to
500 c.c. (i pint) of water, may be added. Powdered alum in the same
amount may be used. A combination much employed is made of magnesium
sulphate, 30 Gm. (i ounce); glycerin, 30 c.c. (i ounce); turpentine, 4 c.c.
(i dram); and water, enough to make 120 c.c. (4 ounces). J. C. Munro
recommended a mixture of 500 c.c. (i pint) of milk, 500 c.c. (i pint) of molas-
ses, and 15 c.c. (% ounce) of turpentine. A tube may be passed occasionally
to assist the expulsion of gas.
For meteorism, the alum enema is most effective (see Laxative Enemata,
page 620). The important thing is that gas shall be expelled. When the
measures for the treatment of meteorism and vomiting fail to give relief in
twelve hours, the surgeon should realize the strong probability of spreading
peritonitis or obstruction being the cause of the trouble (see Peritonitis,
page 546).
Eserin salicylate in doses of o.ooi to 0.0015 Gm. (%Q to ^Q gram) is
useful in some cases. It acts only on the small intestine and an enema should
be given four hours later to empty the large bowel. Hormonal in doses of
15 to 20 c.c. (4 to 5 drams) is perhaps still more effective, as it acts on the
whole intestine. Neither of these should be given in \vell-developed perito-
nitis or obstruction.
Acute dilatation of the stomach may be prevented, diagnosed and cured
by the stomach tube.
Pain following operation usually subsides with the meteorism. During
the first night it may be so severe as to justify an injection of morphin. The
drug is best not to be repeated.
Shock in a slight degree needs only the ordinary postoperative care of
the patient. Its degree cannot always be predicted, and it is a wise rule
THE ABDOMEN 533
to be prepared for it in all cases. Its treatment in abdominal cases is not
much different from that in other cases (Shock, Vol. I, page 213). Procto-
clysis, the slow instillation of warm salt solution into the rectum (Vol. Ill),
is of especial service in shock of abdominal origin. Many surgeons insti-
tute it at once in cases in which shock is feared.
Some surgeons combat shock by filling the peritoneal cavity with warm
saline solution. This is best done by placing a soft catheter behind the
omentum, or through it if preferred, so that its tip lies above the transverse
mesocolon. The peritoneum and transversalis fascia are snugly closed about
the catheter. Saline solution at a temperature of 45°C. (112° to ii4°F.), is
then allowed to run in from a height of about i meter. Five hundred or 1000
c.c. (i or 2 pints) will fill the abdomen. The tube is then withdrawn and
the closure of the wound completed. This treatment gives heat and pressure
to the region of the hypogastric and solar plexuses, and vasoconstriction
results.
A routine practice of some surgeons is a method advocated by Clark for
filling the large bowel with saline solution. At the conclusion of the opera-
tion while the abdomen is being closed, the patient is placed in the lowered-
head position, i to 2 liters (i or 2 quarts) of warm saline solution are allowed
to run into the rectum. This fluid passes through the whole large intestine.
Clark employs this method after the treatment of peritoneal adhesions,
before closing the abdomen, and is able to see the fluid pass as far as the
cecum and sometimes into the ileum, and the colon drop back into its normal
position by the weight of the water. If the patient is carefully handled, and
the pelvis kept slightly elevated, the fluid is retained and absorbed.
Heat applied to the abdominal wall has the effect to increase salutary
hyperemia and peristalsis. A. Strempel (Deutsch. Zeitschrif t fiir Chir., July,
1910, cv, Nos. 5 and 6) advocated heat by means of the hot-air box or the
incandescent electric-light box — 500 candlepower. It is claimed that it coun-
teracts the tendency to shock, promotes peristalsis, diminishes adhesions,
and inhibits peritonitis. A dry air temperature of i3o°C. (265°?.) may be
used for fifteen or twenty minutes twice daily. A temperature of not more
than 55°C. (i3i°F.) may be used for one or two hours at a time, with inter-
vals of three hours, day and night. Other surgeons use it only once or twice
a day. Without any other postoperative treatment it is found that flatus is
usually passed during the first twenty-four hours.
Thirst, after laparotomy, is sometimes distressing. If the patient is
not nauseated he may drink freely of water that is not cold. If the patient
is still nauseated, thirst cannot be slacked with drink. Ice may be taken
into the mouth, or the mouth rinsed with a cooling taste of lemon juice. The
treatment of thirst consists in supplying fluids to the tissues; and this is done
by proctoclysis, hypodermoclysis, infusion, or the other means described for
restoring body fluids. It is not wise to give a vomiting patient fluids which
do not quench the thirst and which do aggravate the vomiting. It should
be remembered that water is not absorbed by the mouth, stomach, or even
the upper part of the intestine, but by the small bowel and colon.
Retention of urine should not be confused with scantiness of urine. The
treatment of suppression is described elsewhere. After a laparotomy the
secretion of urine is diminished. If the patient is kept dry about 360 c.c.
(12 ounces) are passed the first twenty-four hours. This should be increased
by the use of water by mouth and proctoclysis to at least 500 c.c. (i pint).
If urine is not voided in the first eighteen hours, some artificial encourage-
ment should be given, such as a warm enema or hot applications to the
pudendal and pubic regions. If these fail, and the patient feels^that urine
534 SURGICAL TREATMENT
could be passed in the sitting or standing position, it may be tried. With
a firm adhesive strapping to support the wound the patient can do it no harm
by standing up to urinate.
The passage of small quantities frequently, means injury to the bladder,
or it indicates the overflow from a full bladder which should be catheterized.
Catheterization otherwise should be reserved as a last resort. A record of the
amount of urine voided should be kept. The catheter should be passed
carefully. For lubricating the catheter a safe mixture is 25 per cent, argyrol
in glycerin.
Other complications which may arise require their own treatment. Post-
operative hemorrhage, peritonitis, ileus, acute dilatation of the stomach and
phlebitis, are discussed in their respective places. Postoperative hiccough
is to be combated by removal of the cause (usually peritoneal irritation)
and by sedative measures.
Postoperative pneumonia should be treated by giving the patient fresh
air. The shoulders should be slightly elevated, concentrated nourishment
should be given, the surface of the body should be protected from chilling,
and nothing should be permitted that depresses the heart. It is possible
that some day these cases may be saved from a fatal termination by insuffla-
tion of the lungs with fresh air. Pneumonia is to be prevented by sparing
the patient from exposure to cold before, during, and after the operation;
by careful anesthetization; by cleanliness of the mouth; by having the patient
breath deeply as an exercise two or three times a day after the operation;
and in the case of old people, by avoidance of the recumbent position.
Remarks. — -In general, most abdominal cases require no special treatment.
It is best that the patient should not be pestered with attentions. A small
dose of morphin the day of the operation and, if at all indicated, the night
following the operation should make the patient comfortable. The character
of the operation and the amount of traumatism that has been inflicted are
the chief determining factors. Fluid by rectum is useful after all serious
and depressing operations. The patient should be allowed to change his
position as he will. The most comfortable position is the most restful.
The lime for getting up after abdominal section must depend upon many
conditions. A clean undrained abdominal wound is well united in ten days.
The sutures may be removed on from the eighth to the tenth day. Broad
adhesive straps should support the wound and hold on the dressing. With
such adhesive straps a comfortable patient may be allowed up in a chair any
time from the seventh to the tenth day. No harm need be done by sitting
up even earlier. Weak patients should remain in bed longer.
An average healthy patient may be permitted to walk two days after he
begins to sit up. The adhesive straps which support the abdominal wound
and prevent strain upon the union should be worn for a month. Care
should be taken that the patient abstains from straining for two or three
months.
Postoperative feeding must vary for each patient and the nature of the
operation. In operations not involving opening the alimentary canal,
water in small doses may be taken after twelve hours. On the day following
operation fluid nourishment which is least prone to fermentation and putre-
faction may be given. Whey, broth, strained soups, orange juice, peach
juice, malted milk, albumin water, and glucose may be given in small doses.
At the end of forty-eight hours, if no signs of peritonitis are present, milk
may be added. A small glass of milk (120 c.c.) may be given every four
hours during the third day after the operation, and this amount may be
doubled on the next day. Milk may alternate with the other fluids. Solid
THE ABDOMEN 535
food, such as cereals, dry bread and soft egg may be allowed on the fourth
day, and if no complications develop, full diet may be permitted on the fifth
day. All food should be in moderate amounts. It should be well chewed.
And the patient should preferably eat what tastes good (see Nourishment,
Vol. I, page 19),
For emergency feeding, when the conditions are not normal, when the
patient cannot be given the above diet, and nourishment is necessary, other
expedients must be employed. These are intravenous, subcutaneous, and
rectal nourishment (for Nutrient Enemata, see page 620; for Nutrient Injec-
tions, see Vol. I, page 20).
Contusions and Concussion of the Abdomen. — Any injury which the
abdominal wall may suffer is of little consequence compared with the damage
which may be sustained by the contents of the abdomen. Two conditions
call for treatment: (i) the shock of concussion of the sympathetic plexuses;
and (2) visceral injuries.
Sympathetic shock demands the same treatment as described for shock in
general (see Vol. I, page 213).
Visceral injuries demand diagnosis first. The surgeon should bear in
mind that a slight contusion, confined to a small area, is capable of causing
laceration or rupture of viscera, and that this is especially the case with dis-
tended hollow viscera and with organs fixed by adhesions. The signs which
guide the surgeon are those of peritoneal irritation and hemorrhage. During
the first hours these are confusing, as hemorrhage may produce irritation of
the peritoneum sufficient to give rigidity, while infection in its early stages
gives none. Or the shock of peritoneal invasion by infective matter, before
peritonitis has developed, may lower blood-pressure and simulate hemorrhage.
The question to decide is, is there either peritoneal irritation or hemor-
rhage? If either of these, sufficient to give their classic signs, is present, the
abdomen should be opened and the lesion sought. The rule should be added
to this; when in doubt explore. Most surgeons are too sure when they ex-
plore. It is not wholly to my credit that, in all the doubtful cases of this
sort upon which I have operated, I have found a lesion which demanded
surgical treatment to save the patient's life. The surgeon who occasionally
opens an injured abdomen and finds no injury is much to be respected.
THE ABDOMINAL WALL
Wounds of the Abdominal Wall. — Rupture of abdominal muscles from
muscular strain or contusion rarely require operation. With rest, the rent
heals. If there is an opening through the skin, communicating with the torn
muscle, the muscle may be sutured.
Non-penetrating wounds require the same treatment as wounds in other
regions. The probe should not be used, except in the hands of an experienced
surgeon and then with some very definite object in view.
Penetrating wounds (through the parietal peritoneum) not involving
the viscera, require similar treatment to that of non-penetrating wounds,
excepting that provision for drainage of the peritoneum should be made.
In the case of small wounds, if the opening is large enough, a small drainage
tube may be carried down to the presumably infected peritoneum. Larger
wounds, which require to be sutured, should be cleansed and closed excepting
the most dependent part, through which drainage should be conducted to the
peritoneum. Bullet wounds which penetrate the parietal peritoneum are
not large enough to permit inspection to determine whether viscera are
wounded or not. The probability of serious visceral injury is so great that,
536 SURGICAL TREATMENT
if the surgeon is so situated that an aseptic operation can be done imme-
diately, the abdomen should be opened. The operation is done preferably
in the median line, employing one of the incisions already described for open-
ing the abdomen. If the wound is external to the anterior axillary line, the
incision may be made laterally. In these injuries, the surgeon cannot
know before such an exploration what damage has been done. If the bullet
is found external to the peritoneum the operation stops there. If penetration
is discovered, but no visceral injury, it is worth while making a search in the
free peritoneum for the bullet. Too much time and manipulation should
not be used in this search. If the bullet is found to have passed out again
through a second wound in the parietal peritoneum, it may be left undis-
turbed unless it is in easy reach. If it is doing damage in its extraperitoneal
position, it is best that it should be attacked through some other route rather
than across the peritoneal cavity. When asepsis cannot be controlled, as in
operations outside of the hospital, in the field, woods, or at sea, the patient
has a better chance of recovery if treated by an occlusive antiseptic dressing,
abstinence from food for a few days, and rest in the recumbent position.
The treatment of penetrating wounds in which perforation of hollow
viscera is possible but not positively diagnosed must depend upon the sur-
gical facilities available. If the surgeon has experience and facilities for
performing abdominal operations exploration is advisable. If such surgical
help is not at hand the patient should be given morphin or opium and kept
as quiet as possible. Shock should be met by keeping the patient com-
fortably warm and by giving water by hypodermoclysis or proctoclysis. If
the patient cannot be operated upon or must be transported before
operation can be done, morphin should be supplemented by gentle abdominal
compression with a snug binder.
The treatment of bullet wounds of the abdomen by compression is advisable
when facilities for a proper opening of the abdomen are not at hand. This is
especially when the patient has to be transported for some distance. If seen,
immediately under these circumstances, a dressing should be applied, and
a snug bandage or binder should be placed about the abdomen. This has
the effect of immobilizing the abdominal muscles and viscera. The escape
and spreading of intestinal contents is lessened; and the localization of the
peritonitis is encouraged. It is in every sense a splinting process. Without
such abdominal compression, a patient who has to be transported with a
perforating wound of the abdomen is subjected to the hazard of having the
infection disseminated by the movements of the abdominal contents. This
method of artificial compression helps nature do what it is attempting to do
by muscular rigidity, pain and distention. Compression is of value only as
an early expedient. It is not of value after distention has occurred.
Wounds of the Diaphragm. — These wounds are so commonly associated
with wounds of the lung, liver, stomach or other important structures, that
their treatment is usually a matter of secondary consideration. A small
wound, such as that made by a bullet, so far as the diaphragm is concerned,
is of little consequence. Wounds of sufficient size to permit the formation
of hernia should be sutured. This is best done from the upper side, either
by some of the operations already described (page 467) for exposure of the
diaphragm, or by additional resection of the costal margin as described for
facilitating approach to the liver. Suturing is best done with chromicized
catgut.
Infections of the Abdominal Wall. — Such infections are not peculiar, and
should be treated the same as infections elsewhere. The peritoneum need
not be feared, as their natural tendency is to progress toward the skin.
THE ABDOMEN 537
The most common infections are those associated with wounds of the abdo-
men. Infection in operation wounds should be treated by taking out the
sutures for a sufficient distance to permit of opening the wound down to the
infected focus. By doing this promptly, extension of the infection to the
rest of the wound may be checked. An infection under the superficial
fascia or in some other plane of fascia, extending the whole length of the
wound, does not always require opening the wound for its full length. An
opening at the upper and lower ends of the wound, through-and-through irri-
gation and drainage, may suffice to cure it. Unless free drainage is secured,
there is always danger that one by one the union of the sutured planes may
give way, and the wound gap open. This yielding of a wound may all occur
without the skin separating, excepting at one point. One or more of the
planes of fascia alone may separate. These infections are a common cause
of ventral hernia. The best way to prevent hernia in these wounds is to
prevent infection, and when it occurs check its progress by promptly opening
the wound and applying asepsis. Stitch hole abscesses should be treated
by removal of the offending stitch and if necessary enlarging the needle
hole to secure more adequate drainage and asepsis.
Infections secondary to disease of abdominal viscera, such as the intes-
tine, require drainage. Incision for this purpose often leaves a fistula
communicating with a viscus, the treatment of which is described elsewhere
(see Fistulas and Sinuses, Vol. I, page 304; and fistula of various abdominal
viscera) .
Diseases of the Umbilicus. — Infections of the umbilicus are not un-
common. They should be prevented by cleanliness. The treatment con-
sists in opening as widely as possible the skin folds and washing out the
pocket with antiseptic fluid. An alcoholic solution of bichlorid of mercury
(i : 3000) is effective. The fluid should be dried out and the pocket filled with
mild antiseptic powder, such as calomel, stearate of zinc and boric acid or
formidin. Persistent, recurrent and intractable infections of the umbilicus
are best treated by alcohol followed by tincture of iodin, by pure phenol
followed by alcohol or by silver nitrate solution. A powder should be used
after these. If this treatment fails, excision of the umbilicus may be done.
The surgeon should bear in mind that a discharging navel may mean that
there is an internal source of infection, and that the navel is the outlet of a
fistula. In operating, preparations should have been made to meet such a
condition. Granulation tissue protruding from the navel should be cut
away and cauterized.
Fistulas and cysts of the umbilicus may be superficial, extend far into the
urachus or round ligament of the liver, or communicate with intestine or
other hollow viscera. Small superficial pouches, lined with mucous mem-
brane, may be defined by the probe and attacked from the outside. The
lining may be dissected out or destroyed with the sharp curet and iodin
packing. Deeper disease must be attacked from the peritoneal side. Pre-
liminary to such an operation the umbilicus should have been well cleansed
and sterilized with iodin. An incision is then made, preferably at the left
side. When the peritoneum is reached it may be possible to remove the fistu-
lous tract or cyst without invading the peritoneal cavity. Usually the perito-
neum will require to be opened. The diseased area is then excised from behind
forward without opening it; and the wound closed layer by layer. In
making this excision, the transversalis fascia should be spared as much as
possible in order to have adequate tissue for an effective closure.
Tumors of the umbilicus should be treated as elsewhere. Papilloma,
sarcoma, dermoid and carcinoma should be excised.
538 SURGICAL TREATMENT
Diseases of the Urachus. — Fistulas and cysts may be connected with the
umbilicus or bladder. They should be treated the same as those described
above connected with the round ligament of the liver or other umbilical
structures. The treatment consists in eradication of the lining mucous
membrane or in dissecting out the fistula or cyst. This operation will often
lead to the bladder wall. It is not well to leave a pocket communicating
with the bladder, but the dissection should be completed down to the bladder
mucous membrane. Before operating on such conditions urinary obstruc-
tion, such as enlarged prostate, urethral stricture, or stone, should be cured.
Tumors of the Abdominal Wall. — Nevus, fibroma molluscum, carcinoma
and sarcoma should be treated as elsewhere. Lipoma may arise from the fat
just outside of the peritoneum, and by growing into the abdomen demand
relief for intra-abdominal tumor or by growing outward simulate or cause
hernia. Such tumors should be removed early. Lipoma, developing in the
other fatty layers of the abdomen, should be excised because of its tendency
to enlarge indefinitely; and lipoma of the epigastrium, even though small,
when close to the peritoneum, should be removed because of the possibility
of its producing reflex gastric disturbances. Fibroma, which commonly
appears connected with the posterior sheath of the rectus muscle, is best
removed; if not excised it may continue to grow and reach a large size,
although it usually does not become larger than a hen's egg. Fibrosarcoma
commonly grows from the posterior layers of fascia but tends to push toward
the skin. It should be removed early and completely even though a plastic
operation for closure of the opening is required. The fact that sarcoma
grows in the abdominal wall is one of the most pressing reasons for subjecting
to excision the presumably benign tumors. Echinococcus cysts and actino-
mycosis require excision as elsewhere.
Excessive Abdominal Fat. — The treatment of this condition should first
have been hygienic living, which would have prevented the disease. The
next best thing is dietary and hgyienic treatment. Unfortunately many
aggravated cases have not the moral stamina for the latter. Supports by
belts and bands, to carry a pendulous abdomen, are employed. The surgical
treatment consists in excision of the excessive fat. This may be carried out
in one operation or several. The first operation should remove a transverse
ellipse from the lower part of the mass. This may extend all the way across
the front of the belly. By lifting up in the hands a mass of fat the surgeon
may estimate with the eye how much may be removed without making
tension on the sutures closing the wound. A lower transverse, slightly
curved incision should be made with its convexity just above the pubes.
By drawing down the tissues above, it may be estimated where the upper
incision is to be made. The excision should be carried down to the fascia
covering the muscles (Fig. 1204). The opening in the skin should be some-
what larger than the floor of the wound to give good approximation. Bleed-
ing should be checked by fine ligatures. The wound should be closed by
running sutures of catgut in one or more tiers. The skin may fee closed with
a stronger suture. A drain should be left in the two corners of the wound.
The same operation may be done laterally on each side, the ellipse run-
ning vertically or again transversely. Such an excision may be carried also
down upon the thighs. In making a median abdominal section in the
obese, a vertical ellipse of fat may be removed in the middle line as a part of
the operation.
Although these wounds seem poorly supplied with blood, they heal
well, and without postoperative discomfort.
THE ABDOMEN
539
FIG. 1204. — EXCISION OF ABDOMINAL FAT IN ADIPOSE AND PENDULOUS ABDOMEN.
A wedge of fat, as indicated by the lines of incision, is removed down to the deep fascia
covering the abdominal muscles. The transverse wound is closed by a deep and a super-
ficial layer of sutures.
FIG. 1205. — OVERLAPPING OF FASCIA IN TREATMENT OF RELAXED ABDOMEN.
540
SURGICAL TREATMENT
Relaxed and Pendulous Abdomen. — This condition is often associated
with excessive fat in the abdominal wall and the operative relief of the two
conditions may be combined in one operation. In other cases there is no
excess of fat, or, indeed, the abdomen may be quite lean. When hygienic
treatment, exercises, electricity and massage have failed, operation should
be done.
A median incision is made from a point midway between ensiform and
navel down to the pubes. In mild cases, the peritoneum need not be opened.
The aponeurosis should be split, overlapped, and sutured, thus drawing the
two recti closer together.
FIG. 1206. — TRANSVERSE AND VERTICAL OVERLAPPING OF FASCIA AND MUSCLE IN THE
TREATMENT OF RELAXED ABDOMEN.
The two flaps DD' and CC' are overlapped, thus diminishing the transverse dimension.
The vertical dimension is reduced by drawing downward the upper lip of the upper trans-
verse incision and upward the lower lip of the lower transverse incision.
In more pronounced cases, the anterior sheaths of the recti muscles should
be^incised at their inner borders and separated from the front of the muscles.
The anterior sheaths of the muscles should be carried across the median line,
and one sewed behind the other. This overlapping shortens the transverse
dimension of the abdominal wall, and brings the two recti together (Fig.
1205).
In the more aggravated cases, the median incision should open the ab-
domen. The superficial fascia should have been dissected free from the deep
fascia. A transverse incision, about 10 cm. (4 inches) long, or longer, should
be made at either end of the median incision (Fig. 1206). This forms two
abdominal flaps, composed of everything but skin and superficial fascia.
THE ABDOMEN
541
These two flaps are overlapped, one in front of the other and held by two
vertical rows of sutures. The sutures may come out through the semilunar
lines. To take up the vertical slack, the transverse wounds are overlapped
in the same way. Mattress sutures combined with continuous sutures of
chromicized catgut are used.
Relaxation of the abdominal wall, which is commonly seen in the lower
abdomen, and is due to a stretching of the fascia of the external oblique
muscle, may be cured by the operation devised by R. C. Coffey (Keen's
Surg., Vol. VI, page 441). The fascia of the external oblique is split in the
direction of its fibers on either side, the two incisions converging toward the
pubes. The fascia is separated from the internal oblique, and the outer lip
of the wound is drawn under the muscle and sutured. The inner lip is drawn
outward and sutured, overlapping the muscle as a flap. Chromicized catgut
sutures are used (Fig. 1207).
FIG. 1207. — DOUBLE FLAP OPERATION FOR THE CURE OF RELAXATION OF THE ABDOMINAL
WALL.
Before performing these operations the patient's intestinal condition
should have been improved by treatment to minimize the amount of gas.
THE PERITONEUM
The peritoneum is a membrane, covered with endothelium on its free surface, which
lines the inside of the abdominal cavity and covers the intestines and other abdominal
viscera. The total area of the peritoneum is nearly as great as that of the skin. It secretes
a lubricating fluid which permits the surfaces to glide over one another. Disease is capable
of much altering the amount and character of this fluid. The peritoneum has the power to
absorb fluid in large amounts, intoxicating the system with septic fluid or simply removing
benign fluid. Absorption takes place chiefly in the upper part of the abdomen, through
the peritoneum of the diaphragm and omentum especially. For this reason, when ab-
sorption is desired, the lowered-head position is indicated; when the absorption of septic
material is to be prevented, the elevated-head position is indicated.
The sensory nerve supply of the peritoneum varies in different parts. The parietal
peritoneum is very sensitive. The peritoneum of the stomach, intestines, mesentery,
gall-bladder, anterior surface of the liver, the uterus, broad ligaments, tubes, ovaries,
542 SURGICAL TREATMENT
urinary bladder and omentum is practically insensitive to operative attack, although
distension of the peritoneum of any of these organs by a distending force operating within
the lumen causes the pain known as colic.
Injuries of the Peritoneum. — Traumatism of the peritoneum is capable of
producing a local inflammatory reaction which requires for its treatment,
only rest the same as in other endothelial-lined sacs. The traumatism of
operation may be sufficient to cause an exudate to be thrown out and ad-
hesions to form. This may be taken advantage of when it is desired to cause
adhesions. By leaving any foreign body in contact with the peritoneum for
a few hours adhesions will be thrown out around it, and the adjacent peri-
toneal surfaces will become agglutinated. A sufficient degree of irritation
may be produced at once, by vigorously rubbing the peritoneum with a
sponge or scraping it with a knife, to cause adhesion to the surface which falls
against it. If both surfaces are thus irritated the result is still more
assured.
This peculiarity is made use of (i) for the purpose of walling off certain
parts of the peritoneum, (2) for the purpose of causing the mechanical fixa-
FIG. 1208. — DENUDED SURFACE OF INTESTINE TO BE COVERED.
A flap of peritoneum is marked out on the mesentery.
tion of organs, and (3) for the purpose of securing circulatory communica-
tion between two organs or surfaces. Infections are confined and prevented
from spreading by this process. In the treatment of prolapses and displace-
ments, and in the suturing of one surface to another, this principle is used.
Anastomoses and short-circuiting of the circulation may be secured in this
manner, as in cases in which there is portal or hepatic obstruction, the liver
and omentum are caused to become adherent to the abdominal wall, ves-
sels develop in the adhesions, enlarge and carry the blood of the abdomi-
nal organs directly back to the systemic circulation around the hepatic
obstruction.
All suturing of peritoneal surfaces, so important in stomach and intestinal
operations, depends upon the irritation caused by the incisions through the
peritoneum and upon the irritation of the sutures, to cover the wound and
the sutures with plastic fibrin within a few hours, or even minutes, after
the close of the operation. Aseptic foreign bodies left in the peritoneum thus
become encapsulated (see Adhesions, page 520).
Denuded surfaces of peritoneum, such as occur, on the intestine sometimes
in connection with operations for hernia, may be covered by sliding a leaf of
THE ABDOMEN
543
the peritoneum of the mesentery over the denuded surface as a plastic flap
and fixing it with sutures (Figs. 1208, 1209 and 1210). This operation should
be done with especial attention to the blood-supply of the flap. Such
a plastic operation as this is often well worth while in preventing adhesions
which will inevitably follow if the operation is not done.
FIG. 1209. — MESENTERIC FLAP is TURNED UP AND SEWED INTO DENUDED AREA
A second incision is made to secure a secondary plastic peritoneal flap.
Richardson (Bull. Johns Hopkins Hosp., xxii, 283) made an incision
through the peritoneum close to the bowel, dissected up the peritoneum and
sewed it over the raw surface (Figs. 1211 and 1212). These operations should
not injure the blood supply in the mesentery. They are particularly ap-
FIG. 1210. — COMPLETED PERITONEAL PLASTIC FOR COVERING DENUDED SURFACE
ON INTESTINE.
Showing possibilities of plastic flaps of peritoneum.
plicable to the small intestine and to the mesentery which contains a fair
amount of fat.
Another material which may be used for this purpose is omentum;
but this leaves the bowel adherent to the omentum unless an omental graft is
544
SURGICAL TREATMENT
used (Fig. 1213), and that is less apt to succeed than an operation with an
attached flap.
Peritoneal grafts can be taken from the omentum, broad ligament, meso-
colon, hernial sac, hydrocele sac, pelvovesical fold, or any other area where
relaxed peritoneum is to be found. The operation of grafting is done by
cutting out a piece of peritoneum about one-third larger than the area to be
FIG. 1 21 1. — COVERING DENUDED BOWEL WITH SLIDING FLAP OF PERITONEUM.
covered. It is sewed in place and the area from which the graft is taken is
closed by sutures.
In structures in which motility will not be hampered an omental graft is
best used. Thus in denuded surfaces of the mesentery, stomach, or duodenum
the edge of the omentum may be sutured to the surface and a peritoneal
covering promptly secured (Fig. 1214).
FIG. 1212. — SLIDING FLAP OF PERITONEUM SEWED IN PLACE TO COVER DENUDED AREA
ON THE INTESTINE.
Foreign Bodies in the Peritoneal Sac. — While foreign bodies, such as
aseptic sponges and instruments, may remain a long time without producing
serious harm, they are apt sooner or later to cause mischief. They tend
to work out through the skin or to penetrate into some hollow viscus such as
THE ABDOMEN
545
the intestine or bladder. Death results in many cases from these accidents.
Small bodies such as bits of thread, cotton fibers from sponges and bits of
metal from instruments cause no appreciable harm, still they undoubtedly
are capable of provoking adhesions. For these reasons operations should be
**""" ~~\" |
FIG. 1213. — GRAFT OF OMENTUM USED TO COVER A DENUDED SURFACE ON THE
INTESTINE.
conducted so as to minimize this danger (see Toilet of the Peritoneum, page
5I5)-
An aseptic foreign body, known, or even suspected to be in the peritoneal
sac, should be sought for even though the quest involve the reopening of the
FIG. 1214. — GASTROHEPATIC OMENTUM USED AS A FLAP TO COVER WOUND AFTER EX-
CISION OF ULCER OF STOMACH.
wound or the making of a new incision. A "body" may be denned as a
nonabsorbable object larger than 3 mm. (% inch) in diameter (for Bullet
Wounds, see page 535).
VOL. 11—35
546 SURGICAL TREATMENT
Peritonitis. — The treatment of peritonitis cannot be grasped unless one
has an understanding of the anatomy of the peritoneum, its relation to the
viscera, and the physiology and pathology of inflammations. This should
be borne in mind: the danger of peritonitis is not so much from the absorp-
tion of toxic materials from the peritoneum as from paralysis of the intestine
due to infiltration of its wall with the products of inflammation (J. P. War-
basse, "Acute Peritoneal Infection and its Relation to Acute Intestinal
Obstruction," Am. Jour. Med. Sciences, Vol. CXXX, 1905).
Acute peritonitis demands two essentials in its treatment: (i) removal
of the source of infection, and (2) prevention of the spread of the disease.
The removal of the source of the infection is discussed under the treat-
ment of the diseases of the various abdominal organs. Whether the source
be a focus of gangrene or the perforation of an unsterile hollow viscus,
the culture-bed or the infective cavity must be eliminated or closed off from
communication with the rest of the peritoneum. A collection of pus or other
infected fluid must be regarded as a focus of infection so long as it possesses
the power of provoking leukocytosis and serous exudate; for so long as it
can do this it can increase its bulk and invade new fields of peritoneum.
Infected fluid, not walled off by adhesions, must also be regarded as an in-
fective focus to be eliminated. In other words, any collection of infective
bacteria, capable of extending the peritonitis, if so situated that it can be
removed from the abdominal cavity, should be removed. This means that
abscesses and other collections of fluid, containing active organisms should
be evacuated.
Adhesions, separating the infected from the uninfected zones, are the
salvation of the patient. Were it not for peritonitis, infection of the peri-
toneum would be fatal in most cases. Operations for the removal of the
focus of infection should be done with directness and gentleness. Adhesions
should be spared excepting those which prevent access to the focus. The
peritoneum should be preserved from traumatism as much as possible.
And the operation should be short. Irrigation is not advisable in most cases.
If these conditions cannot be complied with, the surgeon may choose one of
two preferable courses: (a) gently to expose the focus of infection and drain
it without disturbance of the surrounding peritoneum ; or (b) to do no opera-
tion at all, but to minimize peristalsis, eliminate toxins, and conserve the
resistance of the patient.
To prevent spread of the infection to uninvaded peritoneum, several
means are at the service of the surgeon. The first and most important is
that already described; removal of the infective focus. When this has been
done, or when it seems best not to do it, peristalsis should be inhibited.
The most effective way to accomplish this is by keeping the bowel empty.
The stomach should be washed out, and the lavage repeated so long as nausea
is present. Food by mouth should be withheld, and nourishment given by
rectum. Laxatives should not be used.
In connection with the above measures, the patient should be placed in
the elevated-head position and proctoclysis should be instituted. These
represent the general principles of the treatment of acute peritonitis.
The results of operation performed during the first hours of peritonitis
are most satisfactory. This is the time of preference for operation. Opera-
tion should be done then. If operation can be done within the first twelve
hours of the infection and the cause eliminated — a perforation closed or an
appendix removed — recovery should be expected. The results of surgery
at this stage are brilliant.
THE ABDOMEN 547
There comes, after the first twenty-four or thirty-six hours of peritonitis
the long period of constitutional reaction, in which the contest goes on
between bacteria and toxins on one hand and the antitoxins and other re-
sisting forces of the body on the other hand. In this contest there is a
balancing of forces. This period of uncertainty continues during the second,
third, fourth and fifth days of the disease. Then, as the natural resist-
ance of the body overcomes the invasion of infection, there is a terminal
period in which operation may again be done more safely. To operate for
peritonitis during the period of acute struggle brutally upsets the balance
of the contest and disconcerts the plan which Nature has employed for
eons to preserve the race. Operations, after the first thirty-six hours of the
disease, on the third, fourth or fifth days, are highly dangerous.
If operation is to be done for the acute disease it should be before the first
thirty-six hours. After that the surgeon should work with Nature, and do
what Nature is trying to do. The patient must be kept quiet, peristalsis
must be inhibited. This means that food must not be given by mouth.
Purgation and laxatives are absolutely contraindicated; they are capable of
doing most serious harm. If food and purgatives have not been given from
the beginning, the patient's chances of recovery are multiplied many fold.
The distressing cases are those in which the fundamental principles have
been violated, and a patient has been given food or purgatives. Here the
surgeon must decide between a hazardous operation and the ineffective
restoration of intestinal quiet in a bowel which has been fed and purged.
These are the cases which die in the hands of the surgeon.
Gastric lavage should be used to remove remnants of food, and backed up
duodenal secretion. The importance and value of this treatment are very
great.
Proctoclysis, to instill fluids into the bowel, restores the bodily fluids,
quenches thirst, assuages hunger, dilutes and washes out the toxins from the
blood, provides fluid for peritoneal and tissue serum, fills the vessels in the
interest of more vigorous circulation, and by reducing temperature contributes
to the comfort of the patient. As much as 8 or 9 liters (16 or 18 pints)
should be absorbed by an adult in twenty-four hours.
Alonzo Clark reduced the mortality of peritonitis by the use of opium.
Later Crile explained the mechanism of its action, and showed that during
the period of acute toxic struggle it performs two important functions: (i)
It inhibits peristalsis, and (2) it protects the patient from the shock, the
nerve depression, and loss of energy, which are caused by the centripetal
impulses, flowing inward to the nerve centers from the sites of disease. In
severe cases, which can not be subjected to ordinary surgical treatment, the
patient may be saved by deep narcotization with opium or morphin. Crile
advocated reducing the respirations to 12 or 14 per minute. With the patient
thus narcotized and rendered immune to the nervous shocks of the disease,
the intestine quiet, and fluid flowing into the bowel from below, a large pro-
portion of the cases once regarded as hopeless may be saved.
After the subsidence of the acute attack any collection of pus which
remains should be evacuated. This will be found in the form of an abscess.
Its drainage should be accomplished with the least possible traumatism.
The elevated-head position is useful. If a collection of pus is diagnosed,
and upon opening the abdomen it is found to have free uninfected peritoneum
between it and the wound, a drain should be placed in the wound and carried
down to the peritoneum, but the abscess should not be opened. Soon the
abscess will empty itself through the drainage tract. If it does not, the
548 SURGICAL TREATMENT
drain may be removed after adhesions have formed, and a tube passed
down to the abscess.
In local acute peritonitis, removal of the infective focus, drying of the peri-
toneum by gentle sponging if fluid is present, closure of the wound with a
small wick drain which is quite as much for the abdominal wall as for the
peritoneum, and inhibition of peristalsis are the essentials of treatment.
A. J. Ochsner showed that peristalsis could be best inhibited by washing
out the stomach and withholding all mouth feeding. Not even a drop of
water is given by mouth. Fluids are supplied by the rectum. No laxative
is given. Movements are secured by enema. Nutrient enemata supply
food. This method of treatment when applied early and consistently
has the power of localizing an infection until it becomes walled off and can
be operated upon with safety. This method is of great value to the physi-
cian when a surgeon cannot be had. It should be employed after opera-
tion in diffuse peritonitis, and in cases of peritonitis in which operation
must be deferred.
In local suppurative peritonitis, the abscess should be evacuated through
the part of the abdominal wall which is nearest the abscess. This should be
done without invading the peritoneal field external to the abscess. If the
focus of infection can be removed without breaking through the adhesions
which confine the abscess, it should be done. A drainage tube should be
placed in the opening and the wound closed about it.
In neither of these local conditions is the elevated-head position necessary.
Proctoclysis need not be used unless the patient is much 'depressed. Food
by mouth should be withheld for one or two days.
In diffuse suppurative peritonitis, there is a pus-producing infection which
is more acute than local suppurative peritonitis, as manifested by the fact
that limiting adhesions cannot form fast enough or firmly enough to confine
the pus. The surgeon has to do with free pus in the peritoneal cavity and a
spreading infection. (This is sometimes erroneously called " acute general
peritonitis" and "acute septic peritonitis;" the former of which never exists,
and the latter of which is fatal before pus develops.) This is the common
form of peritonitis, which supervenes upon improper treatment of the local
form, which might have been checked while still localized, but which in most
cases showed a disposition to spread from the beginning.
The disease should be recognized and treated early. Treatment, to be
successful, should be inaugurated in the first twenty-four hours; in the first
twelve hours, if possible. Operation should be done at once. Tenderness,
muscular rigidity, pain — these are the signs upon which the surgeon should
act. His experience with the disease should enable him to make the diagno-
sis upon these and the general appearance of the patient. He should operate
upon the signs of the disease and not demand that the signs of dissolution
be present before proceeding. Most cases are due to appendicitis or per-
foration of the intestine or stomach.
There is already a beginning intestinal paresis. This means absorption
of toxins which in turn causes vasomotor collapse. When these patients die,
it is from vasomotor paresis. If there is much vasomotor depression, the
patient should be fortified for operation by measures for overcoming shock.
A venous infusion should be given, and this followed by adrenalin (see
Shock, Vol. I, page 213). Preparations for postoperative transfusion of
blood should be made. The anesthetic should be given so as to depress
the patient as little as possible. When shock is present, as it usually
is, much of the patient's blood is in the relaxed vessels of the splanchnic
system. When the abdomen is opened, these vessels relax still more and
THE ABDOMEN 549
suck in from the rest of the circulation the blood that is necessary to keep
the patient alive. This is the "peritoneal collapse" so familiar to surgeons.
The abdomen should be opened at the site of the disease. Blood should
be saved. If the focus is an inflamed appendix, it should be tied off and
removed (see Appendicitis, Vol. III). If the appendix is not gangrenous,
and is buried in adhesions, it need not be removed if liberating it from its
bed will expose to infection uninfected areas of peritoneum. If the focus is
a perforation of the bowel or stomach, the perforation should be closed (see
Perforation of Intestine, page 566).
Free pus or infective serum in the abdomen should be removed. This is
usually best done by gentle suction. Suction may be secured by means of
a glass tube on the end of a rubber tube which is connected with an air
pump. For this purpose the pump may be connected with a tap of run-
ning water or a vacuum bottle exhausted by an electric pump. The suction
device used by dentists is most effective. In the absence of suction appa-
ratus gentle sponging may be employed. In most cases the flat sponges
used to retract the intestines take up what remains after the first exposure
of the focus of infection. In diseases of the lower abdomen the pelvic cul-
de-sac should be exposed by gentle retraction of the intestines and sucked
dry. For sponging a tubular speculum or proctoscope is useful; it permits
sponges to be passed down into the pelvis without scraping over the
intestines. Irrigation should be avoided except in rare instances.
If there is much pus, fibroplastic detritus, or products of perforation
widely distributed, irrigation with warm normal saline solution is more effec-
tive than sponging and does less damage to the peritoneum. If irrigation
must be employed, it should be free and copious; for, inasmuch as it may
disseminate infected matter, it should wash it all out. Fluid should be
used until it returns clear and clean, even though several gallons are re-
quired. While the irrigation progresses the wound is being sutured.
Drainage should be provided. A cigaret drain or tube containing loose
wick should be carried down to the site of the primary disease. A similar
drain or a glass tube should be placed in the pelvis if pus were found
there. The abdominal wound should be closed about these. Packing the
abdomen with gauze is to be deprecated. A copious moist gauze dressing
should be applied. This should be changed twice daily while the discharge is
profuse. The wick in the tubes should be renewed as often as necessary
or the tubes aspirated (see Methods of Securing Peritoneal Drainage, page
524)-
Most of these cases do best in the elevated-head position (Elevated-head
Position, page 529). But if it cause dizziness or disturbed heart action it
should not be used.
The vasomotor disturbance, from which these patients suffer and which
always threatens their lives, fills the great abdominal vessels with blood and
depletes the peripheral vessels. This gives the pinched facies, the small
pulse and the rapid heart. The best means for filling the peripheral vessels
is by adding fluids. This is best accomplished by proctoclysis (Vol. III).
If the emergency is great, fluids may be given by any of the methods used
in shock.
If the emergency is not great, some patients prefer single rectal injections.
A small injection of warm solution by rectum every two to four hours
is of great value. This should begin with 180 or 240 c.c. (6 or 8 ounces).
The patient should be instructed not to expel it unless there is a desire to
pass flatus or feces. If it is expelled, a similar amount should be injected
within an hour. As the patient becomes accustomed to retaining the fluid
550 SURGICAL TREATMENT
the amount may be increased gradually until 500 c.c. (i pint) at a time are
given. Reversed peristalsis carries this fluid up into the colon where it is
absorbed. This method does not entail watching, as does proctoclysis,
which is not always comfortable, and for which especial apparatus is
necessary.
These patients absorb fluid rapidly. The pulse should be watched and
when it approaches the normal in fulness the injections should be stopped.
It is possible to overfill the vessels and produce edema of the lungs.
Hypodermoclysis may also be employed; and, if the patient is still strug-
gling against unfilled peripheral vessels, saline infusion in the veins is to be
used. Enough fluid should be used to give the heart something to contract
upon. The treatment fails unless the surgeon succeeds in filling the vessels
outside of the splanchnic system.
This use of fluids is aimed to overcome shock by filling the vessels,
to dissolve toxins and carry them off through the emunctories, and to
satisfy the thirst of the tissues. It is one of the most important post-
operative measures, and undoubtedly aids in the body's struggle against
the infection and the effects of the peritonitis.
The stomach should be washed out if there is nausea and vomiting. So
long as the contents of the duodenum are running back into the stomach
and producing nausea, lavage should be practised. It may be done twice
or thrice daily or oftener. It makes the patient more comfortable, eliminates
toxic matter, and prevents acute postoperative dilatation of the stomach.
As soon as the nausea or vomiting cease, or if they have not been present,
lavage may be omitted, and water may be given by mouth. This should be
in small amounts at first, and gradually increased from doses of 4 c.c. (i
dram) up. When water by mouth is taken without nausea and vomiting,
the saline enemata may be omitted.
As long as nausea is present, food should not be given by mouth. When
water is taken without nausea or vomiting after the first twenty-four hours
following the operation, diluted milk or other proteid fluid food may be given.
Thirty c.c. (i ounce) may be given every hour, and this gradually increased.
At the end of twenty-four hours, if the patient still vomits, nutrient
enemata should be employed. If proctoclysis is still needed, these may be
given alternately with it. Once daily the rectum should be washed out with
a cleansing enema.
There are cases which are in extremis when seen by the surgeon. If the
patient is moribund operation should not be done. If there is some hope,
an incision may be made under local anesthesia, and drainage secured with
or without suction. Some of these bad cases with intestinal paresis may
be saved by adding to the suction and drainage, opening of the intestine
and washing out its retained contents (see Ileus below).
In the far advanced cases of peritonitis, in which the skin is cold and
moist, the lips dark, the pulse rapid and weak, the temperature below
normal, the leukocyte count low, the abdomen distended, respiration exclu-
sively costal, and the mental state apathetic, operation is not to be considered.
Cases of diffuse peritonitis in which the infective focus is eliminated by
operation, and in which free pus or detritus has been removed, need not
invariably be drained. The abdomen may be closed with only a small drain
in the wound down to the peritoneum for drainage of the wound of the
abdominal wall.
lodin in the treatment of peritonitis has found favor in some hands. J. A.
Crisler (Trans. Southern Surg. and Gyn. Assoc., 1915) used a 2.5 per cent,
solution of pure iodin in alcohol. Theoretically this should produce adhe-
THE ABDOMEN 551
sions and cause decided irritation. Surgeons who use it claim that it does
not.
Dichloramin in the treatment of peritonitis is used in 5 per cent, solution.
Hypochlorites of calcium and soda, chlorinated oil, and others of the chlorin
antiseptics have all been used with more or less success in the treatment of
peritonitis.
Sulphuric ether in the treatment of peritonitis has been proved by the French
surgeons to be a valuable agent. It is antiseptic; it induces salutary hyper-
emia; and it minimizes postoperative pain and restlessness. When opera-
tion reveals an infected peritoneum ether may be applied after removing the
pus or serum. Most encouraging results have been secured by washing out
the peritoneal cavity in diffuse peritonitis with a liter ( i quart) or more of
ether. In local infected areas and abscesses, as much as 30 c.c. (i ounce)
may be left in the abdomen in the case of children from 5 to 15; and 60 to
1 20 c.c. (2 to 4 ounces) in the case of adults. The abdomen may be closed,
and the ether confined. If a drainage tube is used, the tube may be clamped
for a few hours to prevent the escape of the ether. As the boiling point of
ether is 2o°C. lower than the body temperature, it promptly boils, evaporates
and is absorbed by the tissues. It does not, however, materially deepen the
general anesthesia although it prolongs the post-anesthetic quiet.
This treatment is not recommended as a part of the routine handling of
peritonitis, but as an expedient which some surgeons have found useful.
Camphorated oil has been much used by some surgeons in the peritoneum
to provoke a reacti on against infection in cases in which the peritoneum had
to be exposed in the. presence of infection. About 30 to 60 c.c. (i to 2 ounces)
of a 10 per cent, solution are used, or 200 to 300 c.c. (7 to 10 ounces) of a
i per cent, solutioni It seems to inhibit infection, prevent adhesions, and
act as a general stmulant.
Recapitulation. — The first essential to save life in peritonitis is early
operation by skilled hands. A certain number of cases will subside without
operation if the infective origin is self -limiting; but the peritonitis associated
with necrosis of tissue or perforation of a non-sterile hollow viscus urgently
demands operation for the elimination of a constantly acting source of infec-
tion. Since the nature of the infection cannot be known except by opera-
tion, this must be regarded as the essential procedure.
In acute peritonitis, death is caused by (i) absorption of toxic products;
(2) poisonous effects of acid products; (3) fatigue of the nervous system,
and (4) insufficient nourishment.
(i) Toxemia is to be combatted by drainage, increasing the bodily
fluids, and by all of the measures which antagonize infection. (2) Acid by-
products are to be eliminated by excessive intake of water by all channels
except the stomach. As much as 2000 c.c. of solution may be given daily
by hypodermoclysis. The acidosis may be neutralized and nourishment
supplied by proctoclysis with 5 per cent, solution of sodium bicarbonate
and glucose. (3) For the nervous fatigue the patient must have sleep.
Morphin at night may be given freely enough to insure rest.
For the case seen early by the surgeon, the steps should be prompt and
rapid operation, minimization of shock, removal or elimination of the source
of infection, and the institution of proctoclysis.
The treatment formulated by Dchsner is advisable in the cases which have
passed the period for early operation, provided the cases are of localized in-
fection such as occur with infections of the appendix and gall-bladder; but
in peritonitis with strangulation, gangrene of the bowel, perforation, or with
diffused seropus, operation should precede the rest treatment.
552 SURGICAL TREATMENT
The later cases which are treated by the method of Ochsner, should have
an half hourly or hourly pulse record kept. If the pulse-rate shows a steady
tendency to decline during the course of two or three hours, operation may
safely be postponed, but if the pulse-rate shows a steady increase, immediate
operation is indicated. Cases which are clearly moribund should not be
operated upon.
An autogenous vaccine may be made from the exudate and administered
as soon as possible. Its value is still problematical.
The stomach should be kept washed out so long as nausea is present.
Isolated abscess should be opened. Diffused pus should be liberated.
Through-and-through irrigation of paralyzed intestine should be
practised.
Paralytic ileus, caused by peritonitis, or traumatism is one of the most
distressing conditions the surgeon is called upon to treat. It is due (i) to
infiltration of the wall of the intestine with leukocytes, serum and the other
products of inflammation; (2) to the effect of extraintestinal and intraintes-
tinal toxins upon the motor nerves; and (3) to traumatism to the intestine,
peritoneum and abdominal nerves. Dilatation of the bowel aggravates the
paresis. The treatment described above is directed to prevent this ileus.
When there is a degree of distention which looks incapable of recovery unless
given mechanical relief, the bowel should be opened and emptied. The
experienced surgeon will recognize this at the first operation. In other cases
it will be apparent after operation that the patient has a dangerous degree of
ileus which is not yielding to enemata or other measures. Recovery may
be secured for some of these desperate cases by the following treatment:
The intestine is exposed at the lower and upper limits of the ileus. A
purse-string suture of silk is introduced in a circle on the wall of the bowel.
Through the middle of this circle, a large trocar and canula are thrust, and
the contents of the bowel evacuated. At the same time the purse-string is
tied down to prevent leakage. The canula should be connected with a
rubber tube as soon as the trocar can be withdrawn. In lieu of such an
arrangement, an opening may be made in the circle with a slender knife, a
large catheter or stomach tube inserted into the bowel and the suture tied
down upon it. This operation should be repeated at the other end of the
paralyzed segment of bowel. The intestine should be washed out through
these two tubes, fluid passing in at the upper and out at the lower. If the
interval between the two is too great for such irrigation, one or two similar
drains may be introduced between them.
These tubes should be left in place and fixed so that they will remain.
Irrigation with sterile water or saline solution should be practised once or
twice daily, or oftener if indicated. In the mean time the tubes may be
closed. Castor oil may be introduced through one of the tubes. Twenty-
four hours of this treatment may make a striking change for the better.
Thirty-six hours should determine whether it succeeds or fails. At the end
of two days the patient may be quite convalescent. This is the rational
treatment of this condition, and it should not be denied any patient who has
a grain of hope. I have seen patients recover under it who otherwise, it
seemed, would surely nave perished.
This method has been modified by Stewart, who fixed the half of a Mur-
phy button into the bowel and connected a rubber tube with it by means of
the other half. Kocher made one opening in the upper part of the jeju-
num and another in the lower part of the ileum : he washed the bowel through
and then closed the openings. It is always desirable to have such a tube in
the colon. This may often be introduced through the stump of the appendix.
THE ABDOMEN 553
The patient may later be given predigested food through the tube. Such
a tube introduced into the colon lends itself especially for washing out the
bowel, administering fluids, and giving predigested food. There is no limit
to the time the tube may be left in place. It causes no especial harm
and, if fixed by a suture, will not be extruded by peristaltic contractions.
The medical treatment of the inhibition of peristalsis from peritonitis
has much to offer. In the cases in which operation is not positively called
for, such drugs as pituitrin are used with good effect. A fresh solution of
pituitrin should be used. It is given hypodermatically in the muscles. The
dose is i c.c. repeated every one or two hours up to three or five doses. Not
more than five doses in twenty-four hours need be given. In mild cases of
obstruction the passage of gas occurs often after the second dose.
There are other sequelae of acute diffuse suppuralive peritonitis besides
paralytic ileus, which require treatment and which may tax the surgeon even
more than the original disease. Localized peritoneal abscess should be opened
as soon as the disease has become quiescent and the abscess can be evacuated
without invading the general cavity. Secondary abscess in other organs
should be opened at once. Infections of the retro peritoneal lymphatics do not
require local treatment unless they give rise to abscess. Empyema, abscess
of the lung and phlebitis should receive the treatment already described.
Intestinal obstruction, developing as the result of adhesions, angulation, or
bands, should be treated at once by exposure of the site of trouble and relief
of the occluded bowel. Intestinal fistula is described below.
Subphrenic (subdiaphragmatic) abscess may be opened (i) through the
abdomen below the costal arch; (2) through the pleura; (3) through the
chest by pushing up the pleura, and incising through the diaphragm,
without opening the pleura; and (4) by incision in the lumbar region.
The abscesses which are usually due to perforation of the stomach, which
bulge forward in the epigastrium, may be opened through the anterior ab-
dominal wall. This should be by a systematic operation, as described for
entering the abdomen, and not by a simple incision, as described for opening
an abscess. The general peritoneal cavity should not be invaded. The
wound should be retracted and the pus sponged out. The cavity will usually
be found to extend far posteriorly, and a drain may be introduced through a
counter-opening in the flank, crossing in front of the kidney. The cavity
may be washed out with warm saline solution. A drain should be left in
the anterior opening.
An incision along the costal margin is indicated for abscesses which appear
to be located laterally.
In most cases the abscess lies up so close beneath the diaphragm that it
is best reached by incision through that structure. An incision 15 cm.
(6 inches) long is made between the ninth and tenth ribs on the right side,
or between the seventh and eighth ribs on the left side. The middle of the
incision should be in the midaxillary line, or at the point where the aspirat-
ing needle found pus. About 10 cm. (4 inches) of each rib is excised. The
pleura if uninfected should be protected, and the diaphragm exposed (see
Exposure of the Diaphragm, page 467). The diaphragm should then be
incised at the place where the abscess bulges upward, the abscess washed out
and drained. The abdominal incision may be combined with this in some
cases.
Opening between the ribs gives adequate room only when the abscess has
advanced through the diaphragm. If there is no cellulitis of the lower thorax,
resection of a rib is necessary to secure adequate access. The pleura comes
down to the tenth rib in most cases in the posterior axillary and midaxillary
554
SURGICAL TREATMENT
lines. Still the tenth rib may be resected, and the pleura pushed upward.
The ninth rib may be resected between the anterior and middle axillary lines,
and the exposed pleura pushed up. In operating upon these ribs the peri-
osteum should be left attached to the pleura (Figs. 1215 and 1216). After
elevating the pleura the diaphragm may be incised, and drainage provided.
Resections of both ninth and tenth ribs may be done.
In cases in which it is necessary to pass through the pleura, if the two
pleural surfaces are not united by adhesions, they should be sewed together
so that a space is left through which the diaphragm may be approached
without infecting the pleural sac (Fig. 1217). Or the diaphragm may be
sutured to the chest wall.
'
FIG. 1215. — OPERATION FOR EXPOSURE OF SUBPHRENIC ABSCESS.
The retractors are in the right midaxillary line. A section of the X rib has been re-
moved. The periosteum has been left. The lower reflection of the pleura is seen present-
ing in the wound. The diaphragm forms the floor of the wound.
Acute nonsuppurative peritonitis is best treated by the methods used in
acute peritonitis, and especially the method of A. J. Ochsner (page 548) .
Chronic peritoneal abscess is usually a relic of acute peritonitis or some
slowly acting infection. It should be evacuated.
Tuberculous peritonitis should be treated by measures directed to the
patient's general condition (see Tuberculosis, Vol. I, page 276). The acute
miliary and the dry forms are medical, rather than surgical diseases. The
exudative jorm with serum in the abdomen (ascites) is surgical (i) when hy-
gienic and medical treatment fail and (2) when the amount of fluid is so great
as to cause discomfort or interference with function.
The same hygienic treatment as is given to a case of pulmonary tubercu-
losis should be employed. Operation should not be done until this is given a
full trial (three to six months), unless the ascites is distressing or steadily pro-
gressing. Often the fluid will disappear as the patient's resistance improves.
Operation is by no means essential for a cure.
The treatment of cases, not cured by hygienic and medical measures,
THE ABDOMEN
555
demands that an examination and inquiry into the history shall be made to
determine, if possible, the location of any primary focus of the disease. The
abdomen should be opened in the region of such primary focus, or, if none is
found, a median operation between the pubes and umbilicus should be done.
After the ascitic fluid has been removed by sponges, tuberculous foci should
be sought. If any organ or region is preponderatingly affected with tuber-
culosis and its removal is easily accomplished it should be removed. This
rule does not apply to any procedure so serious as resection of the intestine
unless by the operation all foci can be removed. It applies to such struc-
tures as the Fallopian tubes, appendix vermiformis, or ovarian peritoneum.
The most effective operation is the simplest. It consists in removal of the
ascitic fluid. The presence of the fluid in the peritoneum is a natural reaction
against the disease. As the fluid becomes old, it probably loses its bacteri-
cidal power. Withdrawal of the old fluid is followed by the formation of
P05TERIORJ
AXILLARY
LINE:
LINE
FlG. I2l6. SUBPLEURAL DlAPHRAGMOTOMY.
AB, Incision in diaphragm for exposure of subphrenic abscess.
new fluid which has greater antitubercular properties. The abdomen should
be closed without drainage.
Operation is done only when there is ascites, and ascites is usually present
only with disseminated disease. An opportunity to perform a resection
of any tuberculous area is rarely offered. There are two exceptions: When
the Fallopian tubes or vermiform appendix are involved, they should be
removed, and the opening cauterized and occluded. This is recommended
because there is apt to be a tuberculosis of their mucous membrane which
may continue to reinfect the peritoneum. After exposing all of the diseased
peritoneum to the air, the abdomen is closed without drainage. Operation is
best done after the primary febrile stage has passed, but before the patient
becomes debilitated and other organs involved.
It is entirely adequate to open the abdomen, evacuate the fluid, and close
the wound. Nothing more need be done in a surgical way. Systematic
556
SURGICAL TREATMENT
treatment with tuberculin should be begun a week or two after the operation,
and continued after the patient leaves the hospital. Under this treatment,
combined with hygiene, 50 per cent, of cases may be cured, and most all
patients benefited.
A. Florio (Gazzetta degli Ospedalie delle Cliniche, Jan. 2, 1910) aspirated
the ascitic fluid and then injected air into the peritoneal cavity in amount
about equal to the fluid withdrawn. The air is absorbed in from six to twenty-
three days. The benefits of the operation seem to be as great as by lapa-
rotomy. For this operation the same apparatus may be used as is employed
in the similar treatment of pleurisy with effusion (page 401).
In the suppurative form there is either a breaking down of tissues or a
mixed infection. It is best not operated upon unless a distinct well-circum-
scribed wall is present, and then the treatment should be that described for
tuberculous abscess (Vol. I, page 281).
FIG. 1217. — TRANSPLEURAL DIAPHRAGMOTOMY.
Operation for transpleural incision of subphrenic abscess. Showing line of incision in
diaphragm, after pleura has been incised and the parietal and diaphragmatic layers of the
pleura have been sewed together.
The local application of tincture of iodin (10 per cent.) has proved effect-
ive in the hands of some surgeons. The abdomen is opened, and emptied
of fluid. As much of the tuberculous area as is easily accessible is painted
with the iodin, which is then wiped off with gauze. The abdomen is then
closed. Following the treatment the abdomen becomes distended with
fluid, which in the course of two weeks may be expected to disappear. The
tenderness subsides. The patients may be allowed up three weeks after the
operation to resume hygienic treatment. Distinctly tubercular organs,
such as the Fallopian tubes, should be removed.
The internal use of lime is advocated by French surgeons in connection
with other treatment:
Calcium carbonate 0.65 Gm.
Tribasic calcium phosphate 0.2 Gm.
Sodium chlorid 0.15 Gm.
THE ABDOMEN 557
This is given in capsule three times daily after meals. It seems especially
effective when anorexia, vomiting, diarrhea, and pulmonary complications
are present.
Peritonitis of the duodenal region (region of the pylorus, gall-bladder, head
of pancreas, and gastrohepatic area) is usually due, if acute, to perforation of
the duodenum or stomach or to acute cholecystitis, and requires the treat-
ment of these conditions. The chronic form, giving rise to adhesions of the
duodenal region, may have its origin in disease of the duodenum, gall-tract,
pancreatic ducts, or stomach. These adhesions bind together the adjacent
structures and cause symptoms usually referable to the stomach. In 1903
I called attention to this condition, and reported cases upon which I had
operated (Vicious Peritoneal Adhesions of the Duodenohepatic Region,
Brooklyn Medical Jour., January, 1903).
Often the causative disease has healed or disappeared, and there remain
only the adhesions. These may be separated by blunt dissection or with
knife and scissors, and the duodenum, stomach, hepatic flexure, and gall-
bladder, which may all have been drawn into a mass, dropped back into their
normal positions. If no evidence of stone, duodenal or gastric ulcer, or
stricture is present, the abdomen is closed, and the patient kept supine for
two weeks. Great benefit results from the operation. Undoubtedly adhe-
sions form again, but, by keeping the patient supine, they form with the
organs in a better position. This is particularly the case when there is an
angulation at the upper end of the duodenum, as is sometimes caused by the
pyloric end of the stomach becoming displaced to the right and fixed to the
structures in the region of the gall-bladder. If the organs tend to fall back
into vicious position after the adhesions have been divided they may be
fixed with a suture wherever necessary.
Tumors of the Peritoneum. — The primary tumors are rare; most are
extraperitoneal; they should be treated according to the rules already given
(Tumors, Vol. I, page 223). Metastatic tumors are not uncommon; usually
they are secondary to carcinoma of the stomach; their treatment is palliative.
Ascites. — Collections of serum in the peritoneal sac should be treated by
dealing with the causative disease, and by measures to promote absorption
and elimination of body fluids. If this does not relieve the ascites, the sim-
plest way to remove the fluid is by aspiration or " tapping" This operation is
done when the amount of fluid is so great as to cause discomfort, disability,
and interference with respiration and circulation. The operation is done as
follows: The diagnosis of fluid-distention having been assured, the patient is
placed in the upright sitting position, and by percussion the height of the
fluid in that position is determined. With a sharp-pointed knife a small
puncture is made through the skin in the median line of the anterior abdomi-
nal wall about 5 cm. (2 inches) above the pubes. Through this a trocar and
canula are thrust, through the abdominal wall into the peritoneal fluid. The
surgeon should have estimated the thickness of the wall and marked by his
finger the depth which he proposes to allow the instrument to pass. As it
penetrates the peritoneum there is a sense of non-resistance. The trocar is
removed, the fluid runs out through the canula. When it ceases to flow the
canula is removed, and a small sterile dressing is held over the wound with an
adhesive strip.
The operation should be done with aseptic precautions. The bladder and
bowel should be emptied. Usually the intestines float up on top of the fluid
and there is no danger of injuring them. If they should be held against
the lower anterior abdominal wall by adhesions, the percussion note would
give the warning of this unusual condition, and the tapping should be done
558 SURGICAL TREATMENT
at one side. The canula should not be so large as to permit too rapid an
escape of fluid nor so small as to become clogged by bits of fibrin. About
6 mm. (y± inch) in outside diameter is a good size. It should pass only just
through the abdominal wall. The fluid as it spurts out may be caught in a
vessel. Its flow should be stopped at short intervals to permit the abdominal
structures gradually to accommodate themselves to the diminishing pressure.
If the fluid runs out too fast engorgement of the splanchnic vessels may take
place, producing shock, or syncope, or even abdominal hemorrhage. The
patient's circulation should be watched, and the head lowered if the heart
becomes weak and rapid.
The artificial formation of intra-abdominal adhesions for ascites, due to
cirrhosis of the liver, first was advocated by Talma (Berlin Klin. Woch.,
Sept. 19, 1898). The abdomen is opened by an incision in the median
line between the ensiform and umbilicus. The fluid is evacuated and
sponged away. The upper surface of the liver which can be reached is
rubbed with gauze for the purpose of irritating its peritoneal covering and
causing it to become adherent to the diaphragm. The relaxed abdominal
wall is then everted, the peritoneum in the neighborhood of the wound rubbed,
and the great omentum sewed to it, first on one side of the wound, then on the
other. As broad an attachment of omentum to the peritoneum of the
abdominal wall as possible is made. The abdomen is then closed. The
adhesions which form as a result of this operation cause anastomoses
between the veins of the mesenteric system and those of the anterior ab-
dominal wall; and blood from the veins of the abdomen is carried to the vena
cava without passing through the portal veins and the liver. Care should be
taken not to injure the circulation in the round ligament.
The results of this operation are very satisfactory in a large proportion
of cases of cirrhosis of the liver which are not too far gone with other complica-
tions. A. Blad (Ugeskrift for Laeger, July 15, 1915) found that about 40
per cent, of the cases operated upon by this method have been cured of the
ascites. The reason for the 60 per cent, of failures is that the operation has
been improperly used.
The operation usually fails in cases of chronic congestion of the liver —
"nutmeg liver." In these cases there is general venous stasis, associated
with heart disease. Drainage of the ascitic fluid is about the only sure
surgical relief. The operation succeeds in cases of stasis of the portal system.
Success depends largely on the functional potency of the liver. This factor
cannot always be determined before operation. The operation is found
to give relief in some cases of ascites not due to portal defect. This is possibly
because it relieves a secondary portal stasis. If adhesions already exist or
if the omentum is small and shriveled the operation will do no good. If
the operation is done before the general health of the patient has become
seriously impaired, improvement should be secured in 90 per cent, of cases
operated upon.
The operation need not be carried out just according to the method of
Talma. The best results are being secured by bringing an edge of omentum
outside of the abdomen, and fixing it in the abdominal wall. Most surgeons
use local anesthesia. E. A. Babler (Jour. Am. Med. Assoc., Vol. 58, No.
15, April 13, 1912) improved the operation by making a transverse opening
into the abdomen. A vertical incision is made down to the deep fascia;
the sheaths of the recti are opened at their inner borders; the muscles are
retracted outward; a transverse incision is made through the transversalis
fascia and peritoneum; the omentum is drawn smoothly through this open-
ing (Fig. 1218), spread out below it, and fastened with a few sutures behind
THE ABDOMEN
559
the muscles. If necessary to strengthen the opening the muscles or fascia
may be united in front of the omentum in the middle line.
Subcutaneous drainage for ascites has been attempted by many methods.
Glass tubes, silver wire, tubes of fascia, skin, serous membrane, and other
substances have been used. The first of these operations was that of Lam-
botte (Semaine Medicale, 1905, page 19) who used silk thread. The abdomen
is opened in the left semilunar line, and a big needle carries heavy silk in an
out through the peritoneum. The ends of the threads are then carried beneath
the skin, converging at a point on the thigh below Poupart's ligament. The
wounds are then closed.
P. Peterson (Lancet, Oct. 29, 1910) made an incision about 7.5 cm. (3
inches) long in the middle line below the umbilicus, opened the abdomen,
fa,-
FIG. 1218. — OPERATION FOR ASCITES.
Omentum sutured in transverse opening in fascia between recti muscles.
and evacuated the most of the ascitic fluid. The omentum was then drawn
down, tied off and removed at a level well above the wound. The sub-
cutaneous tissues were then dissected outward on one side of the wound as
far as the semilunar line. Through this an opening is made into the peri-
toneal cavity just large enough to admit a flanged spool. This is a cylinder
of glass flanged at each end. Several sizes of these spools are had on hand to
fit abdomens of different thickness. The spools are 2.5 cm. (i inch) across
the flanges, and the canal is 2 mm. (3^2 inch) in diameter. The subcutaneous
opening should be just large enough to admit the spool, which should be
inserted from the peritoneal side in order to be sure that the peritoneum is
not stripped up. The subcutaneous tissues are then tightly sewed to the
560
SURGICAL TREATMENT
sheath of the rectus about 2.5 cm. (i inch) from the margin of the median
wound, to prevent the escaping fluid throwing too much strain on the wound.
The primary wound is then snugly sutured in the usual manner. Swelling
and edema in the neighborhood of the tube characterize the draining off of
the fluid into the subcutaneous tissues.
This operation may be made much less formidable. The glass spool
need have a lumen of not more than i cm. (% inch) . It may be introduced
under local anesthesia through a small wound made between the pubes and
navel. The omentum need not be tied off at the first operation.
Franke contrived a system of drainage, using a simple silver wire. It is
loosely twisted double and the ends are bent so as to have somewhat the
shape of the letter H. One of the sides is 10 cm. (4 inches) and the other 2
cm. (% inch) long. The short side is twisted like a figure 8, and introduced
in the abdomen. The long side lies in the subcutaneous tissue. The
distribution of the fluid which passes out along the twisted wire is facilitated
FIG. 1219. — ARRANGEMENT OF SILVER WIRE AND STRANDS OF SILK THREAD FOR THE
DRAINAGE OF ASCITIC FLUID INTO THE ABDOMINAL WALL.
by three or four strands of silk, caught in the wire and spread out under the
skin as six or eight drains (Fig. 1219).
Blad has used successfully a square of fascia, taken from the thigh, rolled
into a tube, and inserted into the peritoneal cavity in the right lumbar region.
The tube should be about 3 cm. (i^ inches) long and 1.5 cm. (% inch) in
diameter, and terminate in the lumbar muscles.
A piece of vein (saphenous), resected from the patient would serve better
than any of these substances, all of which are doomed to become encysted in
connective tissue. Thus far, the implantation of foreign materials as above
described have given about an equal proportion of failures and successes.
Anastomosis of the saphenous vein with the peritoneum was devised by
Routte for carrying off the ascitic fluid directly into the centripetal circula-
tion. An incision is begun about 2.5 cm. (i inch) above the middle of Pou-
part's ligament and curved inward and downward over the femoral ring and
along the course of the long saphenous vein to a point about 10 cm. (4 inches)
below its entrance into the femoral vein. The fibers of the muscles and fascia
THE ABDOMEN 561
are separated and retracted and the peritoneum exposed about 1.3 cm. (^
inch) above the ligament through a short wound. The incision below this
wound is then deepened and the saphenous vein is exposed and isolated for a
distance of 9 cm. (3^ inches) from its mouth. The peritoneum is then picked
up and incised so as to make an opening the size of the lumen of the vein.
When the ascitic fluid has drained off, the vein is ligated and divided above
the ligature at a point about 8 cm. (3 inches) from its mouth. This proximal
arm of the vein is then turned upward and sutured in the peritoneal opening,
endothelium to endothelium, with fine chromic catgut, and the overlying
tissues closed. The vein should be cut longer or shorter as is necessary to
reach the opening without too much stretching or relaxation. If necessary
the abdominal wound through the fascia may be slightly relaxed by a short
transverse nick in the conjoined fascia. The reports from the few cases
subjected to this operation show good results if the vein was not smaller
than normal. Whether the operation has permanent value has not yet been
determined.
Drainage of ascitic fluid into the bladder was accomplished by P. Rosen-
stein (Zentralb. f. chir., xli, No. 9, Feb. 28, 1914) who made a valved com-
munication between the interior of the bladder and the peritoneal cavity.
Anastomosis between the vena cava and the portal vein was first described by
N. V. Eck (Militar-med. Jour., 1877, cxxx, Jahrg., 55). The first opera-
tion on man was done by Vidal (La Semaine Med., 1903) upon a man with
cirrhosis of the liver who died four months later of cardiac disease. The
second operation was done by P. Rosenstein (Zentralb. fur Chir., No. 9,
Feb. 28, 1914) in a man with cirrhosis of the liver in whom omentopexy had not
given relief. The Eck fistula in this case gave only temporary relief; and the
patient was finally relieved by the operation described above for drainage
of the ascitic fluid into the urinary bladder. The operation has been done
repeatedly and successfully in animals. A bibliography is found in an
admirable paper on the subject by M. M. Peet (Annals of Surg., vol. 60,
1914).
The object of the operation is to permit the return of venous blood from
the abdomen to the heart without passing through the liver. It is naturally
most applicable to cases of cirrhosis of the liver, with ascites. in which the
other organs are fairly healthy. Such cases are found in alcoholic cirrhosis.
These patients show the dilated subcutaneous vessels about the costal arch,
dilated hemorrhoidal vessels, and enlargement of the esophageal veins.
The operation cannot be expected to help the cases of chronic congestion
of the liver, giving rise to "nutmeg cirrhosis." These are cases of increased
pressure in the vena cava itself, commonly associated with valvular disease
of the heart with general venous stasis. In these cases, as well as those due
to nephritis, drainage of the ascitic fluid or tapping are the only forms of
surgical relief to be considered.
Peet is of the opinion that the operation should give relief also in the
cirrhosis which is secondary to the splenomegaly of splenic anemia, and in the
cases of thrombophlebitis of the portal vein. In this latter class of cases it
would be necessary to make the anastomosis between the vena cava or
common iliac vein and some large adjacent mesenteric vein.
The portal vein lies at the right side and in front of the vena cava. The
vena cava is between the portal vein and the aorta. The common bile duct
is to the right of the portal vein and in front of it. From within outward are
the aorta, vena cava, portal vein, common bile duct and descending duode-
num. In the same order the structures may be enumerated from behind
forward. The hepatic artery lies in front of the portal vein (Fig. 1 2 20) . The
VOL. 11—36
562
SURGICAL TREATMENT
common bile duct is the guide. If the peritoneum is divided longitudinally
about midway between the duct and the aorta, and gently retracted the
portal vein and the inferior cava will be exposed. The operation is done in
the space bounded by the hepatic artery above and the splenic vein below.
Some small vessels may need to be tied and divided.
Carrel and Guthrie isolated the veins and closed the veins above and
below with soft clamps. An incision was made in each vessel and all blood
washed out with liquid vaselin. A stay suture unites the ends of each
opening. These are tied externally. A running through-and-through suture
then unites the posterior lips of the gap. This is done with one end of the
stay suture. The anterior lips are united in the same way. Fine straight
needles with ooo silk are used. The stitches should be about i mm. apart
FIG. 1220. — RELATIONS OF PORTAL VEIN.
Showing location for making anastomosis between portal vein and vena cava.
A simpler method is with the use of curved anastomosis clamps (see
Arteriovenous Anastomosis). This permits closure of the vessels and lateral
apposition with the assistance of the same apparatus. By the use of these
clamps the vessels are not entirely occluded, which in man is an important
advantage. Less isolation of the vessels is required by this method. Two
two-bladed clamps permit more facile adjustment of the vessels but take
more room than one three-bladed clamp. Peet, who has done the opera-
tion on dogs with the three-bladed clamp, advises a curved needle. He
advises that when adhesions or thrombosis prevent use of those two veins a
mesenteric vein may be anastomosed with the common iliac vein; or if this
is not long enough the mesenteric vein may be tied near its mouth, cut and
turned downward. It may be anastomosed with the vena cava.
Bier failed in two attempts to complete the operation on account of
bleeding adhesions. Kocher designated it as an unthinkable procedure.
THE ABDOMEN 563
Because of the difficulties, added by the presence of the enlarged liver the
operation is rarely applicable. The surgeon should not attempt the operation
until he has practiced it on the cadaver.
Anastomosis between superior mesenteric vein and vena cava is a more
practical operation than the above. A transverse abdominal incision is made
at the umbilicus. Both recti are divided. The transverse colon is retracted
upward and the small intestine to the left. The horizontal portion of the
duodenum is exposed and passing in front of it is seen through the peritoneum
the superior mesenteric artery and vein. To expose the vena cava, the peri-
toneum is incised below the duodenum and the bowel retracted upward.
The mesenteric vein is freed, and can easily be brought into contact with the
vena cava for a distance of 4 or 5 cm. A lateral anastomosis is made after
first ligating the small lateral branches of the cava, and temporarily occluding
the vessels. The soft curved clamp serves best for partial lateral occlusion
of the vena cava (see Anastomosis of Vessels, Vol. I, page 378).
Anastomosis between the superior mesenteric and ovarian veins may be done
in the above manner for the same type of cases. A branch of the superior
mesenteric vein is used.
Retroperitoneal Disease. — There are three main groups of lymphatics
behind the peritoneum coming from the pelvis and located along the iliac
vessels. The aortic glands number twenty or thirty, grouped around the
abdominal aorta. The latter are a continuation of the pelvic chain. There
are also glands scattered along the great visceral branches of the aorta. The
mesenteric glands are scattered through the mesentery. The pelvic glands
not only receive lymph from the pelvic organs but communicate also with the
external genitals and the groins; and the aortic glands are supplied not only
by the abdominal organs but also from the abdominal wall.
Retroperitoneal infection and abscess may come from infection of pelvic or
abdominal viscera, from infection in the pelvic or abdominal wall, from infec-
tion hi the thorax, from the lower extremities, or from the spine, retroperi-
toneal region, or by metastasis from some distant part. The vermiform
appendix is a common source of infection. If the primary focus is still pres-
ent, it should be eliminated as a factor in future infection. A lymphatic
infection without abscess may be very persistent and yield only to treat-
ment with bacterial products. Abscesses tend to work downward and out-
ward; and, coming near the surface in the groin, flank or lumbar region, they
should be opened.
Retroperitoneal and mesenteric tumors are of great variety. Next to the
lymphatic enlargements and secondary growths, lipoma is the most common.
It should be enucleated. This may be done without opening the peritoneum,
through an incision in the flank entering the retroperitoneal space. Other
tumors presenting in the groin may be reached beneath the peritoneum
through an incision just above Poupart's ligament. Commonly these
growths have had to be reached by the transperitoneal route. With due
regard for the surrounding structures the peritoneum is incised, the opening
enlarged, and the tumor enucleated.
Pedunculated tumors are more easily dealt with, the pedicle being ligated
and the mass removed. After an enucleation, leaving a retroperitoneal
excavation, drainage for a few days should be provided through the flank
by means of a good-sized tube. After such an operation the surgeon should
be prepared to treat paralysis or gangrene of the intestine or disturbance
in any of the abdominal organs whose nerve or blood supply has been harmed.
These operations are as difficult as the preoperative diagnosis of the disease.
Other benign tumors, such a.1-, fibroma, should be treated in the same way.
564 SURGICAL TREATMENT
Primary sarcoma is sufficiently frequent to justify the removal of any sus-
picious retroperitoneal tumor. When sarcoma reaches a size so great as to
demand surgical relief, surgery cannot give relief. The hopeful cases are
those in which an unexpected discovery of the tumor is made. Even then
the successful treatment may demand resection of bowel, kidney or other
important structure. Malignant tumors are best operated upon from in
front, to insure wide exposure.
The retroperitoneal cysts are of great variety, and may be extirpated through
the peritoneal cavity without rupture. In the case of large cysts it may be
best to cause the peritoneum covering the cyst to become adherent to the
abdominal wound, and then after a few days evacuate it and take measures
to effect the destruction of its lining (see Cystomata, Vol. I, page 325). If
the surgeon is sure that such a cyst is not infected, its contents may be
evacuated at once and the cavity drained after the sac is sewed to the abdomi-
nal wound. This is the best way to deal with mesenteric blood-cysts. These
measures, which take the place of enucleation of the cyst, are advisable even
when enucleation could be done but would endanger the blood supply of the
intestine, or when the condition of the patient does not warrant the operation.
As a rule, so far as the mechanical possibilities go, a tumor which has not
caused gangrene of the bowel can be removed without causing gangrene,
provided the opening in the peritoneum is made in such a way as to spare
the vessels and nerves of the mesentery.
Mesenteric tumors and cysts require only the special consideration as to
resection of the bowel. In order to remove the tumor, it often means
that the blood supply of the intestine will be so interfered with that bowel
must be resected. This should be done without hesitation if the tumor is
growing. Several feet of bowel may require to be removed. The hazard
which resection of the bowel adds should prompt the surgeon to remove the
tumor, sparing the blood-vessels in such a way as to obviate the necessity
for resection (see Mesentery, page 568).
PREPARATION OF PATIENTS FOR OPERATIONS ON THE ALIMENTARY
CANAL
In operations upon the alimentary canal the lumen of the canal may be
opened and its contents and mucous membrane become involved in the field
of operation. The surgeon attempts to control the asepticity of the field
of operation down to the mucous membrane; he should also attempt some
control of the bacteria of the alimentary canal.
The Bacillus coli is a natural inhabitant of the intestine. Besides it
there are many other adventitious organisms in large number and variety.
Bacteria are, perhaps, not essential to life. Many animals live without
them. Most of the adventitious bacteria tend to disappear, but are renewed
with the food. It has been shown that at the end of nine hours after a
digestible meal, the stomach contains no bacteria. After the stomach has
emptied itself of food, bacteria cannot be found in its mucous membrane.
Fluids are passed quickly out of the stomach; only solids are retained. Gush-
ing showed in a case of jejunal fistula that a glass of milk taken by the mouth
could all be recovered at the fistula within a few minutes after its ingestion.
While solid food remains in the stomach the number of its bacteria is being
constantly reduced; the longer it remains, the fewer bacteria live to enter the
duodenum.
Gastric digestion destroys even the anthrax bacillus. When ingested after
a solid meal, it cannot be found in the intestine; but when ingested with a large
quantity of fluid in an empty stomach it is easily found in the lower bowel.
THE ABDOMEN 565
The duodenum contains but few bacteria. It is often sterile. From the
duodenum downward, the number and virulence of the bacteria increase.
The maximum of numbers and virulence is reached at the ileocecal valve.
The stomach and upper jejunum may be kept sterile by feeding only sterile
foods, permitting no infected material or object to enter the mouth, and by
proper attention to the cleansing of the buccal cavity. Obstruction or
stagnation anywhere in the gastro-intestinal tract results in a damming back
of material in which the number and virulence of the bacteria are much
increased.
When perforation or opening of the intestine takes place, the dangers of
peritoneal infection are greatly modified by the above conditions. Food
means infection. The empty canal may be free from infection. The higher
up the perforation, the more apt is the infection to be due to some adventitious
organism, such as the streptococcus; lower in the intestine, the Bacillus coli
is most apt to be the chief or only infecting agent.
Drugs, such as salol, borax, salicylic acid, betanaphthol and iodoform,
given for their antiseptic effect, have little or no effect upon reducing the
intestinal flora. It has been shown by Adolph Hofmann (Moynihan:
Abdominal Operations, Sec. Edit., 1906, page 22) thatisoform, given in o.5-Gm.
doses in amounts up to 3 Gm. in twenty-four hours, diminishes the number of
intestinal bacteria. As much as 8 Gm. have been given without harm. The
antiseptic effect in the stomach is rapid; in the intestine the effect is secured
in about thirty hours. It has but little practical value in surgery.
It often happens that emergency operations must be done, in which the
gastrointestinal tract is opened; but when a few days' preparation can be
had, the dangers of infection can be much reduced. The following is the
preliminary preparation: An attempt is made to render all ingesta sterile.
The patient is caused to rinse his mouth with an antiseptic solution at
frequent intervals (see Cleansing of the Mouth, page 244). The teeth are
brushed at frequent intervals with a sterilized tooth brush and especially
before and after taking food. A test meal is given, and if any gastric
catarrh with microorganisms is found, the stomach is washed out twice
daily. Only fluids are given. The food and utensils are all sterilized. Food
consists of boiled water, milk, albumin water, broths, soups and fruit
juices. This treatment may be continued for two or three days; or longer,
if the condition of the mouth is bad. The bowels should be thoroughly
emptied by castor oil, calomel or saline aperient, forty-eight hours before
operation; and an enema should be given the night before operation. All
of the cleansing of the bowels should end on the day previous to operation.
The operation should be done in the morning. No food should be taken by
mouth for six or ten hours prior to operation. If nourishment is demanded,
nutrient enemata may be given (see Preparation of Patient, Vol. I, page 176).
This rigorous sterilization of the food and mouth need not be followed as
a routine, but in cases in which the dangers of infection are contemplated it
may be applied. The bacteria ordinarily found in the intestine are not
inimical to wound healing. This is particularly the case if the contents of the
intestine are not fluid. Dry or soft solid fecal contents are not to be feared.
Fluid feces are apt to contain virulent bacteria. This is the reason a purge
should preferably not be given within twenty-four hours of the operation.
THE INTESTINES
Contusions. — Contusions of the intestine, without rupture, may produce
ecchymoses, local paralysis of the bowel, or be associated with the shock due
to contusion of the sympathetic nerves of the abdomen. If gangrene does
566 SURGICAL TREATMENT
not take place, the intestine recovers and operation is not required. Both
this condition and local paralysis require that the patient should be watched
for signs of peritonitis. He should be kept quietly in bed, the bowels should
be moved by enema only, and no food except fluids should be given (see
Contusions of Abdomen, page 535).
Rupture of the Intestine. — Operation should be done at once for acute
rupture of the intestine with soiling of the peritoneum. The shock present
may be due to peritoneal irritation, abdominal trauma, or it may be confused
with hemorrhage. If shock is pronounced, the first step in the operation
should consist in exposing a vein for saline infusion. As soon as the abdomen
is opened, if hemorrhage is not found as a cause of the depression, an assist-
ant should proceed with the infusion. Shock is the important factor, and
should be combated by every means (see Vol. I, page 213). The abdomen
should be opened near the injury if there are localizing signs; otherwise the
opening should be made in the median line as it gives access to the largest
extent of intestine. The opening should be large enough for free examination.
The injury should be sought in the direction from which fluid comes or where
redness is present. As soon as it is discovered, the surrounding peritoneum
should be sucked or sponged dry, the rest of the peritoneum walled off with
sponges, and the injured bowel brought into the wound. The opening
should be sewed (see Intestinal Suture, page 626). If possible, rents should
be sewed transversely rather than longitudinally in order not to narrow the
lumen of the bowel. Further search should then be made for other injuries
which might demand surgical treatment.
If the condition of the patient is bad, it may rarely be best not to take the
time to suture the rupture but to bring the intestine into the abdominal
wound and suture it there with the view of establishing a fecal fistula.
The lower in the intestine the opening is the more feasible such a course
becomes (see Intestinal Fistulas, page 683).
It sometimes happens that the surgeon finds the intestinal wound closed
by agglutination to adjacent intestine or to some other part of the peritoneum.
Judgment is required to decide whether the adhesions shall be broken apart
and the rent sewed or whether they shall be left undisturbed. A living patient
is always to be preferred to a perfect piece of work in a dead patient.
If the occlusion by adhesions is complete, and the surrounding peritonitis
has subsided or is subsiding, it will often be good surgery to leave the con-
dition as it is. A later operation may be done if necessary to separate the
adhesions. If the occlusion, on the other hand is not complete, or if it is
soft and surrounded by an area of active peritonitis, no chances should be
taken with it; it should be separated and sewed.
The cases requiring most skill and judgment are those with injury about
the wound or injury of the mesentery which threatens gangrene (see Wounds
of Mesentery, page 568). Here the well-equipped surgeon is always on the
safe side in doing a resection of the bowel and anastomosis. If the condition
of the patient will not permit this, then the damaged bowel should be brought
in the wound for the formation of a fistula.
Irrigation is called for in these cases only when intestinal contents have
been spread rather widely away from the wound. Usually suction or spong-
ing should be relied upon to take up infective matter. The abdomen should
be searched wherever peritonitis or fluid leads in order to discover other
injuries.
The use of drainage and the subsequent treatment should be governed
by the rules already laid down for the treatment of peritonitis (page 546).
Drainage in most cases is not necessary (see Ulcers of Intestines, page 576).
THE ABDOMEN 567
Perforating Wounds of the Intestines.— The treatment of these wounds
is the same as that of rupture of the intestine. Penetrating wounds of the
abdomen have been described (page 535). Perforating bullet wounds should
be exposed if the surgeon can control the asepticity. of the operation. With
the modern small-caliber bullet these wounds are by no means always fatal,
and if aseptic and skillful surgery is not available the patient has a better
chance for his life by the application of an occlusive dressing, and the treat-
ment for peritonitis (see Peritonitis, page 546). This treatment should be
applied from the first, and peritonitis not awaited. The essentials are rest
and the inhibition of peristalsis.
Ordinarily the treatment of these wounds, as for incised, punctured, and
lacerated wounds of the intestine, is immediate exposure and suture.
Usually a median abdominal incision is best. Bullet wounds should be
closed by a single very fine purse-string suture. Small incised wounds require
a single suture. Larger wounds, involving a distance equal to more than
FIG. 1221. — SUTURING WOUND OF INTESTINE TRANSVERSELY.
This gives the least narrowing of the lumen.
one-third of the circumference of the bowel, may be closed by two layers of
suture. If the suturing of a wound reduces the caliber of the bowel more
than one-half, resection is to be preferred. Transverse wounds threaten
the vitality of the bowel less than longitudinal wounds. Wounds should be
sutured in such a manner that the caliber of the bowel is not reduced (Figs.
1 221 and 1222). This is best accomplished by sewing wounds transversely
to the long axis of the bowel whenever possible.
If the wound is not found at once, the direction from which fluid or blood
comes is the guide. If it is still not round, or after a single wound has been
found and the injury was inflicted in such a way as to warrant the suspicion
that other coils were wounded, a systematic examination of the whole length
of the intestine should be made. This should begin with the stomach and
follow the duodenum, jejunum, ileum, and colon. As each wound is found
it should be sutured. At the same time, wounds of the mesentery and other
structures should be given attention.
Ragged edges of a wound may require to be trimmed, and bleeding vessels
ligated. The important feature of the suture is that it shall oppose peritoneal
568
SURGICAL TREATMENT
surfaces and that no mucous membrane shall come into contact with peri-
toneum. In multiple wounds if intestinal contents run forth from each, it
is best to find all of the wounds and include each with a clamp before suturing
them. If extensive destruction of the intestinal wall is present, and there
is doubt as to its future vitality, or if suture will leave pronounced angulation
or narrowing of the intestinal canal, resection of the damaged segment is to
be preferred. Complete division of the intestinal canal requires end-to-end
or lateral anastomosis. Badly damaged areas, which are not perforated
but which may slough, should be turned in by sutur-
ing healthy peritoneum over them.
Wounds of the mesentery not involving its main
vessels may be sutured, but any damage to the nu-
trient vessels of the intestine occluding the vessel
should cause the surgeon to consider the advisability
of resection (see Wounds of the Mesentery below).
Wounds with loss of substance, or extensive lace-
rated wounds requiring trimming, located opposite
or nearly opposite the mesentery, may be closed by
angulation, if the simple suturing of the wound
would cause great narrowing of the intestinal tube.
Angulation consists in bending the bowel, so as to
double the wound upon itself, and sewing its edges
together (Fig. 1223). A second row of sutures is
added for purposes of security. If necessary the
wound may be enlarged opposite the mesentery in
order to secure an entero-anastomosis. When such
a wound is closed transversely, an angulation is pro-
duced but it is not of such a character as to narrow
the lumen of the bowel (Fig. 1224).
(For methods of suturing intestine, see Enteror-
rhaphy, page 621.)
Wounds of the Mesentery. — Punctured wounds
need not be sutured, if small. Larger wounds,
parallel to the vessels, should be sutured, care being
taken not to include any large vessel in the suture.
Wounds parallel to the bowel, if they cross one or
gives two iarge vessels, require resection of the bowel.
UcUlKClUUb UilllUWlIlg OI -r-, , ! i T i 1 1 ., 1
the lumen and should be Even though a wound be small, the contusion asso-
avoided whenever possible, dated with it may cause occlusion of adjacent ves-
sels, and demand resection of the bowel. No rules
can be laid down for determining the necessity for resection. Only experi-
ence can teach. Generally, if the peritoneum of the bowel has lost its
luster, if it looks dark and injected, and otherwise shows signs of lack of
circulation resection should be done. When there is doubt the surgeon is
on the safer side to resect. From the above it will be seen that the simple
suture of wounds of the mesentery is not much called for because wounds
large enough to require suturing are apt to have done so much damage to the
vessels as to demand more radical treatment (see Gangrene of Intestines,
page 609).
Nonperf orating Wounds of the Intestine with Wounds of the Mesentery.
— If the wounds of the mesentery do not destroy important vessels and in-
terfere with the nourishment of the bowel, they may be sutured; and at the
same time the wounds of the bowel are closed. If the wounds are extensive
and the denudation does not permit peritoneal suture, omentum should be
FIG. 1222. — LONGI-
TUDINAL SUTURING OF
WOUND OF INTESTINE.
This method
THE ABDOMEN
569
sewed over the raw surface. The use of omentum for this purpose plays two
important parts: it covers the wound with peritoneum, and thus guarantees
healing and obviates vicious adhesions, and it supplies nourishment to a
FIG. 1223. — WOUND OF INTESTINE TO BE CLOSED TRANSVERSELY BY SUTURE.
segment of the bowel which might later fall into a state of gangrene when
traumatic reaction further occludes the mesenteric vessels.
Infections of the Intestinal Canal. — Most of the enteritides are medical
diseases. In general, the treatment consists in emptying the bowel by a
IG. 1224. — CLOSURE OF WOUND BY TRANSVERSE SUTURE AND ANGULATION.
Note that this method of closure does not cause narrowing of the lumen of the bowel.
laxative, such as castor oil, and withholding food which is not wholly digest-
ible and assimilable. If the condition of the patient will permit, the
best results will be secured by allowing no food but water. Albumin water,
570 SURGICAL TREATMENT
fruit juice, whey, glucose, and clear broth leave little residue and offer all
the necessary food elements. These may be used if food is necessary.
Colitis should yield to the ordinary treatment for enteritis. If it does not,
irrigation of the colon through the rectum should be used. This is accom-
plished by placing the patient in the knee-chest position, or on the side with
the foot of the bed raised, and allowing ^ to 2 liters (i to 4 pints) of warm
fluid to run in the rectum slowly from a height of about 60 cm. (2 feet).
The amount should be small at first and increased with tolerance. The
fluid passes into the colon as far as the ileocecal valve, or farther, by reversed
peristalsis. Some of it is absorbed. It should be retained for ten or fifteen
minutes and then allowed to escape. If the rectum is irritable it may be made
tolerant by a preliminary injection of cocain, morphin or hyoscyamus.
First, saline solution should be used. If this does not effect a cure, a
mild antiseptic astringent solution may be employed. Borax or boric acid,
2 per cent, solution, to which is added i per cent, of the fluidextract of
hydrastis, is effective. Instead of the latter, tannic acid (i per cent.),
zinc sulphate (^f o °f x Per cent.), lead acetate (^5 of i per cent.) or aluminum
acetotartrate (i per cent.) may be used. A hot solution of alum, 4 c.c.
(i dram) in water 1000 c.c. (i quart), is useful in hemorrhage of the bowel.
Silver nitrate (i :2ooo) has been recommended. These treatments may be
given once or twice daily. When chronic colitis or colonic diarrhea does
not yield to internal treatment or irrigations, operative treatment has much
to offer. This consists in making a fistula for irrigation at the beginning of
the colon (see Enterostomy for Irrigation, page 572; and Appendicostomy,
page 571).
In amebic colitis (tropical dysentery due to the entameba), the general
strength of the patient should be preserved by careful diet and rest.
Milk diet or a strictly fluid diet should be given. Castor oil, magnesium
sulphate and other laxatives are useful. Bismuth subnitrate or subcar-
bonate in large doses may be given by mouth. About 12 to 24 Gm. (180 to
360 grains) in a glass of water are administered every three to six hours night
and day. The number of doses is diminished as the patient improves.
The specific treatment consists in the administration of emetin or ipecac.
Ipecac is given in salol-coated pills, 2 Gm. (30 grains) daily at a dose, dim-
inishing 0.3 Gm. (5 grains) daily till by the sixth day only 0.3 Gm. is given
at a dose. More effective than ipecac is its resinoid emetin. Injections of
0.3 Gm. (5 grains) are given once daily for a week or ten days. If improve-
ment is not established in three days of this treatment, it is doubtful if the
disease is due to the endameba. In conjunction with the medical treatment
local irrigation is of value.
Treatment with oil of chenopodium was recommended by W. Emrich
(Jour. Am. Med. Assoc., May 19, 1917). The following sequence is used:
15 to 30 Gm. (% to i ounce) of magnesium sulphate at 6 a.m.; i c.c. (16
minims) oil of chenopodium in gelatin capsules at 8 a.m., 10 a.m. and 12
m. ; 30 c.c. (i ounce) of castor oil, containing 3 c.c. (50 minims) of chloro-
form, at 2 p.m. This is the dosage for adults; for children it should be re-
duced according to age.
The amebae can be destroyed by local applications. They may be reached
by irrigation through the rectum. Irrigation is given as above described.
It should be given in the presence of the surgeon. The most effective solu-
tion is sulphate of quinin i 13000 up to i :5oo. The solution is best given
in the knee-chest position. It should be retained for the greater part of an
hour after the patient has gradually become used to it. Silver nitrate
in i : looo solution is also used in chronic cases. Irrigation through the
THE ABDOMEN
571
rectum is uncomfortable and often painful. To be effective a large amount
of fluid must be used. When the lesions are high it is difficult to reach them.
For these reasons a direct opening into the cecum gives much better results
and greatly shortens the period of treatment. Often without this the dis-
ease is incurable. Surgeons who have to treat many cases of this disease in
the Philippine Islands, are performing the operation earlier and earlier
instead of deferring it for the appar-
ently hopeless cases. The results are A ,
most satisfactory. An operation which
gives much satisfaction is appendicos-
tomy (see below). When the appendix
is not available, cecostomy (see below)
should be done. Surgeons are agreed
that amebic dysentery with lesions above
the sigmoid which has existed for more
than a year and has not yielded to irri-
gations through the rectum should be
treated through the cecum. The gen-
eral tendency is for the operation to be
done still earlier than this.
Continuous irrigation of the bowel
may best be carried out by a double
rectal tube; that is, a tube within a
tube, one connected for inflow and the
other for outflow. If this is not at
hand it may be made with two cathe-
ters. The catheters are passed
through a piece of rubber tubing, 8
cm. (3 inches) long. The distal end
of the outer tube should be beveled
so that it will enter the rectum
smoothly. The tube may be sealed
by filling the interstices around the
catheters with paraffin, wax or rubber
cement. The two ends should be 5
cm. (2 inches) apart. The outlet tube
should have at least two eyes (Fig.
1225). By applying clamps to the two
tubes the rapidity of flow may be regu-
lated. The two tubes may be clamped
alternately and the inflow and outflow
thus made to alternate.
The indications for intestinal irriga-
tion are not only colitis, but it is use-
ful in a great variety of conditions.
In shock and hemorrhage it is dis-
cussed elsewhere (see Vol. III). In
sthenic cases, in prolonged diarrhea
and other diseases which exhaust the fluids of the body it is most useful.
In gynecologic conditions in which the warm vaginal douch is useful,
rectal heat may have the same effect. Inflammations of the prostate, semi-
nal vesicles and bladder, spasms of the urethra are often helped by it.
Appendicostomy consists in fixing the vermiform appendix in the abdom-
inal wall, and using it as a fistula for irrigation of the colon. The operation
PIG. 1225. — DOUBLE TUBE FOR CON-
TINUOUS IRRIGATION OF BO\VEL.
Tube held by sphincter.
572
SURGICAL TREATMENT
was suggested by C. B. Keetley and first performed by R. F. Weir. It is
of service for the treatment of diseases of the colon such as mucomembranous
colitis, amebic colitis, some forms of chronic constipation, ileocecal intussus-
ception, ulcerative disease of the colon, as a substitute for typhlotomy in
acute obstruction in the large intestine, for medication of the lower ileum.
and as a means for administering nourishment in cases of combined gastric
and rectal or colonic disorder.
The operation is begun as the ordinary procedure for removal of the
appendix. A small opening, not larger than 5 cm. (2 inches), is made over
the appendix by the McBurney method of muscle splitting (see Vol. III).
The appendix is brought up through the wound. The meso-appendix
is secured to the peritoneum of the wound, and a similar stitch is placed in
the appendix opposite the mesoappendix. The retracted muscles are allowed
to drop together, and a stitch through the skin catches the appendix on either
side. The wound is then closed with the appendix projecting through it. If
the operation is done for acute obstruction, the appendix may be amputated
at once. Otherwise it is best to leave
it for two days until adhesions have
formed. The amputation is done flush
with the skin. If the appendix is am-
putated at once a purse-string suture or
a ligature should be thrown about it
after the catheter is introduced to pre-
vent leakage (Fig. 1226).
After amputating the appendix, the
artery may have to be ligated. The
mucous membrane may be caught with
fine forceps and fixed to the skin with
four sutures. The lumen may be di-
lated so that it will admit a No. 10 or 12
English catheter. It is well to leave
the catheter in constantly for the first
week to prevent contractions; after that
it may be inserted daily for treatments.
In bringing up the appendix it may be found involved in adhesions;
these should be divided. The surgeon should see that the appendix is
straight, so that angulation shall not prevent the introduction of the cathe-
ter. The appendix need not be drawn out until the cecum strikes the wound;
enough should be left in the abdomen so that the cecum lies in an easy
position. If adhesions are too dense or if the appendix has been destroyed
by inflammation, the operation of cecostomy may be done instead. When
the appendicostomy has performed its service, the opening may close spon-
taneously. If it does not close, the wound may be opened as before, and the
appendix amputated at its base as in appendectomy.
Cecostomy is done for the same conditions as appendicostomy. Of the
two operations cecostomy is to be preferred. The approach is the same. The
cecum is brought into the wound and a point in the anterior longitudinal
band selected for the opening. A valvular opening is made after the method
of gastrostomy (page 731). A purse-string suture is cast about the point
selected; and another similar suture placed around the first. A very small
opening is made into the cecum, and a catheter inserted through it into the
bowel. First the inner purse-string is tied, and then the outer, in such a way
that the wall of the cecum is pressed inward making a teat inside of the bowel
with the catheter emerging at its apex (Fig. 1227). The ends of the two
FIG. 1226. — APPENDICOSTOMY.
Showing appendix brought out through
abdominal wound and cecum sutured to
abdominal wall.
THE ABDOMEN
573
sutures are secured to the abdominal wall and the rest of the wound closed
about the catheter. Irrigation may be begun forthwith. Adhesions are
quite firm in two days.
C. L. Gibson, who described this operation in 1902 (Boston Med. and Surg.
Jour., Sept. 25), and whose idea preceded that of Weir for making a cecal
fistula for colitis, made a simple fold in the wall of the bowel by applying
two sutures and then a row of four sutures folding under the first two. A soft
No. 30 F. catheter is used.
The irrigations and dressings can soon be managed by the patient. The
catheter is introduced and the medicated fluid is thrown into the cecum and
expelled by the rectum. Some of the fluid enters the small intestine. Irri-
FIG. 1227. — CECOSTOMY.
Three purse-string sutures have been placed on the wall of the cecum. A catheter is
passed through a puncture in the abdominal wall and through a puncture in the purse-
string circle. The innermost suture is tied tightly around the catheter. The ends of the
other two sutures are passed through the abdominal wall on opposite sides of the puncture
and tied externally.
gation may be practised once daily, or more or less frequently as the case
may require. With such a fistula the cleansing of the colon is entirely in
control. Irrigation through the entire length of the colon may be continu-
ous if desired. By inserting a tube in the rectum the patient may be spared
the effort of expelling the rectal contents.
Colostomy and enterostomy for securing rest for the colon in the treat-
ment of diseases of that viscus are a useful combination. An artificial anus
is made at the lower end of the ileum and a cecostomy is done for purposes of
irrigating the colon. This operation is of value in chronic colitis, amebic
colitis, ulcerative colitis, tuberculosis, obstructive disease in which radical
operation cannot be done, and in chronic intestinal stasis.
574
SURGICAL TREATMENT
The abdomen is opened through the lower part of the right rectus muscle.
An appendicostomy or a cecostomy is made through a stab wound external
to the rectus opening, and a tube fixed in the cecum (see Appendicostomy,
page 571; Cecostomy, page 572). The lower end of the ileum is brought
into the abdominal opening in the right rectus muscle, and an artificial anus
made with a spur (see page 683) . A large rubber tube is fixed in the ileum
to carry discharges away from the wound. Later the tube is dispensed with.
If the opening of the bowel is deferred for a few days no tube need be used.
After a few days, irrigation of the colon may be practised as described
under appendicostomy and cecostomy. With a tube in the rectum irrigation
through the colon may be carried on
daily without discomfort or effort on
the part of the patient. The artifi-
cial anus in the lower end of the
ileum provides rest for the colon.
By this treatment much better re-
sults are secured than when the fecal
current is allowed to continue through
the colon.
This operation will do everything
for chronic intestinal stasis that can
be expected from the more formid-
able procedures. The discharge
from the ileum is much less offensive
than that from the colon. When the
disease is cured, the openings may
be closed (see Closure of Fecal Fis-
tula, page 616). J.Y. Brown (Surg.,
Gyn. and Obst., vol. xvi, 1913) di-
vided the ileum at the cecum, and
fixed the end of the bowel in the
wound, after closing the distal open-
ing, and placing a cecostomy tube in
the front wall of the cecum.
Through-and-through washing of
the bowel with sterile water or saline
solution may be done twice daily or
of tener. If any medicated substances
FIG. 1228.— RESECTED TUBERCULOUS COILS are used, the bowel should first be
OF INTESTINE. washed out. Such agents as quinin,
hydrastin, boric acid, silver nitrate
in o.c>3-Gm. (J^-grain) dosage, methylene blue, ichthyol, and iodoform are
used. It should be remembered that the large intestine absorbs these drugs
and the dosage should be regulated accordingly.
Acute phlegmonous inflammation of the intestine, if presenting abscess foci,
should be treated by free longitudinal incision of the abscess areas, and drain-
age. A case of interstitial infection of the descending colon was treated by
C. N. Dowd (Annals of Surg., vol. 56, 1912) by resection, with recovery.
Tuberculosis of the intestine requires the general treatment described for
tuberculosis (Vol. I, page 276). It usually demands operative treatment
when the above measures fail, or when symptoms of stricture, ulceration and
adhesions, or ulceration and diarrhea, call for relief. The best results are
secured by resection of the tuberculous bowel. This usually means resection
of the segments containing stricture. If a series of strictures are close to-
THE ABDOMEN 575
gether, the whole may be resected; if they are some distance apart each
segment separately should be removed. In case of a coil of intestines, matted
together by adhesions the whole coil may be resected (Fig. 1228). If such a
coil cannot well be removed the bowel may be divided immediately above
and below the disease and the two healthy ends united. The two ends of
the irremovable coil may be brought out through the wound and fastened,
for purposes of drainage and subsequent irrigation and medication. The
later removal of the disease should be planned.
It is possible that, if tuberculosis of the bowel were recognized before
stricture and adhesions had formed, local treatment may be of some service.
A valve fistula, such as described above for cecostomy might be made above
and below the disease, and irrigation and medication instituted, the fluid
being injected at the upper opening and allowed to escape through the cathe-
ter in the lower opening.
Tuberculosis of the cecum is the most common form of intestinal tuber-
culosis and should always be had in mind. Early cases should not be
operated upon as for appendicitis alone, and late cases should not be con-
fused with carcinoma. Whatever is done the appendix should be removed.
The extent of the disease and the condition of the patient must control the
operative procedure. As the disease is usually primary, early cases may be
cured.
Excision of the ileocecal segment of the bowel is the operation of choice.
It can be done in early cases in which the cecum is freely movable. It is
called for if the disease has not widely extended, if adhesions have not yet
made it impossible, and if the condition of the patient is good. The cecum
is lifted up, the mesentery of the ileum and colon are tied and divided, and
the diseased segment resected. The intestinal anastomosis may be a lateral
or end-to-end union. The lowest mortality is associated with resection in
two stages as for cancer of the intestine. Some surgeons prefer to do a
lateral anastomosis at the first operation, and then at a second operation to
do the resection. These latter operations are to be preferred to primary
resection.
Ileocolostomy will relieve most cases and cure many. The ileum is
anastomosed to the colon not nearer than 6 cm. (2^ inches) on either side of
the disease. A simple lateral anastomosis is made. This is of especial value
in cases with adhesions and obstruction. The symptoms are relieved, the
patient improves in strength, and may go on to recovery. Later the dis-
eased segment may be resected. For this reason the anastomosis should be
done far enough away from the disease to permit resection.
Intestinal exclusion may be combined with the above operation. If the
disease is extensive ileosigmoidostomy may be done, combined with exclu-
sion of the diseased bowel.
Artificial anus, just above the disease, in the lower end of the ileum, may
be done in desperate cases with obstruction. It should be followed by ileo-
colostomy or resection.
After performing ileocolostomy and exclusion, if ulceration is present,
direct medication may be applied by doing a secondary colostomy. Through
such an opening the disease may be directly cleansed and medicated. This is
rarely indicated, as healing rapidly takes place as soon as the fecal current
no longer passes through the diseased segment.
The same treatment as is described above for tuberculosis of the in-
testine may be employed. The general hygienic treatment is most important
(see Tuberculosis, Vol. I, page 276).
Actinomycosis of the intestine usually appears in the colon; the appendix
576 SURGICAL TREATMENT
and cecum are the common seats. By the time a diagnosis has been made it
usually has extended too wide for extirpation. The tissues break down and
an abscess or fistula forms. This should be incised and curetted out, remov-
ing in this way all that can safely be removed. Free drainage should be
secured. Local treatment is by peroxid of hydrogen, iodin or some other
antiseptic. The general treatment of actinomycosis is called for (see Vol. I,
page 272).
Typhlitis and perityphlitis are terms which once were applied to appendi-
citis. They still have a place in surgery, as inflammation of the cecum,
without appendicitis, sometimes requires treatment. Most cases belong to
the inflammations of the lining of the colon, the treatment of which is de-
scribed under colitis. I have seen these cases, often simulating appendicitis,
recover under a restricted regimen. The infection may invade the whole
thickness of the wall of the cecum and provoke peritonitis, precisely as occurs
in appendicitis, the appendix being involved but secondarily in the disease,
or abscess may develop beneath the peritoneum. I have operated upon such
cases, removing the appendix and otherwise conducting the operation as for
appendicitis. Gangrene of the wall of the cecum is sometimes found, either
as a primary disease or associated with gangrene of the appendix. The
gangrenous area should be excised and the wound closed with drainage.
Small gangrenous areas, which seem to have reached their limit, may be
inverted by sutures in the healthy bowel; this is not to be preferred to excision.
Pericolitis may occur where infection traverses the wall of the colon;
and require either the treatment described for peritonitis or for retroperi-
toneal infection.
Ulcers and Perforations of the Intestine.— Ulcer of the duodenum should
at first receive internal, treatment. This consists in improving the general
hygiene of the patient, abstinence from hearty meals, spices, and acids, and
the administration of certain substances to act directly upon the ulcer.
It is important that the stomach should not become dilated. Meals should
be small and dry. Water should be taken warm, and preferably when the
stomach is empty; it then passes into the duodenum and cleanses the ulcer.
Calcined magnesia 0.5 Gm. (8 grains) and subnitrate of bismuth 2.0 Gm.
(30 grains) are given 3 times a day, half an hour before meals. Adrenalin,
given by stomach, will relieve pyloric and cardiac spasm in most cases.
Olive oil, 30 c.c. (i ounce) morning and evening has been of service in some
cases. Rest in bed is demanded for cases with severe pain, gastric disturb-
ance or hemorrhage. It has been suggested that a highly proteid diet is of
value to take up the pepsin and trypsin which otherwise would attack
the ulcer.
Hort (British Med. Jour., Jan. 8, 1910) accomplished this by feeding
small dry meals, mainly of meat, and the use of an antilytic serum. He also
gave normal horse serum subcutaneously. Herschell (Clinical Journal, Aug.
10, 1910) insisted that a band should be worn to support the abdomen.
He neutralized the digestive ferments by a daily dose of horse serum, given
by mouth. All vegetables should be put through a sieve. Internal treat-
ment failing to give relief, or if perforation takes place, or serious narrowing
of the duodenum develops, or hemorrhage is intractable, operation should
be done.
B. W. Sippy (Musser and Kelly: Handbook of Practical Treatment,
Vol. Ill, 1911) treated peptic ulcers of the stomach and duodenum by neu-
tralizing the gastric juice. This is done by giving food at such times as are
necessary to keep the digestive juices absorbed by food, administering
alkalies between feedings, and emptying the stomach of juices during the
THE ABDOMEN 577
night. At first in most cases a restricted diet is given hourly from 7 a.m.
till 7 p.m. A powder containing 0.6 Gm. (10 grains) each of heavy calcined
magnesia and bicarbonate of soda is given between feedings, alternating with
a powder containing 0.6 Gm. (10 grains) of bismuth subcarbonate and 2 Gm.
(30 grains) of sodium bicarbonate. Larger quantities are given if necessary.
All this should be regulated by tests for acidity (Jour. Am. Med. Assoc.,
May 15, 1915). These are some of the medical conceptions of the treatment
of the disease. Their value is doubtful.
When I was treating these cases medically I found most gratifying results
from the administration of large quantities of water. The object of this was
to dilute the gastric juice, so that the acid solution which entered the
duodenum was a very weak one, and to irrigate the ulcer with a mild
acidulated fluid. I satisfied myself at least that cures were effected by this
expedient alone. No nonoperative treatment guarantees against recurrence.
Jejunal feeding has been practised with some success, using food which
has been subjected to artificial ptyalin, pepsin and acid digestion. Food
is introduced directly into the bowel through a tube passed through a
jejunostomy opening. This method is of value in ulcer of the stomach and
in ulcer of the duodenum.
Direct duodenal medication is applied by the duodenal tube, which the
skilled gastrologist is able to pass into the duodenum by way of the mouth
and stomach. With such a tube in the duodenum, the bowel may be washed
out, medication applied to the ulcer, and food injected into the jejunum.
These methods have not been generally adopted as routine measures.
E. C. Rosenow (Jour. Am. Med. Assoc., Nov. 23, 1915) has showed that
infections in the mouth, especially at the roots of the teeth are commonly
due to streptococci which are capable of provoking and perpetuating ulcers
of the pyloric region. Therefore these lesions in the mouth should be looked
for with the re-ray, and treated, as one of the first steps in the therapy of
peptic ulcers. So also should infections of the gall-bladder and appendix.
Indications for operation must vary with the condition of the patient and
the availability of skillful surgery. In general it may be said that operation
is indicated: (i) in cases of perforation; (2) in repeated, uncontrollable, or
constant loss of blood, either by vomiting or in the stools, or expressed by
subnormal hemoglobin in the circulation; (3) in uncontrollable pain; (4) when
contracture of the duodenum or pyloric spasm causes obstruction to the exit
of gastric contents; (5) when defective nutrition is interfering with the
health of the patient; and (6) in failure of medical treatment to cure the
disease after thorough trial. A characteristic of the symptoms of duodenal
ulcer is their intermittency. These periods of freedom from symptoms are
often interpreted as a cure. The permanence of medical cures cannot be
assured, and are always doubtful. Inasmuch as operation is capable of
giving positive results, it must be regarded as the treatment of choice in
unhealed chronic ulcers. Operation will cure most cases. Failures and
recurrences after operation are usually due to faulty technic.
Operative treatment of duodenal ulcer is the only guarantee of cure. The
operation of choice is excision of the ulcer and gastroduodenostomy or
pyloroplasty to provide free drainage of the stomach. The ulcer should be
removed by an elliptic or circular excision of the whole thickness of the
ulcerated area of duodenal wall. The cases in which excision cannot be
done are those with much thickening, induration and adhesions. In these
gastrojejunostomy is easier; but the surgeon may often excise the ulcer in
these cases after the gastrojejunostomy has been done.
Excision is called for especially if hemorrhage has been a serious feature
VOL. 11—37
578 SURGICAL TREATMENT
or if the ulcer is near to perforation. All of this can be done without exclud-
ing the remaining healthy duodenal mucous membrane from the energizing
contact of the gastric juice. Excision of the ulcer is usually a simple matter,
because the ulcer is usually single and situated in the upper and anterior
aspect of the gut.
Ulcers of the anterior wall, if small and without much induration, may be
treated by excision without doing pyloroplasty or gastro-enterostomy. But
in doing this operation the surgeon should be sure that there is not a contact
ulcer on the opposite side of the duodenum; and the wound should be closed
in such a manner as not to narrow the bowel caliber.
Pyloroplasty has been advocated especially by J. M. T. Finney as the
operation of choice. It possesses the merit of exposing the ulcer and per-
mitting excision at the same time if on the anterior wall. This operation
surely provides adequate drainage. Finney claims that it gives every advan-
tage that gastrojejunostomy gives, and does not create the abnormal con-
ditions which characterize gastrojejunostomy. Moreover, it is a more simple
operation. It is highly possible that this operation is destined to become
the procedure of preference (see Pyloroplasty, page 740). The essential sur-
gical treatment is free drainage of the stomach and relief of an ulcerated
area from the irritation of gastric juice. There is a growing feeling among
surgeons that excision is the rational treatment of ulcers. If excision is
not done, gastro-enterostomy or pyloroplasty is urgently called for. These
operations are probably the only curative treatment. Nonoperative treat-
ment produces only doubtful cures.
For certain cases, jejunostomy may be done. This operation is capable
of giving rest to the diseased bowel. By feeding the patient through a tube
hi the jejunum, nothing but stomach and duodenal juices come into contact
with the ulcer. These juices may be greatly diluted by having the patient
take an abundance of water by the mouth.
Gastrojejunostomy continues to be the operation of choice with many
surgeons. Closure of the duodenum after gastrojejunostomy, in order to
exclude it entirely from the irritation of food and gastric juice, is of doubt-
ful value. The gastrojejunostomy alone is capable of curing most ulcers.
At the same time, the gall-bladder and appendix should be examined and
operated upon if found infected.
It is wise in some cases to infold the ulcer-bearing area in these cases
with stout thread in order to occlude the duodenum and cover the base of
the ulcer. The suture may be placed for the special purpose of causing
obstruction. It produces a plication of the duodenum. Obstruction pro-
duced by this external suturing is not permanent, but it lasts long enough
to allow the ulcer to heal.
If the ulcer recurs after gastrojejunostomy, it is easy enough to do an
operation for permanent occlusion of the pylorus. This may be done by divid-
ing the pyloric end of the stomach and closing the two ends. Or a band of
fascia cut from the sheath of the rectus may be passed about the pyloric
end of the stomach, woven under the peritoneum, and drawn down tightly
enough to close the lumen.
The effectiveness or necessity of permanent occlusion is doubtful. It
surely has some positive disadvantages. This expression is prompted by
the finding that intestinal digestion and assimilation are much dependent
upon the secretion of the duodenal mucous membrane, and that this secretion
is poured out in response to the stimulus of gastric juice. Occlusion of the
duodenum, of course, must be done in cases in which perforation is threaten-
ing, and excision of the ulcer is not done. It is also well in such cases to
THE ABDOMEN 579
cover the ulcer base with omentum. If excision of the ulcer is not done,
gastroenterostomy may be regarded as the operation of choice. Excision
of the ulcer and simple closure of the wound are rational additions to it, but
by no means essential for a cure.
W. J. Mayo has called attention to the "curative effect of perforation,"
showing that after perforation and recovery of the patient from the peritoni-
tis, the ulcer heals. He has duplicated nature's method in some cases, cut
out the center of the ulcer, closed the wound, and secured healing.
Operation for perforating duodenal ulcer is quite a different matter. This
is not an uncommon disease, and, because of the tendency of the infection
to travel down the outer side of the ascending mesocolon, is sometimes treated
as appendicitis. As about 90 per cent, of duodenal ulcers occur on the an-
terior surface of the first portion, access to the lesion is not difficult.
(a) In acute perforation through the peritoneum, with rapid escape of
much duodenal contents into the general peritoneal cavity, the patient
rapidly goes into a state of shock, and any treatment to save life must be
quickly applied. The fate of the patient depends much upon the promptness
of operation. After twenty-four hours, operation offers little hope; within
the first eight hours operation can save the patient without question. Opera-
tion should be done as soon as possible; shock is no contraindication.
Measures to combat shock should be employed at once with the prepara-
tion for operation. No single treatment has greater value than an intra-
venous infusion (see Shock, Vol. I, page 213; Shock in Peritonitis, pages
546, 551; Rupture and Wounds of Intestines, page 566). The duodenal
region should be exposed as soon as possible. All of the foreign matter
should be aspirated or sponged out. Even though widespread, irrigation is
undesirable. The opening in the bowel should be closed with a purse-
string suture of linen or an infolding suture may be applied. It is well also
to place an edge of omentum over the place of suture, and hold it there by a
few stitches. Drainage may or may not be used. If there has been pus
and plastic lymph, drainage should be employed; a pelvic drain is essential.
The operation should be rapidly completed.
If the perforation is in such a position that it cannot easily be sutured,
a drain should be carried down to it, and gauze packing should hold back the
intestines from the drainage tract.
These acute perforations are the common cases. J. B. Deaver and many
other surgeons treat them by adding posterior gastrojejunostomy to the
plication of the perforated duodenum. The surgeon must be guided by the
ability of the patient to bear further operation, and his own ability to per-
form gastro-enterostomy quickly. Gastro-enterostomy is desirable in most
cases because the plication or suture of the ulcerated area narrows the
lumen of the duodenum and produces more or less duodenal obstruction.
Some surgeons are not deterred even by suppurative peritonitis.
(b) In acute perforation through the peritoneum, in which the amount
of duodenal contents to escape is small, the infection may remain localized to
a limited area and become walled off by adhesions. This abscess should be
opened and sponged out, and the perforation closed with a suture. The
area should be drained for a few days. It may occur in these cases, if they
are not promptly operated upon, that additional leakage causes the limit-
ing adhesions to give way and the infection to become a diffuse suppurative
or septic peritonitis.
(c) In chronic perforation through the peritoneum, in which plastic
exudate and adhesions cause a thickening over the inflamed area, represent-
ing the floor of the ulcer, perforation may be so gradual that it amounts
580 SURGICAL TREATMENT
simply to the infection of a small surface of plastic fibrin. These cases may
not come to operation until the extra-intestinal adhesions cause disturbance
of function, long after the ulcer has healed. Adhesions about the duode-
num are so common that this condition is perhaps more frequent than is
supposed. In some of these cases, actual perforation does not take place,
the ulceration stopping short of the peritoneum, but the inflammation pene-
trating it.
(d} In chronic perforation into the retroperitoneal space an abscess be-
hind the peritoneum may result. This is the rarest condition. The abscess
migrates externally, heals spontaneously, or it may rupture into another
viscus (see Retroperitoneal Abscess, page 563). It requires the treatment
of retroperitoneal infection.
In any form of perforation with peritonitis other openings may have to
be made for drainage of regions remote from the duodenum. This applies
especially to the right flank. Gastro-enterostomy may be done in the
chronic and less acute cases. Usually the conservative policy consists in
attention to the perforation alone, and later, if pyloroplasty or gastro-
enterostomy is indicated, it may be done. If hemorrhage is a feature of
the case, excision of the ulcer and ligation of the bleeding vessel is demanded.
The results in perforated ulcer depend much upon the promptness of
operation. Cases operated upon within five hours of the perforation may be
expected to recover, after removal of foreign matter, and closure of the per-
foration. After ten hours, the prognosis grows more serious, but recovery
may be expected in the majority of cases. After fifteen or twenty hours the
the prognosis becomes grave, except in the limited and chronic cases.
Pyloroplasty or gastro-enterostomy may properly be added to the primary
operation, if the operation is done within ten hours after the perforation, if
the general condition of the patient is good, if the surgeon has skill in this
procedure, and if it can be done under the best of operative conditions.
Otherwise the primary operation upon the perforation should suffice.
Jejunal ulcer and gasirojejunal ulcer are commonly results of gastro-
jejunostomy and must be prevented by a proper technic. Usually these
ulcers have been found to be due to linen or silk thread used in the gastro-
jejunostomy, the unabsorbed thread causing the irritation which produces
the ulcer. This is obviated by using chromicized or other slowly absorbable
catgut in the mucous membrane. The treatment of the condition calls for
separation of the jejunum from the stomach, closure of the two openings,
and the performance of pyloroplasty to provide free drainage of the stomach.
If the adhesions prevent this operation then the ulcer should be exposed by
incision through the wall of the stomach or duodenum. The ulcer and
sutures should be removed, and the wounds closed. If there is much indura-
tion and contracture, precluding pyloroplasty, the anastomosis must be
separated and a new gastro-enterostomy done in sound tissue.
Perforating typhoid ulcer does not yet receive adequate treatment.
Comparatively few cases are saved. It is estimated that about one-third
of the deaths from typhoid fever are due to perforation. In the U.S. Army
in 1899 I saw many cases of typhoid; in which, death was due to perforation
in 90 per cent, of those coming to autopsy. Perforation occurs usually be-
tween the fourteenth and twenty-first day of the disease, most commonly in
the lower ileum. Most perforations occur in the last 30 cm. (12 inches) of
the ilium. The ileum higher up, the cecum, or vermiform appendix may be
the seat of the perforation. The opening in the gut varies from the size of a
a pin to that of a lead pencil (i to 7 mm.).
The operation should be done as soon as the disease can be recognized,
THE ABDOMEN 581
sudden pain, tenderness, and rigidity being the chief signs. The patient
should be fortified against further shock (see Shock, Vol. I, page 213;
Prevention of Shock, page 532; Peritonitis, page 546; Rupture of Intes-
tines, page 566). Ether and nitrous oxid anesthesia is borne well by these
patients. The lesion is best exposed at the site of greatest tenderness.
This is usually to the right of the median line just below the level of the um-
bilicus. The opening in the abdomen is best made at the outer border of
the rectus. If the lesion does not come at once into view, the ileum should
be found by first identifying the cecum. Intestinal contents, serum, and
plastic lymph should be aspirated or sponged away. The perforation, if
small may be closed with a purse-string, or in-folding suture of fine chromic
catgut. Usually the intestinal wall will be found thin about the perforation,
and the suture should embrace all coats. A second suture may then be
applied transversely to the gut, not penetrating the whole wall of the bowel,
and covering in the first suture. Drainage is probably best dispensed with
excepting in late cases in which the patient has survived long enough to
produce an abscess.
More than one perforation may sometimes be found. Subsequent per-
foration should be similarly operated upon. In the region of the perforation,
thin, necrotic-looking places will often be found at the first operation. These
mark the site of other ulcers, and if the condition of the patient will permit,
it is wise to infold these thin areas by a row of transverse sutures, passing
through serosa and muscularis. Where necrotic gut or multiple perforations
with necrosis are found, the making of a resection or fecal fistula must be
decided by the exigencies of the case.
Typhoid ulcers perforating the appendix should be treated by removal of
that organ. Perforation of the colon or other viscera is to be treated by the
methods already described.
The mortality from typhoid perforations should be lowered. Consent
to operate should be secured in all cases of typhoid before perforation is even
threatened, and a surgeon should be in touch with the medical attendant
from the beginning. It should be well understood that a perforation not
recognized early and operated upon early, reflects seriously upon the com-
petency of those responsible in the management of the case. The modern
treatment of typhoid is rapidly eliminating this disease.
Tubercular perforation of the intestine is usually a chronic perforation, pre-
ceded by adhesions which prevent diffuse peritonitis. The area of local peri-
tonitis should be exposed and drained. An intestinal fistula results, the
resection of the diseased bowel may be performed at the first operation or
undertaken later. The perforation is usually an incident of lesser impor-
tance in a more serious disease (see Tuberculosis, Vol. I, page 276; Tubercu-
losis of the Intestine, Vol. II, page 574).
Malignant perforation of the intestine is that of cancer of the bowel. It
perforates somewhat like tuberculosis, the perforation being preceded usu-
ally by adhesions which confine the infection. The treatment becomes that
of the original disease, fecal fistula, and intestinal obstruction.
Perforation of gaseous cysts is very rare and requires infolding or excision
of the cyst wall with suture of the opening.
Suppurative perforation occurs from without inward. A walled-off peri-
toneal abscess or an extraperitoneal abscess becomes adherent to the bowel,
and perforates through its wall, discharging pus into the intestinal canal.
Such abscesses often heal spontaneously, or they may become reinfected and
repeatedly discharge. Usually it is well to give such an abscess an oppor-
tunity to heal without interference. If it continues to fill and empty, it
582 SURGICAL TREATMENT
should be exposed and treated externally. The intestinal fistula which re-
mains may require subsequent treatment.
Duodenal fistula is one of the most serious results of duodenal perforation.
In operating, every effort should be made to prevent it, as a duodenal
fistula tends not to contract but to enlarge; the combined secretions of the
stomach, liver, duodenum and pancreas are poured out in enormous amount;
the skin and surrounding tissues are prone to become ulcerated and necrotic;
the patient rapidly loses strength; and death has been the result in most
cases. This condition can in no sense be thought of lightly as an ordinary
intestinal fistula. As soon as the fistula is discovered, and before the
patient has become greatly reduced, feeding by mouth should be stopped.
The patient should be given nourishment and fluids by rectum. Glucose
and bicarbonate of soda should be given. To prevent digestion of the skin
the sinus should be kept filled with petrolatum. Atropin and adrenalin
inhibit gastric secretion. An alkaline solution, allowed to flow into the
fistula, by the drip method, is often curative.
By giving the patient large quantities of liquid paraffin by mouth the
fistula may be kept bathed with this fluid. The bowels should be kept
open with castor oil. Gradually foods which do not excite much gastric
secretion may be given.
If the surgeon desires to undertake operative treatment, it should be
instituted before the patient becomes hopelessly weak. Gastrojejunostomy
is capable of draining the stomach; and, by combining the operation with
pyloric occlusion, the duodenum is relieved of the presence of gastric con-
tents. Dissecting out the fistula and closing the opening in the bowel, as
can be done lower in the intestine, is possible with skilled hands.
Perforation of the colon may result from any of the ulcerative conditions,
and requires treatment not essentially different from that of the small
intestine. Diffuse soiling of the peritoneum is not so apt to be present. If
there is any question as to the expediency of suturing the opening, it is
always wise to make an artificial anus.
Tumors of the Intestines. — The intestines being composed of epithelium,
glands, muscle, connective tissue, fat, blood-vessels, lymphatics and endo-
thelium, may be the seat of a great variety of new growths. The treatment
of these does not differ from that of tumors elsewhere, excepting that they
produce or threaten intestinal obstruction or stasis, and then the treatment
must be aimed to meet those conditions.
Benign tumors should be removed if they cause symptoms (see Tumors,
Vol. I, page 323). If discovered unexpectedly the judgment of the surgeon
must determine whether the tumor is growing or is apt to make future trouble.
The possibility of even a small tumor causing intussusception, polypus or
other obstructing condition is so great that the removal of any tumor of the
bowel wall should be regarded as conservative surgery, provided the condi-
tion of the patient does not contraindicate the operation. Resection of the
bowel should be done if the closure of the wound after removal of the tumor
is going to narrow the lumen more than 33 per cent. In some cases closure
by angulation can be done (see page 569). Polypoid adenomata should be
removed wherever discovered because of their tendency to produce intus-
susception, hemorrhage and to undergo malignant degeneration.
Cysts of the intestinal wall should be removed. If possible this should
be accomplished without incision of the mucous membrane (see Cystomata,
Vol. I, page 325). Gaseous cysts, if uninfected, may be incised, the interior
irritated with iodin and the wound closed. Infected cysts should be treated
THE ABDOMEN
583
as abscess of the wall of the bowel, the infected fluid evacuated and drainage
established.
FIG. 1229. — OPERATION FOR CANCER OF THE COLON WITH SERIOUS SYMPTOMS OF INTES-
TINAL OBSTRUCTION.
First operation. An artificial anus is made above the tumor. This saves the patient from
obstruction. Note disease of bowel some distance below the opening.
Malignant tumors may occur in any part of the alimentary canal. Sar-
coma of the intestine is usually fatal inside of a year. Treatment inaugurated
FIG. 1230. — OPERATION FOR CANCER OF COLONT.
Second operation. The loop of bowel with the tumor is fastened outside of the abdomen
through a lower wound if the mesocolon is long enough to permit.
after symptoms begin usually is too late to save the patient. The cases that
will be saved by operation are those in which the tumor is accidentally
584
SURGICAL TREATMENT
discovered in an early stage. The small intestine is commonly the seat of
the disease.
Carcinoma occurs usually in the colon. The sigmoid flexure, the cecum,
the splenic flexure, the hepatic flexure, the transverse and the ascending
Third operation.
FIG. 1231. — OPERATION FOR CANCER OF COLON.
The tumor with the adjacent bowel is removed. This leaves two colos-
tomy openings.
colon are the common sites. Surgical treatment offers much in this disease
if applied early. Ulceration of the mucous membrane is usually present
when these cases come to treatment, and the region of the disease is in
FIG. 1232. — OPERATION FOR CANCER OF COLON.
Fourth operation. The spurs in the colostomy openings have been divided and the
openings in the bowel and abdominal wall closed. The bowel is left attached to the ab-
dominal wall.
an infective state. In addition to this there is often stasis above the tumor,
and the patient is not only suffering with cancer but intestinal obstruction
THE ABDOMEN
585
also. This may be chronic or acute. For these reasons a completed cura-
tive operation in one stage cannot often be done.
The best results have been secured by operating for carcinoma in two
or more stages. Each case is peculiar. Many are best treated by doing
first a colostomy well above the disease, making an opening where it will not
conflict with the later operation (Fig. 1229). This relieves the obstruction
and drains the bowel. After a week or two of recuperation, the tumor is
exposed and a curative operation accomplished if possible by wide resection
of the growth. The two ends of the bowel are brought into the wound and
fastened there. Then at the convenience of the surgeon and patient the
fistulae may be closed. This series of operations can be done without
operative mortality.
In some cases all of these operations can be done without exposing the
peritoneum to infection from the bowel at any time. Thus, if there is not
acute obstruction, the colostomy may be done by fixing the gut in the wound
FIG. 1233. — OPERATION FOR CANCER OF COLON.
Fifth operation. The two loops of intestine which are adherent to the abdominal
wall are detached and the raw surfaces covered with peritoneum. The bowel is freed, its
continuity is reestablished, and the tumor has been removed with the minimum of ex-
posure of the peritoneum to infection.
and opening it thirty-six hours later when adhesions are present; if the tumor
is sufficiently movable, the segment of intestine bearing it may be brought
entirely through the second wound and sutured (Fig. 1230), and the resection
done with the cautery as an extra-abdominal operation when adhesions
have formed (Fig. 1231); and next the two intestinal fistulas may be closed
by dividing the spurs between the distal and proximal arms, and then fresh-
ening and suturing the external wounds (Fig. 1232). A still later operation
may be done to liberate the bowel from its attachment to the two places
in the abdominal wall (Fig. 1233). In cases of cancer of the sigmoid, for
example, one operation may be done on the right side and the other on the
left side.
Cases, in which the obstruction is not a pronounced feature, need not
have the preliminary colostomy. The growth may be brought out of the
wound and the resection done later. In this operation, the bowel should
586
SURGICAL TREATMENT
have; been well cleaned out, and, it may be best in the interim between
the two operations, that nourishment should be by some other route than the
stomach. The object of this is to prevent the ileus which might supervene
on account of the evisceration.
In the colon the loop of intestine, having the tumor at its apex, is united
for a distance of 10 cm. (4 inches) by a continuous suture in two lines (most
FIG. 1234. — LOOP OF INTESTINE WITH CANCER FIXED OUTSIDE OF ABDOMEN.
Showing bowel united to bowel to form a spur. This is the operation of choice in cases in
which intestinal obstruction has not developed.
surgeons make but one line of sutures). The tumor is brought out through
the abdominal wound and the bowel sutured to the wound-edges (Fig. 1 234) .
At the end of three or four or five days, more or less, the loop of bowel,
carrying the tumor, is amputated. No anesthetic is required. A few minute
vessels may need to be tied. The wound surfaces are covered with a thick
layer of petroleum jelly, and a dry gauze dressing applied. If there is much
obstruction or question as to the vitality of the bowel, the resection may be
THE ABDOMEN
587
done at once, and a large-sized tube fastened in the upper segment to carry
the discharges into a receptacle. Preferably the resection is deferred. Ten
days or more after the resection a long pair of straight forceps is made to
grasp the septum between the two limbs of the bowel, one blade being passed
into each opening. It should be tightened a little every day (Fig. 1235).
In a few days the pressure of the clamp has caused necrosis of the septum
between the suture lines and a wide communication is established (Fig. 1236).
This usually takes about five days. The later treatment is for closure of the
FIG. 1235. — TREATMENT OF CANCER OF BOWEL.
The loop of intestine, bearing the tumor, has been amputated and the spur clamped.
fistula (page 616). This is the most satisfactory and least dangerous opera-
tion for cancer of the colon.
In many cases the shortness of the mesocolon will not permit sufficient
evisceration to make this operation possible. In that event the mesocolon
and any enlarged glands are dissected free from the back of the abdomen,
and the gut bearing the tumor brought forward through the wound. This
may mean that the mesocolon is divided completely through both layers.
In from thirty-six hours to four or more days, the segment bearing the tumor
588
SURGICAL TREATMENT
is resected. Or the resection may be done at once after the bowel has been
sewed to the wound edges. In the small intestine the upper end may be cut
off 5 to 7.5 cm. (2 to 3 inches) from the skin; and the two ends united by anasto-
mosis suture or connected by a large tube. If the tumor is low down, a
tube may be placed in each opening separately (Fig. 1237).
As a means of treating the distended loop of bowel above the tumor the
glass tube is most useful. It permits keeping the parts clean while the pa-
tient is recovering from the obstruction (Fig. 1238).
Carcinoma of the intestine, if removable, may, of course, be treated by
one complete operation; resection, enteroanastomosis and closure of the
wound. In many cases this treatment may be employed. They are the
cases in which the disease is discovered early before acute obstruction has
developed, and the resistance of the patient is good.
FIG. 1236. — CLOSURE OF ARTIFICIAL ANUS.
The pressure of the clamp has caused necrosis of the spur between the two loops and a wide
communication is established.
In some of these cases the method of entero-enterostomy with the
elastic ligature may be employed. The loop with the growth is brought
out through the wound and a lateral short-circuiting anastomosis made
with the elastic ligature (page 675) about 7.5 cm. (3 inches) from the
tumor. The anastomosis is returned to the abdomen. The bowel is then
clamped for resection of the tumor. A purse-string suture is placed around
each arm of the bowel between the growth and the anastomosis. The
distal limb is divided, its end closed and dropped back into the abdomen.
The tumor is then removed by amputating through the proximal limb and
a glass tube is fixed in the bowel. When the elastic ligature cuts through,
the discharge from the tube stops and the bowel and abdominal opening
may be closed.
THE ABDOMEN
589
An unfortunately large class of cases is not amenable to any of the above
methods. These are the cases in which there are metastatic deposits or
involvement of irremovable structures. Palliative measures are to be
employed here. An artificial anus may be made in the bowel above the
growth, an anastomosis may be made between the intestine above and below
the tumor, or some of the other palliative measures employed (see Inoperable
Carcinoma, Vol. I, page 327).
Carcinoma of the sigmoid is most successfully treated. Metastases are
late, and often a wide resection may be successfully made in advanced
cases. In the cecum, if the growth is one capable of being removed, it is
usually best to excise the tumor and do an ileocolostomy at once. If the
FIG. 1237. — GLASS TUBES FOR DRAINAGE OF BOWEL.
The two limbs of the colon are sewed together and a tube fixed in each.
growth cannot be removed, the best operation is still ileocolostomy, connect-
ing the lower end of the ileum with the ascending colon well beyond the
tumor.
The lymphatics of the colon follow the course of the blood-vessels. For this
reason, to make resection of the bowel for cancer complete the mesocolon
and the mesocolic vessels should be removed. J. K. Jamieson and J. F.
Dobson (Annals of Surg., 50, 1909) showed that for cancer of the cecum or
ileocolic region a radical resection demands removal of the lower 15 cm. (6
inches) of the ileum and the colon beyond the hepatic flexure. The lower
border of the third part of the duodenum should be exposed, the peritoneum
590
SURGICAL TREATMENT
divided and the ileocolic vessel found. The fatty tissue around the vessels
should be stripped downward with gauze, and the artery and vein tied close
to the superior mesenteric artery. Then the corresponding wedge of meso-
colon and intestine should be removed (Fig. 1239).
For the radical removal of cancer at the hepatic flexure, greater difficulty is
encountered because of the early involvement of the pancreas, duodenum
and other neighboring organs. For removal of the lymphatic area, the
middle colic artery should be divided at its roots close to the superior mesen-
teric. This removes the blood-supply of so much of the colon that it must be
followed by removal of the lower 15 cm. of the ileum, all of the ascending
colon, and half of the transverse colon (Fig. 1240).
E
FIG. 1238. — DRAINAGE OF LOOP OF INTESTINE.
The single large glass tube provides drainage of the obstructed bowel and permits keeping
the skin and wound clean.
For removal of cancer in the middle of the transverse colon, the lymphatics
lie close to the bowel, and it is only necessary to remove 8 or 10 cm. (3 or 4
inches) of bowel on either side of the growth together with the attached
wedge of mesocolon.
For cancer near the splenic flexure, the left colic artery should be exposed as
it leaves the inferior mesenteric vein and tied with its vein. The bowel sup-
plied by these vessels must then be. excised. This usually means the last
third of the transverse colon and the upper half of the descending colon
(Fig. 1241).
For cancer of the descending colon, the left colic artery must be tied at the
point where it leaves the inferior mesenteric vein and also the upper sigmoid
artery near its origin. The bowel to be removed is the left third of the
THE ABDOMEN
591
transverse colon, the descending colon, and the upper part of the sigmoid
flexure (Fig. 1242).
COLON
ILEUM
FIG. 1239. — CANCER OF CECUM.
Showing extent of bowel and mesentery to be removed.
For cancer oj the lower part of the sigmoid and upper part of the rectum,
the glands which require removal lie along the inferior mesenteric artery
COLON
FIG. 1240. — CANCER OF HEPATIC FLEXURE OF COLON.
Showing extent of bowel and mesentery to be removed.
and the superior hemorrhoidal artery from the origin of the left colic
downward. The operation consists in exposing the inferior mesenteric artery
592
SURGICAL TREATMENT
and tying it and the vein just below the place of origin of the left colic artery.
The mesosigmoid is then divided downward from the point of ligation to the
middle of the sigmoid flexure. The secondary arches of the sigmoid artery
should not be damaged. The peritoneum is then divided along the inner
side of the artery to the inner side of the mesorectum. The lymphatic
and mesocolic tissue is then stripped forward from the hollow of the sacrum
and the middle sacral artery is tied. The peritoneal reflection between the
bladder and rectum is then divided (Fig. 1243) (see Cancer of Rectum,
Vol. III).
For cancer of the middle and upper part of the sigmoid, the same procedure
as described above is followed. A larger amount of mesocolon is removed.
The bowel is divided above at the end of the descending colon, and below it
should be divided about 15 cm. (6 inches) beyond the growth (Fig. 1244).
COLON
INFERIOR
nCSENTERIC
VEIN-
LIGATURE or
LETT COLIC
ARTERY
FIG. 1241. — CANCER OF SPLENIC FLEXURE OF COLON.
Showing extent of colon and mesocolon to be removed.
If the surgeon would take into account the lymphatics and eliminate
every possibility of recurrence, the operation must be carried out in compli-
ance with these requirements. This is not possible in some cases, and
not necessary in others.
Remarks on Cancer of the Colon. — Before operating everything should
have been done to put the patient in the best possible state of physical
resistance. A laxative should not be given within twenty-four hours of the
operation; if one is required it is best that it should be administered not
nearer than forty-eight hours to the operation. The reason for this is that
if resection is done, it is better performed in the presence of a dry intestine with
solid contents than in the presence of watery feces.
A free incision should be made so that a thorough exploration may be
conducted. The liver should be examined. Enlarged lymphatics do not
THE ABDOMEN
593
FIG. 1242. — CANCER OF DESCENDING COLON.
Showing extent of colon and mesocolon to be removed.
FIG. 1243. — CANCER OF MIDDLE OF SIGMOID FLEXURE.
Showing extent of bowel and mesocolon to be removed.
VOL. 11—38
594
SURGICAL TREATMENT
necessarily mean cancer. Masses of enlarged glands may sometimes be
removed and found entirely free from cancer.
If the cancer is adherent posteriorly it may be necessary to remove the
ureter or the kidney also. Extension of the growth to the abdominal wall
calls for resection of as much of the latter as is necessary.
In some cases one or more loops of small intestine may be adherent and
involved in the growth. There resection and end-to-end or lateral anasto-
mosis is not difficult; the same of involvement of the ovaries, tubes or uterus.
The growth will sometimes be found attached to the bladder. Resection
of this viscus should be done without hesitation. The organ may be sutured
and a good result hoped for.
Operation in one stage, with resection of the cancer and anastomosis of
the bowel, is rarely justifiable in cases which have even moderate obstruction.
FIG. 1244. — CANCER OF SIGMOID AND RECTUM.
Showing extent of bowel and mesocolon to be removed.
The vitality of the bowel is damaged, and sutures may not hold. This is
the condition in the majority of cases; and the surgeon should not be tempted
to do a completed operation. It is much wiser to do cecostomy if the ob-
struction is urgent. If the obstruction is not a pressing factor, the operation
in which the diseased loop is fastened outside of the body, and later resected,
is by all means the safest operation. This operation is especially applicable
to the second half of the colon. Colostomy just above the disease, which
may be resected with the tumor at a later operation, is to be considered for
some cases.
If the surgeon plans a wide resection with removal of mesocolon and
vessels, an end-to-end anastomosis may be made or the bowel ends may be
sewed in the abdominal wall. In the latter case the upper opening serves
as an artificial anus and the lower for irrigation of the distal bowel. The
wide resection, with the view of removing the lymphatics, is the ideal opera-
THE ABDOMEN 595
tion, and should be done if the condition of the patient will permit and the
hopefulness of the case seems to warrant. It is often wise to proceed with
this extensive resection after a simple loop operation has been done, the
tumor removed, and the patient brought to a good state of resistance.
In resections of the sigmoid or descending colon, a good-sized rubber
tube with several openings at the upper end may be passed through the
anus and up above the anastomosis, and contribute materially to lessening
the strain on the sutures, as advised by D. C. Balfour.
Intestinal Obstruction. — Acute intestinal obstruction demands not only
judgment and technical skill but also experience for its best treatment.
Time must not be lost. Operation should not be reserved as a last resort.
It is the conservative treatment, and should be applied at once. The mor-
tality increases with each hour that operation is deferred. Mistakes of
diagnosis are not so serious as delay of operation. The conditions which
may be mistaken for acute obstruction are also conditions requiring opera-
tive treatment.
If the patient is suffering intensely from prostrating pain, and the condi-
tion is recognized as one of acute obstruction, a single injection of morphin
should be given. But it should be understood that this is a preliminary to
operation; and the relief that follows it should not benumb into inactivity
the surgeon also. Morphin should not be given repeatedly nor should it be
ordered excepting by the surgeon who has determined that operation should
at once be done. This does not refer to diaphragmatic pleurisy or to renal
calculus, but to acute intestinal obstruction.
Measures for meeting and preventing further shock should go on with the
preparation for the operation (see Shock, Vol. I, page 213; Prevention of
Shock, page 574). The stomach should be washed out, the lavage con-
tinuing until the fluid returns clear. Unless this is done, vomitus flows forth
as soon as the anesthetic is begun, gushing from mouth and nostrils, and
more or less finds its way into the larynx. These patients are actually often
drowned in their own vomit.
The least amount of anesthetic possible should be given. Many of these
patients are so low that local anesthesia only should be used. Time should
not be wasted upon predetermining just the character of the lesion. The
main fact in the diagnosis is obstruction. Unless some other region such
as the colon is strongly pointed to, the abdomen should be opened in the
middle line between the pubes and umbilicus. The incision should be large
enough to admit the hand 7.5 or 10 cm. (3 or 4 inches) long. Distended
bowel will be found pressed against the anterior abdominal wall, and care
must be taken lest it be injured in cutting through the peritoneum.
The index- and middle fingers introduced in the abdomen usually suffice
to find the obstruction. If it is not come upon at once, the cecum is sought.
If it is distended, the obstruction is in the large intestine; if it is collapsed the
obstruction is in the small intestine. In the first event, the fingers then
follow along the course of the distended colon until the obstruction is reached.
In the event of the disease being in the small bowel, there are certain places
most prone to harbor obstruction. Moynihan called attention to the tend-
ency of the blocked coil of intestine to sink into the pelvis. Search should
be made there. Then the sites of hernia should be explored, especially the
groins and umbilicus. All of this exploration takes but a minute, and may
usually be done with two or three fingers.
If the obstruction is not found in this way, a visual inspection should be
made. Warm cloths, already at hand should be spread on either side of the
wound, and the distended bowels allowed to escape from the abdomen and
596
SURGICAL TREATMENT
be enveloped by the towels. The surgeon should seek below, not above, as
the intestines are rolled out. As soon as the obstruction is come upon, the
rest of the intestines should be returned to the abdomen; and the operation
for its relief performed.
In acute intestinal obstruction the fatal conditions reside in the distended
bowel, its contractile forces inhibited, its contents intensely septic and thrown
back constantly into the more healthy bowel, its nerves and other structures
traumatized by tension, and a transudative peritoneal irritation developing.
The greatest urgency is to meet these conditions rather than to relieve the
obstruction. In cases not too far advanced, relieving the obstruction is all
that is required. But in an unfortunately large percentage of cases, so
much time has elapsed between the incidence of obstruction and the operation
FIG. 1245. — PREPARATION FOR EMPTYING BOWEL IN ACUTE INTESTINAL OBSTRUCTION.
The distended loop has been brought out of the abdomen, a rubber ligature has been
passed through the mesentery, the intestine is about to be opened, and the glass tube
inserted.
for its relief, that conditions have developed which require something more
than removal of the obstruction. At least one thing is certain: acute in-
testinal obstruction in the large intestine should not always be treated by
immediate resection and anastomosis.
Only in the mild cases with little distention and with little depression of
vitality can the surgeon simply relieve the obstruction and do nothing more.
This policy may be pursued in the cases which are seen early.
In cases which have been delayed, in which there are serious distention, toxe-
mia, and shock, the distended bowel must be emptied of its putrid contents.
It should be drawn out of the abdomen and the rest of the intestine carefully
protected. A thin elastic ligature is passed through the mesentery of the
distended bowel, and the bowel grasped by forceps and opened by a transverse
incision about 1.3 cm. (^ inch) in length just below the ligature above the
obstruction (Fig. 1245). Into this opening a glass tube of a similar diameter
THE ABDOMEN 597
is quickly passed before leakage of fluid matter has taken place. This glass
tube should fit tightly into the opening and pass upward. The ligature
is then caught with a clamp and leakage prevented. The tube should be
connected with a rubber tube to conduct the intestinal contents into a recep-
tacle on the floor (Fig. 1246).
If the obstruction has been relieved without injury to the bowel, the
opening may be made in the sound gut below the place of obstruction. If
an opening of the bowel has been necessary to relieve the obstruction, the
tube may be introduced and the bowel emptied through the wound of opera-
tion. The distended bowel above the block may be made to empty itself
by gentle pressure. After emptying the intestine of gas and fecal matter,
the next step in the operation should consist in removal of the obstruction.
The wound in the bowel should be closed by a double row of sutures after
FIG. 1246. — EMPTYING BOWEL IN ACUTE INTESTINAL OBSTRUCTION.
The tube has been passed into the bowel, the ligature has been tightened and caught with
a clamp to prevent leakage, and the bowel has been moved along over the tube.
the tube is withdrawn, and the loop washed, dried, and returned to the
abdomen. The whole operation should be carried out rapidly. Drainage
in most cases is not necessary (see Rupture of Intestine, page 566).
In more desperate cases the procedure must differ somewhat from the
above. Patients in an advanced state of shock and toxemia can have but
one thing done, and that is relief of the distended bowel above the obstruc-
tion. The stomach should be washed out. If the depression from this is
feared, the back of the throat may be touched with cocain solution. The
treatment of shock should precede or accompany the operation. Intra-
venous infusion and adrenalin are of much service. The skin should be
made warm.
Under local anesthesia the abdomen should be opened rapidly by a small
incision. A distended coil of intestine presents itself in the wound. If the
distention is great and the bowel congested the surgeon may know that it
is a part of the gut which is suffering above the obstruction. The coil which
598 SURGICAL TREATMENT
presses anteriorly is usually the most distended and is not far above the ob-
struction. This distended coil which pressed forward should be sewed to the
edges of the parietal peritoneum, leaving an ellipse of the intestine in the
wound. The suture should be a continuous suture of silk, and made tight
enough to prevent leakage before adhesions have formed. As the bowel is
thinned by distention, care must be taken not to penetrate the mucous mem-
brane. A thin curved needle should be used. In the center of the ellipse
a purse-string suture should be applied, making a circle about 1.5 cm. (%
inch) in diameter. An incision into the bowel should be made inside of
this circle, and a tube of glass or rubber about 1.3 cm. (% inch) in diameter
introduced through the opening, and the purse-string tied down upon it.
A tube should carry the discharge from the intestine into a receptacle.
Care should be taken that the tube does not tear out the sutures.
After this operation the condition of the patient may improve. With a
fecal fistula in the small intestine, improvement may not continue long. If
the obstruction still exists, inanition soon supervenes. Or life may only
have been prolonged while a gangrenous loop of strangulated bowel goes on
and produces fatal peritonitis.
If fecal matter cannot be recovered at the rectum, it may be judged that
obstruction still exists. If peritonitis does not cause death and the bowel
remains blocked, a curative operation must be attempted. There are two
ways of going about this: (i) The intestinal fecal fistula may be tightly
sutured as a temporary procedure, the outside of the wound cleaned, the
gut dissected free from its attachment to the abdominal wall, wrapped in
cloth, and the obstruction lower down attacked. This may mean resection,
or making a fecal fistula, or intestinal anastomosis. The original tempora-
rily closed fistula may then be reestablished, or the temporary closure may
be converted into a permanent closure. Whatever is done with this first
intestinal wound, it should be left in close contact with the median abdominal
wound or reached by a drain because of the danger of infection in connection
with it. (2) Or the skin may be cleansed, a gauze plug placed in the fecal
fistula and another opening made in the abdominal wall, through which the
obstruction may receive treatment. The second operation in these cases
requires more skill and judgment than the first. Many of these patients
succumb before a second operation can be done. Many of the desperate
cases which recover had not been suffering from actual mechanical
obstruction, but from peritonitis or some other curable condition.
Cases in which the obstruction has disappeared offer less of a problem.
Here the intestinal fistula may close spontaneously. If it does not, it is
easily closed by operation (see Intestinal Fistula, page 616).
The after-treatment should be similar to that of peritonitis. The stomach
should be washed out freely. Food should not be given at first by mouth.
Saline solution should be given by rectum. Nutrient enemata are indicated.
It should be borne in mind that the bowel below an artificial anus collapses
and degenerates; adhesions often form; and it becomes difficult to reestablish
its function. For this reason, it should be compelled to exercise by injecting
fluids into it from above or below; and reestablishment of the natural fecal
current should be brought about at as early a time as possible. In the
treatment of palsied bowels, strychnia, electricity and similar measures are
of little service.
Acute obstruction of the colon when due to a cause, such as cancer, which
cannot be removed at once, or which it is not advisable to remove at once,
may be treated by anastomosis of the cecum to the rectum. This operation
may be easily and iquickly done with a button without suture. The
THE ABDOMEN
599
small intestine, cecum, colon or sigmoid may be used. The convenient
segment above the obstruction is evacuated by a trocar puncture surrounded
by a purse-string. After the bowel has been emptied, the upper half of a
large colonic button is substituted for the tube and held by the purse-string
suture, the lower half of the button is then passed up through the rectum
by means of forceps (J. S. McArdle had special forceps made for this purpose).
The button is pressed against the upper rectal wall, which is incised from
the peritoneal side enough to allow the stem of the button to squeeze through
the opening. Then without further suture the two halves are pressed to-
gether and the anastomosis completed. A still safer procedure consists in
drawing out a loop of bowel above the obstruction and rapidly making an
artificial anus.
FIG. 1247. — ADHESIONS CAUSING MILD OBSTRUCTION CURED BY DIVISION OF THE
ADHESIONS.
Special Forms of Intestinal Obstruction. — Intestinal obstructions due to
the paralysis of peritonitis and to tumor have been discussed. Hernia is dis-
cussed in a separate chapter (Vol. Ill, page 17). Whatever may be the
cause of obstruction the first consideration should not be its removal, but
to do the thing necessary to save the patient's life; the treatment of the
causative condition may then follow in due time.
Strangulation by bands should be treated by dividing the band. This
may be a fibrous cord, formed by stretched-out adhesions, which is friable
and requires no ligature, or it may be some vascular structure such as a tab
of omentum or tip of Fallopian tube, and require to be ligated on either side.
It often happens that the examining finger breaks the band and relieves the
obstruction. The bowel which is angulated across the band, may have
sustained so much damage at the line of pressure, that when the constriction
is relieved and intestinal contents dilate this injured place, rupture of the gut
600
SURGICAL TREATMENT
may occur. This should be guarded against by compressing the bowel above
the stricture to control its contents while the degree of injury is determined
A narrow line of weakness may be reinforced by a transverse suture of the
outer coats over the damaged strip. When a band is divided it should be
cut away entirely at both extremities, as the free ends will form other
attachments and may again cause trouble.
Obstruction from adhesions may be the sort which occurs as a result of
peritonitis matting together coils of bowel and inhibiting peristalsis. It may
be necessary in these cases to resect the adherent mass or to exclude it by
anastomosis above and below, as is done for tuberculosis of the intestines
FIG. 1248. — RESULT AFTER DIVIDING ADHESIONS AND REMOVING APPENDIX.
(page 574). In some cases the adhesions may be divided and the bowels
placed in corrected position by being caught here and there with a suture.
Or the simple treatment of adhesions may suffice (see Adhesions, page 520).
After dividing adhesions, the raw surface left should be covered by suturing
the peritoneum over it.
The offending adhesions may have caused angulation either by traction,
pressure, or adhesion, involving only a small area (Figs. 1247 and 1248). The
adhesions should be divided. Both mild and complete obstruction may be
remedied by this simple operation (Fig. 1249). After division of the adhe-
sions a compressing pad held on the outside of the abdomen may be applied
so as to prevent the bowel falling back into its old position. Such a pad may
THE ABDOMEN
601
FIG. 1249. — PRONOUNCED ANGULATION, CAUSING OBSTRUCTION.
This condition is to be remedied by division of the angulating bands. It is obvious that
the treatment of such angulation as this is division of the adhesions in the lines indicated,
to be followed by straightening out of the kinks. Removal of the appendix is also
called for.
FIG. 1250. — PERICOLIC ADHESIONS. WHICH MAY BE CURED BY DIVISION, REMOVAL AND
COVERING RAW SURFACES.
602
SURGICAL TREATMENT
be adjusted immediately after the operation. If the gut does not fall into
better position, its position may be corrected by a few sutures converting
a concavity into a convexity by sewing it to some neighboring peritoneal
surface. An angulation which is intractable must be treated by making a
longitudinal incision on its concave side, the middle of the incision being
at the apex of the angle, and closing the wound as an enteroanastomosis,
producing a transverse wound.
Pericolic adhesions (membranous pericolitis, pericolic veils) have been best
described by J. N. Jackson, W. A. Lane, and L. S. Pilcher (Annals of Surg.,
vol. 55, 1912). Usually in treating the thin veil of adhesions found about the
FIG. 1251. — PERICOLIC ADHESIONS REMOVED AND BOWEL LIBERATED.
The adhesions have been divided and removed. The raw surfaces have been sewed over
and the appendix amputated.
ileocecal angle, removal of the chronically inflamed vermiform appendix is
also required. This region is best approached by an incision through the
outer part of the sheath of the right rectus muscle. All of the hands and
sheets of adhesions which confine the free motion of the bowel should be cut.
The raw surfaces remaining should be covered by sewing the peritoneum
over them (Figs. 1250 and 1251). Adhesions of other regions are amenable
to_the same treatment. In the sigmoid region the adhesions may cause
fixation of the sigmoid and give rise to obstinate constipation, which is
relieved only by dividing the adhesions and restoring the mobility of the
bowel (Figs. 1252 and 1253) (see Peritoneal Adhesions, page 520; and
Chronic Intestinal Stasis, page 610).
Ileocecal valve obstruction is not uncommonly seen as an abnormal tight-
THE ABDOMEN
603
ness of the valve, giving rise to dilatation of the ileum, ileal stasis, and often
symptoms similar to appendicitis. Many of these cases have been operated
upon for appendicitis, and the appendix found to be normal. The treat-
ment is highly satisfactory. An incision should be made 5 to 7 cm. (2 to 2^4
inches) long in the direction of the long axis of the ileum. Its middle should
be at the ileocecal valve. It should involve the whole thickness of the
bowel wall. The two ends of the incision should then be brought together,
and the wound closed at right angles to the incision which made it. This
operation enlarges the orifice and cures the disease.
PIG. 1252. — SIGMOID ADHESIONS, CAUSING CONSTIPATION, WHICH CAN BE CURED ONLY BY
DIVISION OF THE ADHESIONS.
Diverticula cause obstruction in several ways, (i) The extremity of the
diverticulum may have become attached at the umbilicus or have become ad-
herent in any part of the peritoneum, forming a band under which bowel
becomes strangulated. The diverticulum may be so large that confusion is
caused by mistaking it for intestine. The extremity should be freed from its
attachment and the diverticulum amputated after the manner of removing the
vermiform appendix. It is ligated at its base a short distance from the
bowel, cut off, the mucous membrane distal to the ligature sterilized by
cauterization, and the stump buried by a seromuscular suture of the intestinal
wall. Usually this should make a transverse line. In the case of a small
604
SURGICAL TREATMENT
diverticulum, a purse-string suture may be used. The treatment of the
obstructed bowel is the same as that for strangulation by bands, (i) The
diverticulum, as a floating cord, may form a loop or knot about the intestine,
or it may cause rotation of the loop to which it is attached. In any of these
events, it should be removed. (2) Becoming inverted into the lumen of the
bowel, it may produce obstruction by causing intussusception. Its treat-
ment here also is by removal. (3) Inflammation in the interior of a diver-
ticulum may cause peritonitis, adhesions, or any of the obstructing lesions
similar to appendicitis. Its treatment is the same as that of appendicitis.
FIG. 1253. — LIBERATION OF SIGMOID BY DIVISION OF ADHESIONS AND CLOSURE OF WOUND.
Operation in progress.
The removal of a small diverticulum is the same as the appendix. The
removal of the ordinary sized diverticulum should be by amputation near
the base and closure of the opening the same as a wound of the intestine.
The wound should be sutured preferably transversely, with two layers of
suture.
Intussusception usually' occurs in infants. Early diagnosis is the most
important prerequisite to treatment. Treatment must promptly follow
upon the appearance of certain characteristic phenomena. The onset is
sudden. A previously well baby screams, turns pale, and vomits. The
THE ABDOMEN 605
abdomen is tender. The first pain subsides, and is then followed at intervals
by waves of colic in which the child cries with pain. A normal movement
often follows the first attack of pain. During the first nine hours after this,
blood will usually be passed by rectum. The child does not seem ill except
from pain. A mass can be made out under general anesthesia.
In reducible intussusception a cure should be expected. If the case is
seen during the first few hours reduction may be accomplished by the injec-
tion of fluid into the bowel. The pelvis is elevated and warm sterilized saline
solution is permitted to flow into the rectum. Five hundred or 1000 c.c.
(i or 2 pints) may be used. The child may be inverted to facilitate retention
of the fluid and reversed peristalsis. After four hours, or before this if blood
has appeared, swelling and adhesions have developed which make reduction
by this method both improbable and dangerous.
In all cases the child should be protected against shock (Vol. I, page 213),
and in all cases the abdomen should be opened. This should be done also
when injections are supposed to have reduced the invagination, because of
(i) the possibility of reduction not having been accomplished, and because
of (2) the possibility of injury to the intestine which may require further
treatment. An exception to this rule may be made in the case which is
seen very early, in which a mass is distinctly felt to disappear under general
anesthesia and colonic injections, and in which the child seems well after
this. Even in these cases the reduction may have been only partial, reducing
the invagination in size but not in fact. Abdominal section in a cured case
does no harm; in an uncured case it may save life.
Having opened the abdomen at the side of the rectus if the mass is felt
there, or in the middle line, by a 5-cm. (2-inch) incision, reduction may be
accomplished by gentle manipulation. After an intussusception has existed
for forty-eight hours, reduction is difficult; after it has existed for three days,
reduction is difficult or impossible. Reduction by operation is possible in
the majority of cases up to the fourth day. Reduction should not be at-
tempted in late cases by traction alone. The lower limit of the intussuscep-
tum should be sought, the gut grasped between the thumb and forefinger,
and the apex of the invaginated portion gently pressed upward. This ma-
nipulation also pulls downward the outer bowel. The apex of the intussus-
ceptum is usually edematous, and when it reaches the place of entrance its
further reduction may be impossible. The edema may be reduced by gentle
and steady pressure, embracing, if necessary, the whole circumference of the
gut in the hand. Having completed the reduction, the bowel should be
inspected for wounds, any of which should be sutured. The cause of the
intussusception should be sought. If a diverticulum, polyp or tumor is
discovered, it should be removed. Shock will be minimized if all manipula-
tions are conducted within the abdomen.
If the colon involved has undue mobility, it should be fixed to the lateral
and posterior abdominal wall by a few sutures, and the invaginated small
intestine should be similarly fixed. If the mesentery of the intussusceptum
is unduly long it should be shortened by peritoneal sutures. Time should
not be taken for this if the child's condition is bad.
In irreducible intussusception, the conditions are more serious. The
bowel below may be injected with fluid as an aid to the operation and as
a preventive of shock. In adults immediate resection is the operation of
choice. In children resection gives a high mortality.
If the invagination is irreducible but not gangrenous, the procedure should
depend upon the general condition of the patient. If urgency is demanded,
an intestinal fistula should be made. In the event of a small invagination,
606
SURGICAL TREATMENT
it may be brought outside of the abdomen, fixed in the wound, and the bowel
opened at once and drained, as for malignant tumors (see Intestinal Obstruc-
tion, page 595; Malignant Tumors, page 582). For this, intussusception
FIG. 1254. — OPERATION FOR INTUSSUSCEPTION.
The intestine is opened to expose the intussuscepted segment.
may be incised or resected. In the less urgent cases resection and anasto-
mosis is indicated in adults; in children, an intestinal fistula may be made,
either with or without immediate resection.
FIG. 1255. — AMPUTATION OF THE INTUSSUSCEPTED SEGMENT
It is possible in some cases in children to bring the disease out through the
wound, and suture the bowel to the peritoneum above and below the tumor.
THE ABDOMEN 607
This is the method of eventration. The bowel is placed in such a position
that its parts farthest from the mesentery lie in contact. A purse-string
suture is placed on the upper limb, the bowel incised in the circle, a tube
introduced and the suture tied down upon it (see pages 596 and 597).
This empties the bowel and fixes it for the formation of adhesions. One
or two days later, the intussusception is resected and a clamp introduced to
cause sloughing through of the spur (see Fecal Fistula, page 587).
In some cases it is possible to make a longitudinal incision through the
intussuscipiens at the place of invagination, and thus relieve the stricture
which prevents reduction.
In the cases in which a great length of gut is invaginated, resection is
still more urgently demanded.
If the intussusception is irreducible and gangrenous, it is best treated by
the above method of eventration. In adults the mass may be excised and the
bowel united end-to-end or laterally. Resection and the formation of an
intestinal fistula may be done.
In some cases resection of the intussusceptum may be done by the method
similar to that of Maunsell for intestinal anastomosis. The operation was
FIG. 1256. — STUMP OF AMPUTATED INTUSSUSCEPTUM SUTURED.
first applied by Jessett to intussusception. A continuous seromuscular
suture is caused to unite the bowel at the line where the intussusceptum enters
the intussuscipiens. A longitudinal incision about 5 cm. (2 inches) long is
then made through the invaginating part opposite the mesentery (Fig.
1254). This exposes the invaginated bowel. The incision is carried to
within 1.3 cm. (^ inch) of the circular suture. The invaginated bowel is
then amputated (Fig. 1255), leaving a proximal stump. This stump repre-
sents two coats of bowel. These are sewed together by a continuous suture
(Fig. 1256). The wound is then closed by suture (Fig. 1257). When done
for gangrene, at least all of the gangrenous bowel should be removed. This
method is becoming more and more employed for nongangrenous irre-
ducible cases, and is to be recommended.
In infants the mortality following resection is very high; but it is possible
that if resection is done at once, and time and traumatism not bestowed upon
the lesion, better results may be secured.
C. P. B. Clubbe reported 173 cases of intussusception under his care. In
16, reduction was accomplished by injections. Laparotomy was done in
608 SURGICAL TREATMENT
157 cases. He had 25 deaths in the first 50 cases operated on, 12 deaths in
the second 50, and 4 deaths in the third 50. In his last 7 cases, which were
operated upon, there were no deaths. The reason for the better results in
the latter cases is that the patients were operated upon earlier. He insists
that all cases should be treated by operation.
Volvulus may be alone or associated with adhesions or angulation. Here
distinct volvulus will be discussed. It is commonly found in the sigmoid
flexure, but other parts may be involved. An anatomic peculiarity usually
is a determining cause, and if the volvulus is simply untwisted the tendency to
recur is greater than it was before. The volvulus having been discovered, it
should be untwisted if this can be done without damage to the gut. In
some cases the distention of the gut may be so great that manipulations can
not be made until it is brought outside of the abdomen. In extreme cases it
becomes necessary to incise and empty the gut before anything else can be
done.
After untwisting a volvulus and permitting the obstructed intestinal
contents to pass onward, it may seem as though the loop would remain in
good position; but this hope should not be entertained, because when it again
FIG. 1257. — WOUNDS CLOSED AFTER OPERATION FOR INTUSSUSCEPTION.
becomes distended or the same conditions are present which produced the
first volvulus, recurrence is to be expected. In order to prevent this, the
offending loop should be fixed by sutures. If there is an abnormally long
mesentery it may be shortened by making a fold parallel to the gut; the
sutures should not catch the blood-vessels. Such a fold need not damage the
circulation of the bowel. If this is not necessary, the bowel may be prevented
from rotating by suturing it to the posterior, lateral or anterior abdominal
wall. In ptosis of the sigmoid, it may be fastened to the peritoneum of the
pelvic brim by sutures catching its mesentery close to the bowel. In doing
these operations the bowel should be placed in a natural position, so that
no strain shall fall upon the sutures or danger of angulation be incurred.
Foreign bodies causing intestinal obstruction may have been swallowed or
formed in the body. Usually such a body which can traverse the gullet can
traverse the rest of the gastro-intestinal canal. But a slight narrowing,
the result of old ulcer or adhesions, may stop it, and obstruction supervene.
The ileocecal valve is the narrowest part of the bowel, and here the body
may become engaged. A foreign body may by its irritation cause spasm of
the bowel which grips the body and causes ileus.
The most common causes of foreign body obstruction are gall-stones.
The occlusion is usually at or above the ileocecal valve. The circulation of
the bowel is not damaged by this form of obstruction. Operative mortality
THE ABDOMEN 609
should be very low. It is high because in some of these cases after obstruc-
tion was apparently established, the body has been passed, and the patient
has recovered; the hope that this may occur prompts delay, and operation
is sought as a last resort, often for a moribund patient.
The foreign body is located by the methods already described (page
595). If the bowel is not much damaged a longitudinal incision is made
opposite the mesentery and the foreign body removed. The opening should
be closed with two rows of sutures. If the body has been present long enough
to produce ulceration or the bowel looks badly the body should be moved
upward and removed through better intestine.
Intestinal obstruction due to impacted gall-stone in the intestine is
especially serious because the retained fluid above the obstruction, if ab-
sorbed in large amount, is distinctly poisonous. If the gall-stone is removed
and the obstructed fluid permitted to flow down into the lower bowel, whence
it will be absorbed, serious consequences may follow. It is best to introduce
a tube through the wall of the bowel at least 10 cm. above the obstruction
and wash out with warm saline solution all of the septic fluid. Then the
impacted stone may be pushed up to the opening in the bowel and removed
with safety. By making this opening high enough to be in healthy bowel
the danger is greatly reduced.
Stricture usually requires treatment for chronic obstruction. In some
cases it may contract rapidly, or be associated with other conditions, and
cause acute obstruction. The treatment should be conducted on the prin-
ciples already laid down (page 595). A single stricture or a loop of intes-
tine beset with strictures is radically cured by resection and anastomosis.
Stricture causing partial closure of the lumen of the bowel may be treated
by a longitudinal incision, crossing the stricture, and closure of the wound
transversely (Figs. 997 and 998).
The dilating of intestinal strictures, which give symptoms of obstruction,
is to be considered only if the stricture can be reached through the anus.
Gangrene of the Intestine. — This condition may follow traumatism,
infection, strangulation, or thrombosis or embolism of the mesenteric vessels.
Its treatment must often be combined with the treatment of other conditions.
For limited areas of gangrene — up to 9 cm. (3^ inches) — invaginationha,s
been done with success. The bowel is invaginated, as in intussusception,
and secured by a continuous suture.
If a greater length than 5 cm. (2 inches) is to be invaginated the mesentery
may have to be removed. In stoppage of the mesenteric vessels, gangrene
occurs independently and unexpectedly. A few centimeters or one or more
meters of bowel may be found gangrenous. If the diseased segment is not
soon removed from the abdomen, perforation of the slough and fatal peri-
tonitis supervene. In all cases of gangrene, involving the whole circum-
ference of the bowel, it is essential that the gangrenous tissue be removed
from the abdomen. If the condition of the patient will permit, resection of
the diseased segment and anastomosis may be done. In resecting for
gangrene care should be taken that enough bowel is removed to insure good
vitality in the remaining ends. The hazard in the removal of 5 cm. (2 inches)
of gut is not materiallly less than that in the removal of 50 cm. (20 inches).
It is always best to lean toward the safe side.
In cases in which the condition of the patient is bad, eventration may be
done. The gangrenous loop is brought out through the abdominal wound,
and sewed to the peritoneum above and below the lesion. The bowel may
be emptied at once or later, as the degree of ileus demands (see Obstruction,
page 595; Eventration, page 586). If perforation has already taken place,
VOL. 11—39
610 SURGICAL TREATMENT
the gangrenous segment should be cut away. A tube may be fixed in the
upper limb to conduct intestinal contents away. Later an operation for
fecal fistula should be done.
The mortality in spontaneous mesenteric gangrene is high. A few cases
have been saved by resection and anastomosis. The best hope for all
desperate cases of intestinal obstruction and palsy is the two-stage proce-
dure— intestinal fistula and its cure.
Chronic Intestinal Obstruction. — Many of the conditions described as
causing acute obstruction, are capable of causing chronic obstruction and
should have been treated radically before the acute condition supervened.
Such conditions as tumors, strictures, adhesions, angulation, and abnormally
long mesentery, should be remedied (see treatment of each of these condi-
tions; for treatment of long mesentery, see Volvulus). Adhesions are often
found about the cecum and appendix which need treatment. Tumors
causing obstruction to the portal system may require removal. Hemorrhoids,
fissure, or anal ulcer may require attention to relieve pain which prompts
voluntary abstinence from stool. Mucous colitis may be treated by ap-
pendicostomy.
When coproslasis occurs, the accumulation of fecal matter in the bowel
may be only relieved by mechanical measures. Warm soap enemas, given
slowly and allowed to remain a long time help dissolve and bring down the
masses. Abdominal massage may be added, but should never be used if
painful. Hardened impacted feces should be removed from the rectum by
means of the finger and a spoon. As the material is removed below more may
come down. A volvulus or sagging of the sigmoid may hold a mass and re-
quire colotomy for its relief. Accumulations of hard feces at the cecum may
refuse to move onward, and colotomy may be necessary.
The treatment of dilatation of the colon is largely medical. When these
measures fail, as in congenital dilatation (Hirschsprung) , operation is re-
quired. By anastomosing the lower end of the ileum with the large intestine
below the disease, relief may be secured. Resection of the diseased bowel is
also practised.
In the treatment of acute flexures or angulations of the sigmoid and colon,
either palliative or radical measures may be employed. Relief may be given
by inflation of the colon with air, and by passing long rectal bougies through the
flexure. by means of the sigmoidoscope and leaving them in place for fifteen
minutes. These measures fail when the condition is due to firm adhesions
or congenital malformation. Then operation should be done. The op-
eration should straighten out the angulation and suture the bowel in such
position that angulation cannot recur. Raw surfaces should be covered.
In some cases operation by angulation is indicated (pages 568, 600).
Chronic intestinal stasis (chronic intestinal toxemia) is largely a medical
problem, to be met by better hygiene and internal treatment. No case
should be operated upon until these measures have been faithfully and in-
telligently applied; I am tempted to say that no case will be operated upon
if they are. Perhaps no method of treatment has given better results
than that employed by J. H. Kellogg at Battle Creek. This consists in a
low proteid diet of bulky foods, consisting largely of whole grain products,
fruits and fresh vegetables. Bran or agar-agar at each meal is desirable;
from 15 to 30 Gm. (^ to i ounce) of cellulose daily in this form seems useful
as a stimulant of peristalsis. At every meal 15 to 45 c.c. (^ to i^ ounces)
of liquid petrolatum is advised. This may be given plain, in emulsion, or
the petroleum jelly may be used. In obstinate cases the patient should take
30 Gm. (i ounce) of bran three or four times daily. Fresh fruit should be
THE ABDOMEN 611
eaten at the same time. Bran furnishes bulk and petrolatum supplies
lubrication; these are prime essentials in most cases.
The abdominal muscles should be strengthened and the abdominal
circulation improved by exercises. If these do not suffice, abdominal mas-
sage should be added. The vegetables which are of especial value are
tomatoes, lettuce, celery and spinach. If hyperacidity is present the
non-acid fruits are recommended: bananas, melons and pears. There is
often advantage in making the diet exclusively for a few days of cooked and
raw green vegetables and agar-agar or bran. Bran may be baked into cakes.
A useful formula for the employment of agar consists in mixing 30 Gm.
with i liter of water and the juice of a lemon. This should be kept hot and
taken in small doses between meals during the day.
The patient should cultivate a regular habit of going to stool, preferably
immediately after rising in the morning and after each meal. If satisfactory
bowel action is not secured, an enema of warm water should be used once
daily. This will rarely need to be continued with the above regimen. Kel-
logg advised in cases of colitis with spastic condition of the descending colon,
warm saline enemas, after which 50 or 100 c.c. or more of liquid culture of
Bacillus bulgaricus and B. bifidus is introduced into the colon with the patient
in the knee-chest position. To this should be added a small amount of
malt sugar and boiled starch as a culture medium.
If the lower colon is weak in peristaltic power it may be stimulated with
electricity. A bipolar electrode is used in the upper part of the rectum. A
solution of citric acid (0.25 to 0.5 per cent.) is useful; also a mixture of equal
parts of carbon dioxid and pure oxygen gases. If the chronic proctitis has
caused atrophy of the mucous membrane, 100 or 125 Gm. of petroleum jelly
may be introduced into the lower colon at night.
The above measures will cure most cases. Kinks, ptosis, and "veils"
are results of stasis. When the bowels are given the work which they are
physiologically adapted to do, the symptoms may be expected to abate.
Treatment with autogenous vaccines of colon bacillus is of help in some
cases. Stock vaccines are of little value. The beginning dose is from 10 to
25 million dead bacilli, injected subcutaneously. The dose is repeated every
five or seven days, and gradually increased by 25 million at each injection
until 150 or 300 million are given. If a colon bacillus toxemia is present,
there will be a local reaction — redness, pain and swelling, at the point of in-
jection, and a general reaction — -malaise, headache and soreness. Relief
follows after three to six weeks of treatment.
The conditions, described above, requiring operation, are the exceptional
causes of this condition. These cases should come to the surgeon from the
physician who has discovered the surgical character of the case by the failure
of nonsurgical measures. As the disease concerns especially the neurotic
and persons with visceroptosis, prolonged treatment is necessary before
surgery should be considered. When these patients finally are sent to the
surgeon, it is best that no operation be done which irretrievably destroys
important bowel-function. Some of the radical operations which have been
done for these conditions have been temporary fads which have not with-
stood the tests of time. Partial colectomy and even complete colectomy
have never attained a position in surgery in the routine treatment of chronic
stasis. The fad of short-circuiting should not mislead the surgeon; none of
these operations have been placed upon a secure basis as measures to be
applied with assurance.
If any operation can be of value it must meet some definite pathologic
condition which the surgeon finds. The surgeon should bear in mind that the
612
SURGICAL TREATMENT
colon has a function and should not be sacrificed as freely as a useless organ.
If the surgeon can remove a chronically inflamed or adherent appendix,
relieve abnormal intra-abdominal pressure, remedy some angulation or other
condition which actually is causing obstruction, or secure some means for
treating infection of the colonic mucous membrane, he is justified in operating,
for he is applying rational measures to this disease. But he should .beware of
operating upon the bowels for lesions which reside in the nervous system or the
glandular mechanism. Such surgery is not rational. Any condition which
justifies opening the intestinal canal in this disease is rare.
Most of these cases which have passed through medical hands and been
referred at last to the surgeon, will best be served by referring them again to
FIG. 1258. — STRICTURE OF COLON, CAUSING CHRONIC CONSTIPATION, WHICH CAN BE
CURED ONLY BY OPERATION.
Longitudinal colotomy at site of stricture.
more competent medical hands. The treatment requires special under-
standing. Many cases improve under hygienic treatment and the adminis-
tration of vaccines, liquid albolene, petrolatum or paraffin oil.
Most surgeons have had experiences with cases with adhesions, angula-
tions, abnormally elongated mesocolon, or enteroptosis in which removal of
the upper half of the colon, or more, has been followed by improvement.
The number of patients in whom this extirpation of cecum, ascending, and
part of transverse colon will be justified for the treatment of chronic stasis,
without any distinct obstruction being discernible, is exceedingly small.
Another condition in this category is the so-called redundant sigmoid
It is said to come within this definition if it is longer than 25 cm. (10 inches)
THE ABDOMEN
613
and "is the seat of symptoms of redundancy." Chronic constipation is the
chief symptom calling for treament. If hygiene, massage, hydrotherapy,
laxatives, restricted diet, and modified external pressure do not give relief,
operation is indicated. Sigmoidopexy, ileosigmoidostomy, cecosigmoid-
ostomy, sigmoidectomy, and colectomy are the measures resorted to. In
this condition also the number of cases in which operation is indicated as the
rational procedure is very small.
These operations have been advocated by some for arthritis deformans
upon the ground that the disease is due to Streptococcus mridans the common
habitat of which is the lower ileum. Ileosigmoidostomy seems to have
improved a certain proportion of these cases. If there is any obstruction in
the colon above the contemplated point of anastomosis, removal of the colon
FIG. 1259.— CURE OF STRICTURE OF COLON.
Longitudinal incision of stricture and suture of wound transversely.
seems necessary. The object of the operation is to give better drainage to
the lower ileum.
Upon the hypothesis of Metchnikoff, that the upper part of the large
intestine is "the cesspool of the system," ileocolostomy has been advocated
and practised by many surgeons and advocated as the "highway of hope"
not only in obstinate constipation and arthritis, but in melancholia, arterio-
sclerosis, nephritis, and all of the ills to which the theory of autointoxication
can be connected.
W. A. Lane claimed that in a large proportion of advanced cases, division
of the adhesions gives relief only in so far as the patient is benefited by the
rest in bed which the operation entails, and that as soon as the patient re-
sumes active life the old symptoms return. When a-ray tests show a marked
614 SURGICAL TREATMENT
degree of stasis in the colon in advanced chronic cases, treatment of the iliac
kink or division of adhesions may be omitted, and instead an anastomosis
between the ileum above the disease and the sigmoid below the disease may
be done. Lane and his school divide the ileum and implant the proximal
end into the sigmoid. If the large bowel is very static, and especially if the
abdomen is relaxed, these surgeons remove the large bowel and report highly
satisfactory results. If the removal of the bowel entails any great risk to the
patient, the practice is to make a short-circuit, and do the resection later
when the patient has been relieved of autointoxication and complains of the
distention of the colon. Distention of the excluded colon may be expected
to follow these operations unless it is kept clean by irrigation.
The operation of choice is (i) lateral ileosigmoidostomy, (2) sewing the
opened cecum and the opened sigmoid into an abdominal wound, (3) irri-
gating the colon through-and-through until it atrophies. Later the atrophied
colon may be removed, if desired, without hazard.
Incompetent ileocecal valve, when a cause of iliac stasis, has been suc-
cessfully treated by J. H. Kellogg (Annals of Surg., Jan., 1918) by a simple
operation. Sutures are passed m such a way as to mvaginate the ileum
into the cecum and thus form a valve. This is done by catching the wall
of the bowel with one or more mattress sutures in such a way as to turn in
about 3 cm. of the ileum. Kellogg carefully dissected free the peritoneum
before applying the sutures. The patency and competency of the valve
are tested by squeezing the intestinal gas along the bowel before tying the
second knots in the sutures.
Megacolon (congenital or acquired dilatation of the colon) may be
relieved by hygienic and medical treatment. It should not be treated by the
surgeon until such measures have been well applied. The presence of cop-
roliths may demand colotomy for their removal. Colopexy and coloplasty
for this condition have proved to be of but little value. Coloplasty for
enlarging the outletj of the dilated segment has not seemed of service.
Coloplasty, by making longitudinal folds in the bowel, seems to have given
relief in some cases. Colostomy, to make an artificial anus, gives relief,
but is a poor substitute for the disease. Some surgeons have followed it
with resection. Ileosigmoidostomy and colostomy have cured some cases;
in others the dilated segment has become filled with fecal material, and re-
section has been necessary. The operation which gives the most certain
results is resection. It may be done as a primary operation, or it may follow
anastomosis, if the anastomosis operation fails to give relief.
Acute Intestinal Stasis. — This condition, usually due to acute obstruction
or to peritonitis, requires treatment of the causative condition. When
due to the traumatism of operation, or reduction of hernia, defective nerve
supply, partial paralysis, gas distention, toxemia, etc., relief may be secured
by means of laxatives and enemata. In some cases gas distention pre-
vents the action of laxatives. Those drugs which act on the spinal cord and
sympathetic centres may be used. Hormonal is given by intravenous injec-
tion in doses of 15 or 20 c.c. (4 or 5 drams). It may be given subcutaneously.
Eserin (physostigmin) is also used hypodermically in doses of 0.0005 to
0.002 Gm. (K20 to 3^o grain) for the same purpose. These drugs should not
be expected to help in the paresis of acute peritonitis.
Another drug having a marked effect on the musculature of the bowel,
and capable of causing contractions to overcome the temporary paralysis
which follows the traumatism of operation, is pituitrin or pituitary extract.
From 0.5 to i c.c. (7^ to 15 minims) of the extract may be hypodermically
given every four hours after operation. The injection should be made into
THE ABDOMEN 615
muscle. Some surgeons use it as a routine during the first day after abdom-
inal operations, with the result that the patients suffer less from gas pains.
There is a form of duodenal occlusion, which commonly occurs after
abdominal operations but which may appear spontaneously, due to dragging
downward of the mesentery of the small intestine and compression of the
duodenum as it passes under it, the superior mesenteric artery acting as a
band pressing upon the duodenum. This condition may be prevented by
keeping the small intestine from falling into the pelvis, and by preventing
adhesions. When it occurs, it is promptly relieved by washing out the dilated
stomach and turning the patient so that he lies face downward. This is
probably the condition which has to do with postoperative dilatation of the
stomach, the postural treatment of which should be borne in mind. It may
become necessary in this condition to open the abdomen, and release the root
of the mesentery. B. Rosenthal (Archiv fiir Gyn., vol. 86, No. i) suggests
placing the patient in the knee-chest position and manipulating the intestine
upward.
Acute dilatation of the stomach, occurring after operations, may be pre-
vented by proper preparation of the patient for operation. The intestine
should have been well cleansed of food and gas. Anesthesia should not be
too profound. The stomach, bowel and splanchnic area should be trau-
matized but little. Exposure of the peritoneum to air, gauze sponging and
other irritations which cause adhesions should be avoided as much as possible.
After operation food should not be taken into the stomach for several days
if there is ether nausea. The surgeon should daily palpate the epigastrium
of abdominal cases to discover fulness. If it is present, the stomach tube
should be passed at once. Nausea should call for lavage. Upon the first
appearance of distention of the stomach with fluid or gas, of vomiting, or of
nausea, the stomach should be emptied and washed until the fluid returns
clear.
If the stomach is found distended after operation, and not normally
emptying itself, lavage should be practised often enough during the day to
keep it empty. The fact that the patient has become comfortable after
having presented the first symptoms of dilatation, should not deceive the
surgeon that danger has passed. Lavage should be continued. If there
are any drains in the abdomen, they should be removed. The patient
should lie on the right side with the head of the bed raised.
It is doubtful if the disease is due alone to obstruction by the mesentery,
as it occurs after gastro-enterostomy; therefore operations to relieve obstruc-
tion are not indicated. The disease seems to be a paresis of the stomach
wall, to be treated by sparing it from dilatation.
If the patient suffers from loss of body fluids they should be restored by
proctoclysis or infusion. The patient should be placed in the elevated-head
position, even to sitting upright if it gives the most comfort. Usually it will
be found that the stomach empties itself best if the head of the bed is raised
and the patient lies on the right side.
Postoperative vomiting, which is relieved by lavage, may in some cases
be treated by passing a rubber tube, about 7 mm. (% inch) in diameter,
through the nose into the stomach. It should pass down about 45 cm.
(18 inches). The tube should have two or three openings in the end. Con-
nected with this tube should be a long tube reaching to a vessel on the floor.
The tube is made fast by a tape tied around the head. Fluid siphons out
and the patient is kept comfortable. He may drink as much water as he
can (see Postanesthetic Vomiting, Vol. I, page 104; and Vomiting after Ab-
dominal Operations, page 531).
616
SURGICAL TREATMENT
Enteroptosis is a most common condition, though in most cases it causes
no symptoms which demand relief . It may often be discovered in the search
for causes, but the surgeon should not attempt to change the arrangements
of the abdominal viscera unless he is quite sure that he is correcting the defect
which causes the symptoms. It is natural for the viscera to be movable.
Hygienic and medical treatment should precede surgery. Actual enterop-
toses may be cured by proper eating, exercise and sleep. Reflex irritations,
as found in the eyes, vermiform appendix, and genital organs, should be
corrected. Ochsner has children with enteroptosis sleep with the foot of the
bed elevated 15 to 30 degrees, to cause the abdominal viscera to move up-
ward, and relieve the supporting structures from strain.
An elongated mesocolon may permit prolapse or actual torsion of the cecum
simulating appendicitis. This can be corrected by making a fold in it with
sutures to the posterior and lateral abdominal walls (see Volvulus, page
FIG. 1260. — PTOSIS OF THE TRANSVERSE COLON TO BE REMEDIED BY OPERATION.
608). Ptosis of the transverse colon may be so extreme as to lodge that organ
in the pelvis. This may be corrected by shortening its mesenteric attach-
ment, by shortening the gastrocolic omentum, or by fixing the omentum
just below the colon to the anterior abdominal wall (Figs. 1260 and 1261).
The hepatic and splenic flexures may be fixed in place by sutures anchoring
their mesenteries to the posterior abdominal wall. Ptosis of the sigmoid has
been discussed under volvulus (page 608).
In extreme cases of elongation and ptosis of the transverse colon, giving
rise to constipation and other disturbances, resection of bowel may be done
(see Gastroptosis, page 710).
Closure of Intestinal Fistula (Fecal Fistula, Artificial Anus). — A small
intestinal sinus should be easily closed (see Fistulas and Sinuses, Vol. I,
THE ABDOMEN
617
page 304). In addition to the ordinary local treatment, the patient may be
caused to fast for a few days or subsist on nutrient enemata. If these meth-
ods fail, the sinus may be dissected out, and the intestinal opening sutured.
Before such an operation, the skin should be gotten into healthy condition
by keeping it dry, by applying boric acid powder, ointment, or other medica-
tion. The operation is done by packing the sinus with dry gauze; sewing its
mouth tightly together with silk; sterilizing the wound area with iodin
or chlorin solution; isolating the sinus, without opening it, by an elliptic
incision; liberating the bowel with tissue containing the sinus attached
to it; amputating the sinus at its entrance to the bowel, closing the bowel
opening with two layers of sutures; and closing the abdomina] wound.
FIG. 1261. — OMENTUM SEWED TO ABDOMINAL WALL, HOLDING COLON IN PLACE.
The great omentum, immediately below the transverse colon, is caught to the anterior
abdominal wall with three or four sutures. The bowel is here shown lifted up. When it is
released and the wound closed it drops below the level of the wound.
Later, if necessary, the intestine may be liberated from its adhesion to the
abdominal wall.
A fecal fistula, having a larger opening, without a spur or without obstruc-
tion in the distal arm tends to close spontaneously. If it does not close, it
may be treated as above (Fig. 1262). If it is not desired to expose the peri-
toneum, the elliptical dissection may be carried down to the peritoneum but
not through it, and the opening in the bowel sutured. This leaves the bowel
still attached to the abdominal wall, where it may be left, or liberated at a
subsequent operation.
In most cases it is best to carry the incision through the peritoneum (Fig.
1263). The finger then can determine the position of the adhesions. All
of the inflammatory mass containing the fistula is excised, together with a
618
SURGICAL TREATMENT
small ellipse of bowel having the fistula in its center (Fig. 1264). The lon-
gitudinal opening in the bowel is closed transversely with two rows of sutures
(Fig. 1265). The transverse closure of a longitudinal wound is to prevent
narrowing of the bowel at this point. In the case of fecal fistula with obstruc-
tion beyond the fistula, closure should not be attempted until the obstruction
FIG. 1262. — EXCISION OF INTES-
TINAL FISTULA.
Incision made in skin about
fistula.
FIG. 1263. — EXCISION OF IN-
TESTINAL FISTULA.
The mouth of the fistula
has been closed by suture
passed through the dissected-up
skin.
is removed. In some cases this may be done as a separate operation through
a separate wound; in other cases the obstruction and fistula may lie so near
together that they both may be attacked through the elliptical wound made
about the fistula.
The treatment of fistula with a spur (Fig. 1265) consists in division of the
spur. As a preliminary, when a fecal fistula is made, if time will permit, it is
FIG. 1264.— FISTULA DISSECTED OUT WITH SMALL SEGMENT OF INTESTINAL WALL.
wise to sew two arms together on either side so that the spur shall consist of
two adherent bowel walls (see Artificial Anus, page 587). When this has been
done, the division of the spur by means of a clamp can be accomplished with-
out danger to other structures. One blade of a clamp is introduced on either
THE ABDOMEN
619
side of the spur, and the spur grasped. The pressure of the clamp in a few
days causes necrosis through the spur, and a free passage for the intestinal
contents is provided. An adhesive peritoneal inflammation is caused by the
pressure. This extends for some distance beyond the line of necrosis. The
clamp should be tight enough to occlude all vessels. A screw clamp requires
to be tightened frequently. It may be left on for two days, and reapplied
if perforation does not occur within ten days. I have found the best satisfac-
tion in using long, straight, stomach or intestinal clamps and regulating the
bite by placing elastic bands on the handles.
Some surgeons prefer to leave the clamp on until it has cut through the
spur. Two light clamps may be applied side by side, or the ordinary pedicle
clamp may be used. Unless a pre-
liminary suturing of the bowel sur-
faces has been done, it is possible that
the adhesions which form as a result
of the clamp pressure may be so deli-
cate that they fail to hold. In this
event intestinal contents escape into
the peritoneal cavity, and the opera-
tion ends in disaster. While this is a
possibility, it rarely occurs, and sur-
geons usually are satisfied to do the
operation without sewing the loop
together.
In order to obviate the above
danger the following procedure may
be adopted: The bowels are
thoroughly cleared out. A circular
incision is made through the skin
about 5 mm. (%g inch) from the fis-
tula. A good-sized, stiff, rubber tube
is introduced in the upper limb of the
fistula, and the skin closed tightly
around the tube by a purse-string su-
ture of silk. The wound region is then sterilized with iodin. The perito-
neum is then opened and the bowel liberated by an elliptic incision, as
above described. In opening the peritoneum in these operations care must
be taken lest adherent bowel be wounded. The afferent and efferent seg-
ments of bowel are then sewed together by a continuous suture passing down
one side and up the other in the form of a U. This suture embraces the
spur. The loop of bowel is again sewed in the wound as before. After
two days, adhesions have developed, the tube may be removed, and a
clamp put on the spur. This is a safer operation than making an anasto-
mosis or doing a resection.
Another expedient consists in temporarily closing the fistulous opening;
dissecting free the loop of bowel by an elliptic incision; applying the U-
shaped musculoserous suture to the two limbs; drawing out the bowel and
protecting it; removing the temporary suture; enlarging the opening longi-
tudinally; dividing the spur with scissors between the two arms of the U-
suture;4 applying a continuous through-and-through suture to the divided
edges of the spur, running parallel with the U-shaped peritoneal suture; clos-
ing the opening in the bowel; and then closing the abdominal wound. If
there are raw surfaces left on the bowel, they may be covered with a peritoneal
flap, taken from the adjacent abdominal wall or by omentum. To make the
FIG. 1265. — -DIAGRAM OF SEVERAL
FORMS OF FECAL FISTULA WHICH MAY BE
CURED BY OPERATION.
620 SURGICAL TREATMENT
operation still more safe, the fistula may be left open in the abdominal wound,
and closed at a later operation.
The Omentum. — Inflammations of the amentum are a part of peritonitis
and are treated the same. When found inflamed and gathered into a solid
mass, the omentum is best removed.
Ligation of the omentum is done in sections, each ligature embracing
enough tissue to make a pedicle about 3 mm. (% inch) in diameter. A torn
string of omentum should be ligated and removed.
Strangulation of the omentum found with hernia and bands requires
removal of the strangulated part.
Torsion of the omentum may be of such a degree as to shut off the circula-
tion. Removal of the strangulated part is called for.
Tumors of the omentum should be treated as tumors elsewhere (Vol. I,
page 323).
Cysts of the omentum should be extirpated or incised and drained (see
Cysts, Vol. I, page 325).
Enemata. — Laxative enemata are best given with a fountain syringe. This
consists of a bag or vessel, holding i or 2 liters (i or 2 quarts), with a rubber
tube about 2 meters (6 feet) long, and a tip for introduction in the rectum.
The tube should have a stop for closing it, and have a piece of glass tubing
introduced somewhere in its course so that the flow can be seen. The
receptacle should be elevated from 60 to 120 cm. (2 to 4 feet) above the level
of the rectum. The patient should lie on the back or right side with the
pelvis elevated. In some cases better results will be secured by the knee-
chest position. The temperature of the injection should be about io5°F.
(41 °C.) in the receptacle. The fluid should run in slowly, the patient hav-
ing been instructed to relax himself, breathe deeply with the mouth open,
and not to resist. The sphincter should control any tendency of the fluid to
escape (see Intestinal Irrigation, page 570). The patient should retain the
enema about ten minutes, and then pass it with the defecation.
A soap enema consists of about 30 Gm. (i ounce) of nonirritating soap
mixed into a suds with i liter (i quart) of water.
A turpentine enema adds 4 c.c. (i dram) of oleum terebinthinae rectifica-
tum to the above. The turpentine may be increased up to 30 c.c. (i ounce)
if necessary.
The glycerin enema consists of 3oc.c. (i ounce) of glycerin in 125 to 500
c.c. (4 to 1 6 ounces) of water.
The alum enema is made by adding 4 Gm. (i dram) of powdered alum to
500 or 1000 c.c. (i or 2 pints) of water.
The milk and molasses enema is composed of 500 c.c. (i pint) of each of
these ingredients. Munro adds 15 c.c. (^ ounce) of turpentine.
A mixed enema is made of 60 Gm. (2 ounces) each of magnesium sulphate
and glycerin, with water enough to make 180 c.c. (6 ounces).
The oil enema is composed of as much warmed olive oil as the patient
will take, usually about a pint.
Nutrient enemata should be preceded by a washing out of the bowel with
simple warm saline solution. If there is irritability of the rectum it may be
allayed by the injection of a mixture of 0.03 Gm. (^ grain) of cocain, 0.015
Gm. (y± grain) of morphin, 0.06 Gm. (i grain) of extract of hyoscyamus
and 0.6 Gm. (10 grains) of bromide of soda, dissolved in 60 c.c. (2 ounces)
of water. If either the morphin or cocain are contraindicated they may be
omitted. If it is desired to make the injection smaller, the bromide and half
of the water may be omitted.
Nutrient enemata may be given every four or six hours. The material is
THE ABDOMEN 621
injected into the rectum, with the patient's pelvis elevated. Reversed peris-
talsis sometimes carries it up into the colon where it is absorbed. It should
not be too large or it will excite progressive peristalsis and be expelled. The
maximum amount should be 250 c.c. (8 ounces). It should be given at a
temperature of about 39°C. (io2°F.). It should be given through a soft-
rubber rectal tube 10 or 12 mm. (% to ^ inch) in diameter. The tube should
be lubricated with vaselin and introduced 15 or 20 cm. (6 or 8 inches) into the
rectum. The enema should flow in slowly by gravity, being poured into a
funnel.
Nutrient enemata fail to be of use unless the predigestion has been carried
to an advanced stage. It must go beyond the peptone stage. The latest
studies have shown that the amino-acids produced from meat and milk which
have been digested for twenty-four hours with pancreatic enzymes are well
absorbed. Dextrose is absorbed well. The dextrose should not be used
stronger than 10 per cent. Milk which has been subjected to vigorous
pancreatic predigestion, and the subsequent addition of 5 per cent, dextrose
makes the best nutrient enema. The milk should be treated for twenty-four
hours with an active pancreatic extract. Eggs and poorly digested milk are
probably useless. Fats and oils are not absorbed.
Defibrinated blood is absorbed from the rectum. As much as 90 to 120
c.c. (3 to 4 ounces) of blood plasma can be absorbed in eight or ten hours.
The drip method is useful. Either a glucose solution or glucose and
peptonized milk may be used. With a i or 2 per cent, dextrose solution
30 to 60 drops a minute may be given. An enema of 125 to 250 c.c. (4 to 8
ounces) of peptonized milk and 500 c.c. (i pint) of a 4 per cent, glucose
solution may be given by the drop method 3 or 4 times daily. The glu-
cose solution may be used as strong as 50 Gm. to 500 c.c. of water, given
every six hours (see Proctoclysis, Vol. III). Not more than 25 Gm. of
glucose should be given at one injection.
Often the drip method is not well tolerated. Single injections of meat
or milk amino-acids with glucose may be given. About 10 Gm. of nitrogen
with 50 or 75 Gm. of glucose in twenty-four hours may be divided into
three or four enemas. A single enema of 225 to 275 c.c. is best absorbed.
By this method it is possible to supply the body with 400 to 600 calories
daily. This diet is deficient in fats, but supplies nitrogen and carbohydrates.
The patient consumes his own fats. It is possible to maintain a fair degree
of nutrition for two or three weeks by this method.
OPERATIONS ON THE INTESTINES
Anatomy. — The stomach and intestines are composed of four coats, the serous
(peritoneum), the muscular, the submucous, and the mucous. A thin but tough layer of
muscle fibers (muscularis mucosae) lies between the mucous and submucous coats (Fig.
1266).
The upper limit of the root of the mesentery of the small intestine, the duodenojejunal
angle, is usually 8 or 10 cm. (3 or 4 inches) above the level of the umbilicus. The root of
the mesentery extends from the left side of the body of the second lumbar vertebra down-
ward to the right sacro-iliac synchondrosis (Fig. 1267).
As the mesentery approaches the intestine its two serous surfaces separate and leave a
space on the bowel which is free from peritoneum. This mesenteric triangle must receive
especial attention in making intestinal anastomosis lest leakage occur. G. H. Monks
showed that the situation of the loop of small intestine exposed may be determined by the
character of the mesenteric blood-vessels (Figs. 1268, 1269, 1270 and 1271).
The duodenum is 25 to 30 cm. (10 to 12 inches) long. It lies posterior to the peritoneum
and may be said to have no mesentery. Its first or hepatic portion passes from the pylorus
of the stomach upward, backward, and outward to the neck of the gall-bladder. The
second, vertical or descending, portion passes down along the right side of the spine behind
622
SURGICAL TREATMENT
.LortGj ITUDIHAU
FIG. 1266. — MAGNIFIED CROSS-SECTION OF SMALL INTESTINE.
Showing the various coats with which the surgeon has to deal.
FIG. 1267. — THE MESENTERY.
The small intestine is lifted upward and to the side. The oblique attachment''©! the root
of the mesentery is shown.
THE. ABDOMEN
623
FIG. 1268. — SMALL INTESTINE ONE METER BELOW THE DUODENUM.
The primary mesenteric loops give off the vasa recta. Note translucent space between
the vessels.
FIG 1269. — SMALL INTESTINE Two METERS BELOW DUODENUM.
The secondary vascular loops are well developed. The translucent area is less than above.
FIG. 1270. — SMALL INTESTINE FIVE AND A HALF METERS BELOW DUODENUM.
The mesentery is opaque and the vessels have become a complicated network.
624
SURGICAL TREATMENT
the transverse colon, and receives the bile and pancreatic ducts posteriorly. The third,
the transverse or preaortic, portion passes behind the mesentery from right to left to
emerge just below the transverse mesocolon. The fourth or ascending portion passes
upward along the left side of the spine. The fifth portion, or duodenojejunal angle curves
sharply to continue downward into the jejunum (Fig. 1272).
FIG. 1271. — SMALL INTESTINE SEVEN METERS BELOW DUODENUM.
The mesentery is fatty and more closely resembles that of the large intestine. The arrange-
ment of the vessels is complicated and obscured by the opacity of the mesentery.
The jejunum is about 3 meters (10 feet) long. Its coils are generally on the left side
of the abdomen, in the lumbar, inguinal, and left half of the umbilical regions.
The ileum is about 4 or 5 meters (14 feet) long. Its coils are generally on the right side
of the abdomen and pelvis, in the lumbar, inguinal, and right halves of the umbilical and
hypogastric regions.
Ai. Vfem
HCKEA5
'KjDrtEt
FIG. 1272. — DUODENUM.
Showing its anatomic relations.
The^large intestine differs from the small intestine in that, it is larger; it is more fixed;
it has speculations, separated by transverse ridges; it has longitudinal bands, and appendices
epiploicae (Fig. 1273).
The cecum lies in the right iliac fossa on the psoas-iliacus muscle. It is entirely covered
by peritoneum, being free, and usually without a mesentery. It is just above the outer
half of Poupart's ligament. The appendix -vermiformis generally is attached about 1.7
cm. (XH6 inch) below the ileocecal valve, to the inner and posterior aspect of the cecum.
THE ABDOMEN
625
The ileocecal valve, at the junction of ileum and cecum, is on the posterio-internal aspect of
the upper part of the cecum.
The ascending colon is about 20 cm. (8 inches) long. It ends at the lower surface of
the right lobe of the liver at the right of the gall-bladder. It is usually behind the peri-
toneum, having no mesentery in about three-fourths of cases. The transverse colon is
about 50 cm. (20 inches) long. Its mesocolon is long. The descending colon is about 22
FIG. 1273. — CROSS-SECTION OF ASCENDING COLON.
cm. (S^z inches) long. Its peritoneal covering is similar to that of the ascending colon.
A mesocolon is present in about a third of the cases. The sigmoid colon is about 31 cm.
(13 inches) long, and lies in the left iliac fossa. It ends opposite the brim of the pelvis
opposite the left sacro-iliac synchondrosis. It has a freely movable mesentery.
The mesenteric triangle is that part of intestine having a mesentery where the two peri-
tonea layers of the mesentery separate to pass around the bowel. The two layers begin
FIG. 1274. — MESENTERIC TRIANGLE, WHICH REQUIRES ESPECIAL ATTENTION IN MAKING
INTESTINAL ANASTOMOSIS.
to separate about 1.5 to 2 cm. (^3 to % inch) from the bowel, and leave about 8 mm.
(^{e inch) of the bowel wall without a serous coat (Fig. 1274).
The surface topography of the large intestine is less variable than that of the small
intestine, but still quite variable. In general, the lower border of the cecum corresponds
to a line drawn from the anterior superior spine of the ilium to the symphysis pubis. The
VOL. 11—40
626
SURGICAL TREATMENT
ascending colon traverses the right lumbar and hypochondriac regions to the hepatic
flexure just below and to the outer side of the gall-bladder. The transverse colon commonly
passes across the abdomen at the junction of the epigastric and umbilical regions. It
lies between the greater curvature of the stomach and the umbilicus. The splenic flexure
FIG. 1275. — METHODS OF TEMPORARY CLOSURE OF INTESTINE DURING OPERATION.
A, Digital compression; B, safety pin and sponges (Maunsell); C, pin of metal or wood
(probe, nail or skewer) with rubber band; D, fillet of gauze held about bowel with hemo-
static clamp; E, forceps protected with rubber tubing and held together by a small ring
of tubing; F, wooden strips covered with gauze and held together with rubber elastics; G,
special intestinal clamps covered with rubber tubing; H, rubber cord combined with hemo-
static clamp.
is posterior to the cardia of the stomach in the left hypochondrium. The descending colon
passes downward through the left hypochondriac and lumbar regions to the sigmoid.
Instruments for Intestinal Operations. — Intestinal clamps for temporary
closure of intestine are used. In lieu of these a hemostat and a rubber elastic
THE ABDOMEN 627
band may be employed, or any other device giving gentle and even pressure
(Fig. 1275).
Needles should be both straight and curved. A round, straight needle,
such as used by milliners, may be held in the fingers, and is very satisfactory
for intestinal work (Fig. 1276). Nos. 6 to 8 are used. Many surgeons prefer
a curved needle to be used either with or without a holder (Fig. 1277). The
straight needle is usually best where there is room; the curved needle is best
for work which must be done inside of the abdomen. Round needles are
to be preferred to needles which cut the tissues. For interrupted sutures,
FIG. 1276. — MILLINER'S NEEDLE USED IN INTESTINAL SUTURING.
many needles may be ready threaded, or a long thread may be used and cut
at each suture. It is usually best not to tie interrupted sutures until all
have been introduced. No. o chromic catgut has the largest range of useful-
ness. No. i silk or linen thread is also used. For special purposes still
larger and smaller sizes of thread are employed. The needle may be held
and passed toward or away from the operator or laterally.
Knives, ligature carrier, hemostatic clamps (short and long), anatomic
and toothed forceps, scissors, probe, tenaculum, needle holder, sponge
holders, rubber and glass drainage tubing, laparotomy pads, sponges, gauze
or wick drains, ligatures, and the instruments for opening and retracting
the abdominal wall are used (see Instruments and Materials, Vol. I).
Special instruments and appliances are used for special operations.
FIG. 1277. — CURVED NEEDLE USED IN INTESTINAL SUTURING.
General Principles. — Successful intestinal suturing requires experience
and skill to begin with. They are best secured by operations on animals
and by assisting an experienced and skilled surgeon. The basic principle
in the suturing of intestinal wounds is the even apposition of serous surfaces,
which are to be held by the sutures, without leakage to infect them, until
they become adherent and the adhesions organized. The broader the
surfaces, the less the danger of leakage. The scar tissue that unites the
surfaces contracts, and allowance should be made whenever possible for
this contracture by making artificial openings from 2 to 4 times as large
as they need ultimately to be.
The closure should be water-tight. If two tiers of suture are employed,
it is generally best that a suture penetrating the mucosa should not pene-
trate the serosa; and a suture penetrating the serosa should not penetrate the
mucosa. The serosa suture should pass as far as the mucosa, embracing,
if possible, the muscularis mucosae. Sutures embracing the mucous mem-
628 SURGICAL TREATMENT
brane should preferably be of silk or linen, except in the stomach. For
sutures which pass through all the coats, silk or linen is the best material.
To prevent leakage of intestinal contents during operations, clamps are
used. These should be so protected that they cannot do injury to the bowel.
If lock clamps are employed the jaws should each be covered with rubber
tubing. In the absence of any clamping device a bit of gauze drain may be
pulled through a small opening in the mesentery and tied or caught by a
clamp.
The submucous vessels may bleed after the operation. They should be
controlled by the suture. The suture which embraces the mucous membrane
should be tight, and, if continuous, it should be tied or interrupted frequently.
The relation of the supplying vessels in the mesentery to the bowel to be
resected should be observed. No chances should be taken to leave any
segment of bowel to be supplied by damaged mesenteric vessels. Resections
should be made larger, if necessary, to insure a safe blood supply.
Two forms of suture are used: the interrupted and the continuous. The
interrupted suture more evenly distributes the strain; if one becomes weak
or loose, it does not affect the others ; the blood-vessels are compressed only
at each suture; and expansion of the wound is not hindered. The continuous
suture is more quickly applied, but the whole suture is as weak as its weakest
part. The disadvantages of the continuous suture may be prevented some-
what by tying the thread at frequent intervals. This interrupts the suture.
Certain interlocking sutures, such as taking two turns about each suture
before pulling it taut, also give it the character of an interrupted suture.
It is best to use two tiers of sutures. In doing this, at least one tier may
be a continuous suture. To tighten a suture, after it has been introduced,
it should be pulled in a direction nearly parallel with the direction in which
it was introduced. Traction at a right angle to the direction of introduction
will cause the suture to tear out.
The bowel at the place of operation should be emptied by placing a
clamp above and then gently stripping its contents downward and placing
a clamp below to prevent regurgitation. The clamps should be far enough
apart to give ample room for work. Bowel to be opened should be placed
upon a separate towel or pad which may easily be removed and renewed
without interference with the rest of the field of operation. With care, it is
possible to soil only the sponges which touch the mucous membrane. Soiled
instruments are laid aside or rinsed off. There should be but few instruments
in the field. The only instruments to become soiled should be a needle and
forceps. The field of operation should be dry. Soiled instruments and
sponges should not lie about. Skillful surgery is simple and orderly. Mussy
surgery means bad results.
Hemorrhage should be minimized by making incisions through areas
having the smallest vessels. Cut vessels should be caught quickly and
tied with fine catgut. The peritoneum should be left dry. Drainage is
usually not to be employed.
Intestinal Suture (Enterorrhaphy). — There are many methods of applying
intestinal sutures. The most important will be described. They are applied
in such a way that as the suture is tightened, the wound edges are invagin-
ated. The width of tissue embraced hi the suture is about 3 mm. (^ inch)
the sutures should emerge about 2.5 to 3 mm. (^IQ to % inch) from the edge
of the wound; and they should be about 3 mm. (^ inch) apart. Moynihan
estimates the tightness to which a continuous suture should be drawn as
follows: the last =uture should be pulled to raise up into prominence the part
of the wall into which the next suture is to be passed. Suturing the intestine
THE ABDOMEN
629
should be done with the loop to be operated upon outside of the abdomen.
All the rest of the bowel should be in the abdomen, and the field of operation
thoroughly protected. An extra protective pad should be placed under the
place where the bowel is to be opened. As soon as soiling has ceased, this
should be changed. After completing a suture in which the lumen of the
bowel has been exposed, the bowel should be washed off with warm salt solu-
tion before being returned to the abdomen.
FIG. 1278. — SEROMUSCULAR SUTURE.
The needle passes as far as the submucosa.
For applying the seromuscular suture with a straight needle, the needle
is passed as far as the submucosa and then caused to lift up the wall of
the bowel as a fold and push the needle on so that it passes out through
muscularis and serosa without penetrating the mucous membrane (Figs.
1278 and 1279).
The use of omental grafts is indicated in some cases where the line of suture
may be weak. The best omental graft consists in a surface of omentum
FIG. 1279. — SEROMUSCULAR SUTURE.
The wall of the bowel is lifted up to make a fold and the needle is passed on through mus-
cularis and serosa without penetrating mucous membrane.
sewed about the line of sutures so as to cover it. This imitates what nature
does in just such cases. A detached piece of omentum may also be used
for this purpose.
The sterilization of mucous membrane which is exposed in the course of
operations is usually not necessary. It is infected, of course, but the bacteria
630
SURGICAL TREATMENT
of the intestine when carried by sutures seem not to grow in the tissues. Still,
so far as the surgeon's hands, instruments, and sponges are concerned, it
should be assumed that dangerous infection is present in the mucous mem-
FIG. 1280. — BEGINNING STITCH FOR SUTURE OF THE INTESTINE.
brane, and material from the mucous membrane should not be conveyed to
uninfected tissues. This means that when the surgeon's hand touches the
mucous membrane, the hand should be washed off before it touches sterile
parts such as peritoneum or wound surface.
FIG. 1281. — TYING THE FIRST KNOT FOR THE CONTINUOUS PARALLEL SUTURE.
The first layer of through-and-through sutures has been introduced.
If the intestinal contents are in a fluid state, the danger of infection is
much greater. Fluid feces are much richer in virulent organisms than are
dry or soft feces. This should be borne in mind, and before operations for
THE ABDOMEN
631
opening the intestine a purge should not be given within twenty-four hours.
It is best in these cases that the laxative be given forty-eight hours before
the operation, after which only such foods as leave the minimum of fecal
residue should be taken.
1
FIG. 1282. — THE PARALLEL CONTINUOUS STITCH.
The first layer of sutures has been introduced. The second layer is in process of application.
When the surgeon desires to sterilize the mucous membrane which appears
in the wound at the time of operation, it may be done by applying 5 per cent,
alcoholic solution of thymol. Tincture of iodin serves the same purpose, but
not so effectively as the thymol.
FIG. 1283. — SIMPLE RIGHT-ANGLE STITCH OF LEMBERT.
Showing interrupted suture (at left) and continuous suture (at right).
suture has been placed.
The primary
The parallel continuous stitch (Gushing) is applied with the needle always
passing parallel to the wound, first on one side and then on the other. At the
extreme ends the suture may be caused to double back upon itself in order
to cover the knot (Figs. 1280, 1281, and 1282).
The simple right-angle stitch (Lembert) (Figs. 1283 and 1284) passes
632
SURGICAL TREATMENT
\
FIG. 1284. — SIMPLE RIGHT-ANGLE SUTURE OF LEMHERTI
Suture shown in cross-section of bowel.
FIG. 1285. — SIMPLE RIGHT-ANGLE INFOLDING SUTURE OF LEMBERT.
Transverse section.
THE ABDOMEN
633
transversely from one side of the wound to the other. It may be interrupted
or continuous. It may be used as a simple infolding suture (Fig. 1285) or
combined with an underlying penetrating stitch (Fig. 1286).
FIG. 1286. — SIMPLE RIGHT-ANGLE INFOLDING SUTURE OF LEMBERT, COMBINED WITH UN-
DERLYING PENETRATING SUTURE, DIAGRAMMATIC.
The seromuscular mattress stitch represents two stitches with one tie (Fig.
1287).
FIG. 1287. — SEROMUSCULAR MATTRESS STITCH.
The right-angle mattress stitch (Halsted) (Fig. 1288 ) represents one
tie for every two simple right-angle stitches (Lembert). This is modified
(Gould) by reversing the direction of introduction on one side (Fig. 1289).
634
SURGICAL TREATMENT
FIG. 1288. — RIGHT-ANGLE MATTRESS STITCH OF HALSTED.
The primary suture has been applied.
PIG. 1289. — INFOLDING RIGHT-ANGLE MATTRESS SUTURE OF GOULD.
The primary suture has been applied.
FIG. 1290. — MUCOSA SUTURE OF CZERNY.
This suture is usually applied as a first layer to the mucous membrane and muscularis.
THE ABDOMEN
635
The mucosa suture (Czerny) (Fig. 1290) is applied to the mucous mem-
brane and submucosa. It is usually interrupted, but may be applied as a
continuous suture with occasional interruptions.
FIG. 1291. — PURSE-STRING SUTURE APPLIED TO LATERAL OPENING OF BOWEL.
The purse-string suture (Figs. 1291, 1292, and 1293) is used for fixing a
tube or other device in the side of the bowel or in the cut end. The mucous
membrane is not included except in using such devices as the Murphy button.
FIG. 1292. — PURSE-STRING SUTURE APPLIED TO END OF BOWEL.
Suture used to hold Murphy button.
For suturing wounds of the intestines, large enough to require two rows of
sutures a deep interrupted row of simple right-angle sutures (Lembert),
636
SURGICAL TREATMENT
covered in by the continuous parallel stitch (Gushing) is to be preferred. A
mucosa suture may be used if there is bleeding from the mucous membrane
edges which is not controlled by ligatures.
The perforating stitch (Figs. 1294 and 1295) involves all of the coats of
the bowel. It may be continuous or interrupted. It is used in some forms
FIG. 1293. — PURSE-STRING SUTURE FOR CLOSING END OF BOWEL.
of enteroanastomosis (Connell). It may be a simple running suture or some
form of button-hole or glover's stitch may be used. It was once thought
that such a suture would convey infection to the peritoneum ; but experience
has shown that it sinks into the peritoneum, becomes sealed with plastic
exudate, and is virtually a buried suture.
FIG. 1294. — PERFORATING STITCH OF CONNELL.
The first three sutures have been applied.
The mattress interlocking stitch (Tiirck) (Figs. 1296 and 1297) obviates the
danger of the open space between interrupted sutures, and combines many of
the advantages of the interrupted and continuous stitch.
Intestinal Resection (Partial Enterectomy). — In man removal of 80 per
cent, of the small intestine is compatible with life. As much as 540 cm.
THE ABDOMEN 637
(18 feet), have been successfully removed. The whole of the large intestine
may be taken out without causing serious disturbance. While all of the
colon can be removed without serious impairment of health, the removal of
more than one-half of the small intestine is a serious undertaking. Removal
of a segment of the intestinal canal is done for injury and disease. It is
followed by intestinal anastomosis or the formation of an intestinal fistula.
The abdomen is opened, and the segment to be removed is identified and
brought out through the abdominal wound. The surgeon should mark with
his eye a triangle on the mesentery, having its base at the segment of bowel
to be removed and its apex about one-half of the distance toward the root of
the mesentery. The vessels running into this triangle should be tied with
FIG. 1295. — PERFORATING STITCH OF CONNELL.
The first third of the through-and-through suture has been applied.
the aid of the ligature carrier. The base of the mesenteric triangle to be
removed should be slightly shorter than the bowel to be removed, in order
that the nourishment of the cut edges of the intestine shall be adequate.
The bowel is then emptied and clamped or its lumen obstructed by the
fingers of an assistant about 6 or 8 cm. (3 inches) from the place to be cut.
Protective towels and pads are placed in position, clamps are also placed on
the segment to be removed in order to retain its contents.
The clamps placed on the bowel ends to be joined should not be at right
angles to the gut but their tips should incline toward one another. The
bowel should not be divided at right angles to its long axis, but about 25 or
45 degrees away from that. This means that as the cut surface is farther
from the mesentery, the more bowel is removed (Fig. 1298). This oblique
638
SURGICAL TREATMENT
division of the bowel makes a larger lumen, and guarantees better nourish-
ment to the distal side. If 45 degrees are removed from each side this means
that an angulation of 90 degrees is produced by the union. There is no dis-
advantage in this.
The mesenteric triangle is then cut on two sides up to the intestine.
When the intestine is divided, its ends are cleansed and covered, and the
segment of bowel and mesentery removed (Figs. 1299 and 1300). Soiled
pads and cloths are removed, the hands are rinsed off, and a general cleaning
up instituted.
FIG. 1296. — MATTRESS-INTERLOCKING STITCH OF TURCK.
Manner of cutting one-half of the double stitch.
Some surgeons prefer not to remove the mesentery, but to place the liga-
tures close to the bowel and parallel with it, and then cut the mesentery
between the ligatures and the bowel. After removal of the intestine and
anastomosis, the redundant mesentery is folded over and stitched to the
adjacent mesentery (Fig. 1301). Another method of dealing with the un-
removed mesentery, which I have used with satisfaction, consists in splitting
it down midway between the two bowel ends, and leaving it in the form of
THE ABDOMEN
639
two triangular flaps, one connected with each segment. After the anasto-
mosis, one mesenteric flap is placed on one side and the other on the other
side, and each is sutured to the flat surface of the mesentery as close to the
bowel as possible (Fig. 1302).
Whatever method of dealing with the mesentery is followed, it is always
important that for anastomosis a firm suture to relieve tension on the stitches
should be placed on either side at the enteromesenteric junction. This
should not be placed so deeply as to interfere with the nutrient vessels.
Intestinal resection is done for obstruction caused by tumors, adhesions,
or stricture; for gangrene of the bowel; for wounds and perforations of the
bowel too extensive or complicated for satisfactory suture; for cases of
intestinal fistula not capable of closure by simpler measures; for bowel which
FIG. 1297. — MATTRESS-INTERLOCKING STITCH OF TURCK.
Showing manner of tying sutures.
has been excluded and no longer functionates; and for injuries, vascular dis-
eases, or tumors of the mesentery, in which the blood supply of the intes-
tine is so compromised or threatened as to cause or threaten gangrene of
the bowel.
In resections where there is gangrenous or distended bowel, the mesentery
should be freed from the bowel to the full extent; the distal division of the
intestine is then made; and the segment which is to be removed used as a
tube to convey away from the field of operation the contents of the bowel
above. After the intestine has thus been emptied, the upper clamps are
applied, and the resection proceeded with (the methods of anastomosis are
given below).
Anastomosis may be difficult in some situations because of adhesions or
640
SURGICAL TREATMENT
FIG. 1298. — RESECTION OF INTESTINE FOR END-TO-END ANASTOMOSIS.
The lines of incision having been determined, the mesenteric vessels are first tied and the
mesentery is divided. No clamps are applied to the bowel until after this has been done.
FIG. 1299. — RESECTION OF INTESTINE FOR END-TO-END ANASTOMOSIS
Note oblique division of the bowel. Such oblique division provides for better nourish-
ment to the distal side of the gut and insures against stricture better than does transverse
division.
THE ABDOMEN
641
FIG. 1300. — RESULT OF ANASTOMOSIS AFTER OBLIQUE DIVISION OF BOWEL.
FIG. 1301. — METHOD OF TREATING REDUNDANT MESENTERY WHICH HAS NOT BEEN
REMOVED WITH THE RESECTION OF INTESTINE.
The mesenteric fold is stitched over at its raw border and sewed to the adjacent mesentery.
VOL. 11—41
642
SURGICAL TREATMENT
anatomic peculiarities. In resection of the lower part of the sigmoid and
upper end of the rectum, it may be difficult to manipulate the distal stump.
To meet this, W. J. Mayo passed a large soft-rubber tube out through the
rectum, and fixed its upper end inside of the upper stump by a catgut suture.
The tube is then pulled down, and the proximal gut drawn inside the distal
gut, after which the edges may be united by a suture. Further traction
draws the gut down farther, invaginates the suture line, and a second row of
sutures may be applied on the peritoneal side (Fig. 1303).
Removal of the cecum and ascending colon is often indicated for cancer,
ulceration, stenosis and chronic stasis. In all such resections the operation
should be done through a good-sized opening through the sheath of the rectus
muscle. The resection should be preceded by a thorough investigation of
the abdomen to determine the extent of the disease or the presence of other
lesions. For resection of the right colon, after placing the protective gauze
FIG. 1302. — METHOD OF TREATING UNREMOVED MESENTERY BY DIVIDING IT INTO Two
EQUAL TRIANGULAR FLAPS AND SEWING EACH ON OPPOSITE SIDES OF THE MESENTERY.
or rubber sheeting along the inner side of the bowel, an incision is made at
the "white fold" of parietal peritoneum where it passes to the outer side of
the bowel. The bowel may then be lifted forward, and the subperitoneal
wound packed with gauze. The ileum should then be ligated with catgut
about 7 cm. (3 inches) from the colon, clamped i cm. distal to the ligature,
and divided about 5 cm. distal to the ligature. The two cut ends of bowel
should be sterilized with 5 per cent, thymol alcoholic solution, tincture of
iodin, or phenol. The proximal stump is covered with a warm towel.
Then from below upward the mesocolon is tied at intervals, clamped on the
bowel side and divided. This proceeds rapidly to the hepatic flexure or as
far as necessary. In the case of chronic stasis resection is carried to the
junction of the right and middle thirds of the transverse colon.
THE ABDOMEN
643
In malignant cases, the division of the mesocolon is made far from the
bowel; in non-malignant cases it is made close to the bowel. Care should be
taken not to injure the duodenum as it passes under the mesocolon. Ureter
and kidney must also be considered.
In removing the omentum, it should be ligated and cut from the right
third of the colon. (For preserving the omentum, see below.) The colon
is then tightly ligated with catgut, clamped proximal to the ligature and
cut about 7 mm. proximal to the ligature, and the liberated bowel removed.
The puckered mucous membrane of the stump is sterilized with the actual
cautery, and buried with a purse-string suture of catgut. The stump of
FIG. 1303. — METHOD OF RESECTION AND ANASTOMOSIS WITH INVAGIXATIOX.
When anastomosis is made between sigmoid and rectum a tube is left in the bowel to pre-
vent distention.
the ileum is buried with a purse-string suture, and the ileum is brought up
and united to the colon by a lateral anastomosis 5 or 6 cm. (2 or 2^
inches) from the end of the stump of the colon.
Instead of ligating the bowels, they may be clamped in two places and
cut between the clamps. The male half of an anastomosis button may be
fixed in the end of the ileum, and the female half inserted into the lumen of
the colon. The end of the colon may then be closed by two rows of sutures,
and the button manipulated into position and an opening cut for it in one of
the longitudinal bands of the bowel about 5 or 6 cm. from the end. This
644
SURGICAL TREATMENT
may then be united with the ileum, making an end-to-side anastomosis (see
Anastomosis with Button, page 667). Or an end-to-end anastomosis
may be done. The peritoneum should be sewed over the raw surface in
the back of the abdomen.
To prevent obstruction to the passage of gas is a most important considera-
tion in connection with these operations on the colon. The great danger is
peritonitis from yielding of the sutures because of gas distention of the bowel,
which is apt to be pronounced between the fourth and sixth days. To obvi-
ate this, after resection such as is described above, the stump of the colon
is brought up to the anterior abdominal wound by a couple of silkworm-gut
sutures which hold the wound at the closed end of the bowel, against the
rectus muscle. The parietal peritoneum is not permitted to intervene. The
ends of the purse-string suture should be left long and lie free in the wound
FIG. 1304. — SAFETY OPERATION TO INSURE AGAINST OBSTRUCTION AFTER RESECTION OF
COLON.
The end of the bowel has been closed with a purse-string suture. Two sutures are
passed on either side of this and through the abdominal wall to hold the place of closure
against the abdominal wound. The ends of the purse-string suture are brought out through
the wound to guarantee drainage, as suggested by Mayo.
as a guide. A strip of gauze is passed down to the puckered bowel wound
(Fig. 1304). This gives a communication to the bowel through the abdomi-
nal wall. The ends of the purse-string suture lie beside the gauze and
project beyond the skin. The two sutures which hold the bowel against
the abdominal wall are left long and are removed at the end of seven days.
If the colon becomes distended with gas, it is a simple matter to withdraw
the gauze, and pass a trocar and canula or a grooved director down into
the colon along the purse-string sutures, and relieve the distention. Mayo
has emphasized the importance of this procedure.
Another method of accomplishing the same result is to make a lateral anas-
tomosis about 10 cm. (4 inches) from the end of the ileum. The stump of the
ileum is then brought up to the abdominal wound and fixed with a tube in it.
After the enterostomy opening has proved its patency and gas distention has
THE ABDOMEN
645
subsided, the fistula may be allowed to close. If the above anastomosis can
not be made without great tension, the ileum may be connected with the
sigmoid, and a tube passed through the rectum and fixed in such a position
that its upper end is above the anastomosis (Fig. 1305).
FIG. 1305. — ANASTOMOSIS BETWEEN ILEUM AND SIGMOID.
Note rectal drainage tube extending into ileum. This prevents gas retention and dilata-
tion of the bowel. The cecum and ascending colon have been resected. The stump of
the colon at the hepatic flexure is brought out through a small opening in the abdominal
wall.
If the colon is not removed, but only an ileosigmoidostomy done, the distal
stump of the ileum may also be brought out through a right iliac opening and
used for irrigation purposes as in appendicostomy. It is possible in this short-
FIG. 1306. — ANASTOMOSIS BETWEEN ILEUM AND SIGMOID WITH RECTAL DRAINAGE TUBE
PASSING AB*OVE ANASTOMOSIS.
The stump of the ileum is brought out through a wound in the lower right abdomen;
the stump of the colon is brought out at a small wound in the upper left abdomen; the
descending colon is resected.
circuiting operation to divide the sigmoid or upper rectum and do an end-to-
end anastomosis with the ileum. The two ends of the excluded bowel are
then brought out at the abdominal wall, permitting preservation of the
646
SURGICAL TREATMENT
omentum, and providing means for through-and-through cleansing of the
colon (see Intestinal Exclusion, page 677).
After excision of descending colon, the ileum may be united with the distal
stump, and the two ends of the colon connected with the surface by two
openings through the abdominal wall (Fig. 1306).
The transverse colon should not be sacrificed unless absolutely impera-
tive, because by so doing the omentum is often either damaged or lost.
Removal of the omentum is highly undesirable, as it serves an important
function in distributing heat to the bowels, in equalizing the circulation, in
preventing the spread of peritonitis, and in safeguarding the viscera from
mechanical injury. When it is removed, the bowels tend to become matted
together by adhesions.
FIG. 1307. — DIAGRAMS OF INTESTINAL ANASTOMOSIS.
A, End-to-end anastomosis; B, lateral anastomosis; C, lateral implantation by end-to-side
anastomosis; D, lateral loop anastomosis for intestinal exclusion or short circuiting.
For resecting the transverse colon with preservation of the amentum, J. E.
Summers (Annals of Surg., September, 1917) proceeded as follows: The
bowel is held taut. The omentum is lifted up, and with a straight narrow
knife the peritoneum is nicked along the line of junction of the under surface
of the omentum and the upper surface of the colon. With a sponge the
omentum is forced upward from the transverse mesocolon to the lower border
of the stomach, exposing but not injuring the mesenteric blood-vessels. The
colon is then resected in the usual manner by view from above of the mesen-
teric vessels. After the anastomosis is made the omentum is sewed over the
place of bowel union. This operation serves the two purposes of preserving
the omentum and protecting the line of anastomosis.
Intestinal Anastomosis (Entero-enterostomy) .—There are many forms of
intestinal anastomosis. In general they fall under the following methods:
end-to-end anastomosis, lateral anastomosis, intestinal exclusion or short-
circuiting, and intestinal implantation or end-to-side anastomosis (Fig. 1307).
THE ABDOMEN
647
When end-to-end anastomosis is to be done between two tubes of unequal
size, the larger may be made smaller by cutting out a V-shaped piece opposite
the mesentery and sewing the notch together; or the smaller may be made
larger by cutting it obliquely instead of at right angles, or by making a lon-
gitudinal cut in its margin (Fig. 1308). Instead of end-to-end anastomosis in
such cases, the end of each may be closed and a lateral anastomosis done.
Anastomosis should not be done with an upper bowel segment that is
much distended. The bowel must not have lost its power to contract. If
it has, a higher operation or some other procedure should be undertaken.
It is always desirable that in preparing the bowel for end-to-end suture
the bowel be cut obliquely and not at right angles, so that the mesenteric side
is longer than the side opposite the mesentery. This is to insure better
blood supply to the distal side and to make the lumen larger at the anasto-
FIG. 1308. — METHODS OF END-TO-END ANASTOMOSIS IN CASES IN WHICH ONE SEGMENT
OF BOWEL is LARGER THAN THE OTHER.
A, The larger segment is made smaller by removing a wedge of bowel wall.
B, The smaller segment is cut obliquely thus increasing the size of the end opening.
C, The smaller segment is cut into longitudinally to increase its calibre.
mcsis. If the obliquity is 45 degrees, an angulation of 90 degrees, or a right
angle is formed, after the anastomosis is made. Experience has showed that
there is no objection to this, although it will rarely be necessary to make so
great an obliquity in the section of the bowel. Half of this obliquity usually
suffices (see page 640).
Simple end-to-end anastomosis begins with the closure of the mesenteric
angle. This is done as follows: A suture 30 cm. (12 inches) long, with a
straight needle is taken in hand. The needle is passed from within the bowel,
being entered in the mucous membrane a little more than 3 mm. (% inch) from
the edge, and passed into the connective tissue of the mesenteric angle, and
thence out through the peritoneum, emerging about 1.5 mm. (%$ inch) from
the edge, in the line where the peritoneum is reflected from the mesentery to
the bowel. It then, enters the peritoneum and mucous membrane of the
opposite segment in just the reverse line, passing into the mucous membrane
again and repeating its course on the other side of the mesentery, to enter the
648
SURGICAL TREATMENT
lumen of the bowel whence it started. The two ends are then tied and cut.
The transverse suture loop inside of each bowel end is about 4.5 mm. (% Q
inch) long (Fig. 1309).
The two bowel ends are folded back upon the mesentery, and a suture
introduced at one side of the mesenteric angle, apposing serosa to serosa. It
is tied on the serosa side, and its end left long to serve as the first traction
guide. Another suture is then introduced through all the coats, the same
distance from the mesenteric angle as the previous suture, apposing serosa to
serosa. It is not tied, but the ends are left long, to be used as a second trac-
tion guide. The distance between the first and second guides should be
about one-third of the circumference of the bowel.
The two guides are then used for gentle traction in the hands of an assist-
ant, bringing the wound edges in a line. The needle end of the first
guide is employed to make a continuous suture between the two (Fig. 1310).
When the second traction guide is reached, a third traction guide is intro-
duced, in a manner similar to the second, midway between the two first guides
FIG. 1309. — FIRST STITCH IN END-TO-END ANASTOMOSIS.
This is the mattress mesenteric stitch.
The stitch is then continued between the second and third guides. The
second guide is then removed, and the last third of the suture completed by
using the first and second guides for traction alignment. The last part of
thisj suture, of course, cannot be drawn tightly until all of the stitches have
been introduced (Fig. 1311). The last stitch ends on the outside, and the
suture is tied to the end left as the first traction guide. The third guide is
removed and the ends of the last knot cut. Some surgeons prefer to tie the
first traction suture on the inside, and end the suture by a knot which sinks
into the lumen of the bowel as the last suture is tied.
In applying such a continuous suture, it should be interrupted at short
intervals or several separate sutures used. This is in order to prevent unequal
tightening or relaxation of the suture. This inner stitch controls bleeding
and prevents leakage.
The more important stitch is the second or outer tier. This is aimed to
give broad serous apposition and still further strengthen the union. It
should not take in too much tissue lest the circle of inverted bowel encroach
too much upon the lumen and cause some obstruction or conduce to intus-
THE ABDOMEN
649
susception. It should embrace all of the coats except the mucous membrane.
Some surgeons employ parallel continuous stitch (Gushing) for this, others the
simple right-angle stitch (Lembert), and others the right-angle mattress
FIG. 1310. — SUTURING FIRST THIRD IN END-TO-END ANASTOMOSIS.
The mattress mesenteric stitch has been tied. The guide sutures are held by an
assistant. One guide is the tied end of the first continuous suture; the other will become
the second continuous suture.
FIG. 1311. — SUTURING LAST THIRD OF CIRCUMFERENCE IN END-TO-EXD ANASTOMOSIS.
The right hand guide is opposite the mesentery; the left hand guide is midway between it
and the mesentery and is the end of the first continuous suture.
stitch (Halsted). The continuous suture is used when haste is necessary,
otherwise the interrupted or interrupted continuous stitch is to be preferred.
The first serosa interrupted stitch is placed directly opposite the mesen-
650
SURGICAL TREATMENT
teric attachment. One is placed on either side midway between this and the
mesentery. The ends of these are left long to serve as guides. The intervals
between these guides are sutured as for ordinary enterorrhaphy (Fig. 1312).
FIG. 1312. — PLACING THE SEROSA LAYER OF SUTURES.
The first layer of sutures has been placed; guides have been inserted; and the interrupted
parallel mattress sutures are being applied.
FIG. 1313. — END-TO-END ANASTOMOSIS COMPLETED.
The caliber of the bowel is increased at the place of anastomosis by the obliquity of its
division.
After completing the second row, instruments are removed, the mesen-
teric wound is closed with a few interrupted sutures (Fig. 1313), the bowel
replaced, the omentum drawn down, and the abdomen closed.
There are many modifications of this method of suture. If time must be
THE ABDOMEN
651
economized, the serosa layer of sutures may be omitted entirely. The inner
suture may be interrupted and the outer suture continuous.
End-to-end anastomosis -with mattress sutures (Connell) uses but one row
of sutures and all knots are tied inside of the bowel. It is done as follows:
The mesenteric stitch is introduced as in the above-described operation.
A similar stitch is placed on either side of the first one, the inner punctures
of these two stitches being placed so close to the first that they pass into the
mesenteric angle (Figs. 1309 and 1310). These are tied. The ends of the
outer ones are left long to be used as guides. A similar mattress suture is
placed at a point represented by one-third of the distance on the circum-
FIG. 1314. — END-TO-END MATTRESS SUTURE CONTINUED.
The suturing is progressing between the two guides. The lower guide is one of the
first three mesenteric sutures. The upper guide is a mattress suture, with the ends left
ong, placed one-third of the distance from the mesentery.
ference of the bowel measured from the mesentery. This is tied and the
ends left long to be used as the second guide. The first guide should be on the
side opposite the mesentery from the second guide. Gentle traction on
these two guides brings into alignment the edges to be joined, and perforating
mattress sutures are applied and tied (Fig. 1314).
The sutures are about 3 mm. (% inch) from the cut edge of the bowel,
a little less than this distance apart, and each suture makes a span a little
greater than this. If bleeding is observed between any sutures after they
have been tied another mattress should be placed to control it.
652
SURGICAL TREATMENT
FIG. 1315. — END-TO-END MATTRESS SUTURE CONTINUED.
Sutures are being applied to the second third of the circumference. Two mattress|sutures.
with the ends left long, serve as guides. The knots are all tied on the mucous membrane
surface.
FIG. 1316. — END-TO-END MATTRESS SUTURE.
Placing last sutures. The bowel has been inverted. The last stitches are applied in
inverted form from the serosa side. When the knot is tied on the mucous membrane side
it continues the-inversion. The last two sutures remain yet to be inserted.
THE ABDOMEN
653
When the first third of the circumference has been sutured the ends of the
first mattress guide are cut off. Another mattress guide is introduced and
tied midway between the two first guides on the ununited border. The
ends of the^second guide are brought forward under this last one, and by
pulling these two taut the bowel edges are made prominent for suturing
FIG. 1317. — END-TO-END MATTRESS SUTURE.
Method of inserting needle for tying last knot. After the knot is tied the ends of the
thread are caught in the loop of the threaded needle and drawn inside of the bowel.
FIG. 1318. — END-TO-END ANASTOMOSIS.
Inserting parallel mattress serosa stitch instead of last through-and-through suture.
(Fig. 1315). When the suture has been completed between the second and
third guides, the ends of the second one are cut off, and the gut inverted
into position.
The last third of the circumference now remains to be sewed. This is
between the mesentery and third traction suture. This part of the operation
is less easy than the first two-thirds. The needle is passed in and out through
654 SURGICAL TREATMENT
each wall separately making four transfixions for each suture, beginning and
ending in the mucous membrane. The ends are left untied until all have
been passed (Fig. 1316). Then all are tied excepting the last one. Gould
has an assistant hold the bowel across an index-finger. The long ends of
each tied suture are used for traction while the next stitch is being introduced.
The tying of the last suture is not a simple matter. Connell introduces
into the space between two sutures at an opposite point, a straight needle,
shank first, threaded with silk. The needle is made to emerge at the un-
closed space. The ends of the suture are threaded into the loop between
the silk thread and the needle and drawn out through the space into which
the needle was introduced. They are tied, cut off, and allowed to retract
into the lumen of the bowel (Fig. 1317). Instead of this, the last mattress
suture may be omitted, and the opening closed with a serosa parallel mattress
stitch (Gushing) (Fig. 1318).
FIG. 1319. — MAUNSELL'S INVAGINATION METHOD OF END-TO-END ANASTOMOSIS.
Traction sutures have been applied and the ends brought out through an antimesenteric
incision.
End-to-end anastomosis by the imagination method (Maunsell) is charac-
terized by a temporary opening made through the wall of the gut. After
performing a resection of the bowel, without removing a segment of mesentery,
two traction sutures are introduced. One is placed at the mesenteric side
and the other directly opposite it. The mesenteric suture should be passed
in the same manner as that described in the previous operations. The
opposite suture is passed so that its knot falls within the lumen of the bowel,
penetrates all coats of the bowel, is loosely knotted, and the ends left long.
An opening is now made in the larger bowel segment, in its long axis, op-
posite the mesenteric attachment. This opening should be about 2.5 cm.
(i inch) from the end. Its size should depend upon the size of the gut to be
invaginated through it. For the small intestine it will be about 4 cm.
(i>£ inches) long (Fig. 1319).
A pair of forceps are passed into the bowel through this opening and
caused to grasp the two traction sutures. They are pulled out through the
THE ABDOMEN
655
opening, bringing with them the two bowel ends. The hand assists this
imagination process. The opening should be sufficiently large to accommo-
date it without undue strain upon the traction sutures. The ends are brought
out far enough to allow of easy suturing. The peritoneal surfaces of the
ends of the two segments are made to lie in contact by this means. The
two bowel ends are adjusted early, and a long straight needle, threaded with
silk or chromicized catgut (Maunsell used horsehair), is caused to transfix
all the coats of the apposed bowel ends midway between the traction sutures,
about 5 mm. (2f6 inch) from the free edges. The needle is drawn through
four thicknesses of bowel, and the thread caught up in the middle and cut.
Each half is then tied over the two bowel thicknesses through which it passes.
Twenty sutures may thus be introduced with ten thrusts of the needle
(Fig. 1320).
FIG. 1320. — INVAGINATION METHOD OF END-TO-END ANASTOMOSIS.
The ends of the bowel have been drawn through the antimesenteric opening by the traction
sutures. Sutures have been passed and are in process of being tied.
The traction guide sutures may then be tied down or removed. The
invagination is reduced by careful traction and manipulation. The mes-
entery is sutured. The longitudinal opening is then closed by continuous
or interrupted sutures. The parallel continuous stitch (Gushing) is well
adapted to this (see Wounds of Intestine, page 566; Enterorrhaphy, page
628). Care should be taken in reducing the invagination not to put any
strain on the suture line. As soon as possible the mesentery should be su-
tured. It is done with care that all slack is taken up at the enteromes-
enteric junction so that traction strain shall fall on the mesentery rather
than the bowel.
In this operation the sutures may be tied as each is inserted or they may
all be inserted before tying. Some surgeons after reducing the invagination,
656
SURGICAL TREATMENT
place a parallel continuous stitch (Gushing) through the musculoserous
coats (Fig. 1321).
End-to-end anastomosis of segments of unequal size by the imagination
method differs from the above operation first in reducing the size of the larger
end. Bickham (Operative Surgery) proceeded as follows: The mesenteric
FIG. 1321. — INVAGINATION METHOD OF END-TO-END ANASTOMOSIS.
The invagination has been reduced, the mesentery sewed, and the bowel opening is being
closed.
traction suture is introduced as above described. The second traction
suture is introduced also as that in the above operation, excepting that
while it is passed opposite to the mesentery in the small segment, in the
larger segment it is passed at a distance from the mesenteric attachment
FIG. 1322. — INVAGINATION METHOD OF END-TO-END ANASTOMOSIS WITH AID OF RING.
The bowel has been tied to the ring or hollow bobbin by means of two strong ligatures and
an elastic band.
equal to the diameter of the smaller segment. A third traction suture is
introduced through the larger segment alone at a point opposite the mesen-
tery. The opening is then made in the larger bowel segment as above de-
scribed, and the three traction sutures drawn through it.
THE ABDOMEN
657
The ends are then invaginated, the smaller being surrounded by the larger,
and the sutures introduced and tied, beginning at the mesenteric side. This
should proceed evenly on either side. As the side opposite the mesentery
FIG. 1323. — ANASTOMOSIS BY THE CIRCULAR OCCLUSION METHOD.
The bowel is to be tied tightly on either side of the disease with strong ligatures and
the ends left long. Clamps are applied on the segment to be removed between the two
ligatures. The bowel is cut between the ligature and the clamp.
is reached, it will be apparent how much excess of the larger segment is to be
disposed of. This should be removed as a triangle. The V-shaped gap
should be sutured serosa-to-serosa by a continuous over-and-over stitch.
FIG. 1324. — ANASTOMOSIS BY THE CIRCULAR OCCLUSION METHOD.
The two tied ends are brought together and anastomosed by suture.
Care should be taken that the triangle removed is not so great as to give
inadequate coaptation in closing the space; and in closing the space care
VOL. 11—42
658
SURGICAL TREATMENT
should be taken that the closure is brought snugly down to the caliber of the
smaller segment. The suture is then completed, the invagination reduced,
and the longitudinal wound closed.
Invagination method with aid of a ring or bobbin was devised by Ullmann
as a modification of the method of Maunsell. The ring or bobbin may be
of absorbable material (decalcified bone, carrot or magnesium) or of slowly
absorbable or non-absorbable metal. The ring is inserted into the opening
of the two bowel ends after they have been brought out through the anti-
mesenteric wound. A heavy silk thread is tied around the bowel ends, sink-
ing into a groove in the ring. A rubber elastic band may be added to this,
and the bowel is then disinvaginated. No anastomosis sutures are required.
The bowel ends beyond the ligature necrose and the ring if insoluble, is
passed by the rectum in about a week (Fig. 1322).
Anastomosis by the circular occlusion method has never met with general
acceptance. In 1893, I tried it repeatedly upon the cadaver and then in the
living. It has a field of usefulness in the small intestine. The bowel is
FIG. 1325. — ANASTOMOSIS BY THE CIRCULAR OCCLUSION METHOD.
The tied ends of bowel are anastomosed. Before the last suture is tied the circular tie-
strings are cut and removed.
ligated on either side of the disease by a temporary ligature of strong silk.
This is passed through the mesentery close to the bowel. It is tied very
tightly with a firm square knot, the ends left long, and knotted for identifi-
cation. The diseased segment is then clamped and cut out with the mes-
entery (Fig. 1323). The division of the bowel is made about 1.5 mm. (^f e
inch) from the ligature. The mucous membrane is cauterized with the actual
cautery or with phenol followed by alcohol (Fig. 1324).
The two stumps are then brought together, and a musculo-serous suture
applied to unite them. The first suture should be a mattress suture closing
the mesenteric angle. This is the most important and weakest place in the
anastomosis. Three other stay sutures should be placed at equal distances
connecting the two segments. The suture for completing the anastomosis
should be a mattress interlocking stitch best introduced with a curved needle
(Fig. 1325).
Before tying the last two sutures, which should close the space through
which the ends of the occlusion ligatures emerge, each of these ligatures is
THE ABDOMEN
659
FIG. 1326. — ANASTOMOSIS BY SIMPLE INVAGINATION.
The stump of the colon has been invaginated into the rectum. To increase the size
of the latter a longitudinal incision has been made. Sutures are applied on the serosa side.
A large tube is passed above the anastomosis and fixed in the rectum.
FIG. 1327. — CLOSING END OF INTESTINE.
A continuous through-and-through suture has been applied. The overlying seromuscular
suture is in process of application.
660
SURGICAL TREATMENT
drawn up and cut. This is done with narrow pointed scissors, or with a
cataract knife or tenotome. • If necessary, the ligature may be caught up
with a tenaculum. The distal ligature should be cut first and then the proxi-
mal one. Each should be pulled out, demonstrating that the constriction has
FIG. 1328. — PURSE-STRING CLOSURE OF END OF BOWEL.
been relieved. The remaining sutures are then tied, and the mesentery
sutured.
This operation, as done by F. B. Walker (Jour. Am. Med. Assoc.,
Aug. 15, 1908, vol. 51, No. 7, page 546), was performed with a purse-string
FIG. 1329. — CLOSURE OF END OF BOWEL BY SIMPLE LIGATURE AND PURSE-STRING SUTURE.
The bowel end has been tied, the mucosa of the stump sterilized and buried as in
appendectomy.
ligature, tied in a bow-knot. The ends emerge, and by pulling, the knot
is untied and the ligature pulled out, after applying the apposition suture.
The parallel continuous stitch (Gushing) is used. The same principle is
applied by Walker in making lateral anastomosis. A purse-string suture
THE ABDOMEN
661
is inserted and the opening in the bowel or stomach is made inside of it.
The anastomosis is then made, and the purse-string is pulled out. The
first half of the anastomosis suture is inserted before the openings are cut.
These methods have the disadvantage that a redundant free edge of
bowel is left on each stump. These free ends hang as a constricting flap in
the lumen of the bowel and increase the amount of scar tissue.
Anastomosis by simple imagination, with mucosa to peritoneum may be
done with the rectum and in rectosigmoid anastomosis. The upper seg-
ment is simply invaginated into the lower segment for a distance of 2.5 to
5 cm. (i or 2 inches). A large rubber tube is placed in the bowel, one end
above the anastomosis and the other end in the rectum or projecting through
the anus (Fig. 1326). The upper end of the rectum is sewed to the outer
layers of the sigmoid. Ultimately the mucous and serous coats become
FIG. 13290. — CLOSURE OF BOWEL ENDS BY LIGATIOX INSIDE OF THE BOWEL (METHOD
OF MAUXSELL.)
The first half of the lateral anastomosis has been done, and the lateral bowel openings
made. One stump has been inverted and tied; the other is about to be inverted by draw-
ing through the guide ligatures with a long clamp.
adherent. If the sigmoid end has not been incised longitudinally, it may
require to be cut later with scissors through the proctoscope to relieve
circular contraction.
Lateral anastomosis may be employed in the stead of end-to-end anas-
tomosis or it may be done to accomplish short-circuiting or intestinal occlu-
sion. As a substitute for the end-to-end operation, it possesses the advantages
that (i) it has simplicity of application in some respects; (2) the hazardous
mesenteric triangle is not involved; (3) the opening can be made sufficiently
large to allow for contraction, in contrast to the end-to-end method in which
the bowel is often narrowed by the operation; and (4) a considerable part of
the anastomosing suture can be introduced before the bowel is opened.
662
SURGICAL TREATMENT
When done in the stead of end-to-end union, the closure of the ends of the
bowel must first be done. The formation of a blind end may be accomplished
by any one of several different methods. The most useful are the following:
1 . The bowel is divided between two clamps. The end to be closed is then
sutured with an over-and-over suture through all of its coats bringing the
wound edges together or serosa to serosa. This suture begins opposite the
mesenteric attachment and ends at the mesentery. Its object is to compress
the blood-vessels. A second suture begins opposite the mesentery and
buries the first line of sutures. This should be the parallel continuous stitch
(Gushing), embracing all but the mucosa (Fig. 1327).
2. An angio tribe is used as the clamp on the end to be closed. This
occludes the vessels. The clamp is removed, the bowel is divided along the
crushed strip, and the crushed edge buried by a musculoserosa suture as above.
3. Instead of using the angiotribe, hemostasis may be secured by pass-
ing the thermocautery along the cut edge. This insures asepticity.
FIG. 1330. — LATERAL INTESTINAL ANASTOMOSIS.
The ends of the bowel have been closed. The protected clamps grasp the bowel seg-
ments and place them side-by-side. The edges of the mesentery are sewed to the mesen-
teric surface.
4. The purse-string method is particularly useful in the small intestine.
A purse-string suture is passed around the bowel, penetrating only the outer
coats. A clamp then grasps the bowel at a right angle, and the intestine is
cut across about 6 mm. (Y± inch) from the clamp. To control hemorrhage
the free end is sewed over-and-over with a running stitch passing through
all the coats. The clamp is then taken off, the sewed end inverted, and the
purse-string suture tightened and tied (Fig. 1328).
5. Ligation of the bowel was recommended by H. Lilienthal (Am. Jour,
of Surgery, March, 1909). He applied it to both the small and large intes-
tine. He insists that the ligature should be tied tightly enough to crush the
mucosa, and that the mucous membrane remaining in the stump be steril-
ized with pure phenol. A catgut ligature, a short stump, and the addition
of a purse-string suture to bury it, as in the treatment of the stump of the
vermiform appendix, should make this a highly satisfactory operation
("Fig. 1329). Pleth (Am. Jour. Surg., July, 1909) applied the angiotribe
THE ABDOMEN
663
to the bowel and then tied the bowel in this line with a linen thread. It is
not inverted. Moynihan crushed a line with the angiotribe, ligated with
catgut in this line and cut beyond. He then buries the stump with a purse-
string suture. This is the most effective method.
6. Ligation inside of the bowel is done by the method of Maunsell. The
first half of the lateral anastomosis is done, the bowel opened, and then the
bowel ends are inverted, pulled into the opening, ligated and replaced.
This leaves the ligature inside of the bowel, and apposes serosa to serosa
(Fig. 13290).
The technic of lateral anastomosis is simple. The bowel is occluded above
and below the place of anastomosis. Each bowel end is grasped by a clamp
in such a way as to include a lateral segment, about 9 cm. (3^ inches)
long and representing about half of the circumference of the gut. The
FIG. 1331. — LATERAL ANASTOMOSIS.
The serosa-muscularis'suture has been applied. Dotted lines show place of bowel incisions.
infolded end should not be grasped. These two segments are laid side-
by-side, the stumps in opposite directions (Fig. 1330). The clamps should
not cause undue contusion. The jaws should be covered with rubber or cloth
and should lie evenly together. Two layers of sutures are to be applied.
A curved needle that can be held in the fingers is used.
It is best to introduce the first half of the outer suture before opening the
bowel. This is a continuous simple right-angle stitch of chromicized No. o
catgut, penetrating serosa, muscularis and submucosa. Rather than miss the
latter, the surgeon need not fear if the mucosa also is penetrated. It is
placed longitudinally, about 6 mm. (^ inch) from the antimesenteric aspect
664
SURGICAL TREATMENT
of the bowel, and after tying, the ends are left long at each end of the suture
(Fig. 1331). A needle is left on each of these ends, and they are covered
with a towel for future use.
Each bowel is then incised longitudinally at its antimesenteric aspect:
that is, 6 mm. (^ inch) from the suture line and directly opposite the mesen-
teric attachment. The incisions should be about 6 mm. (^ inch) shorter
than the stitch which they parallel. Bleeding is prevented by the clamps.
The inner suture is then inserted. It is a continuous simple right-angle
stitch, uniting the cut borders throughout the whole circumference of the
opening (Fig. 1332). The needle passes through all the walls of the gut. It
passes from mucosa to serosa and from serosa to mucosa, and is tied inside
of the bowel on the mucous membrane. No. o chromicized catgut is used
FIG. 1332. — LATERAL ANASTOMOSIS.
The serosa-muscularis suture has been applied, the bowels incised, and the through-
and-through suture is in process of application. One corner has been turned. Towels
and gauze protect the environment.
with a needle on either end. The stitch is begun in the middle of the wound,
the knot being tied in the middle of the thread, and then continued halfway
around the circumference of the opening. When the middle of the side
nearest the operator is reached, the needle on the other end is taken in hand
and the opposite half sewed (Fig. 1333). This suture passes around both
ends, and is tied on the side toward the operator. The mucosa should be
inverted and not show along the suture line. The suture should be applied
with such a degree of tightness as to close off the lumen of the bowel.
At this stage the clamps may be removed. The remainder of the outer
stitch is now completed. One of the end needles which had been laid aside is
THE ABDOMEN
665
taken in hand and the suture continued around the end of the sutured opening
at the same distance as before (Fig. 1334). This ends after rounding the
corner, and the other needle is then used to complete the circumference of
the suture. The two ends are tied and cut. The raw edges of the mesen-
tery are caught by a few stitches to the flat surface of the mesentery upon
which they lie (Fig. 1335).
Some surgeons do this operation with celluloid thread. This method may
also be used for end-to-end anastomosis. When it is desired to secure more
positive serosa-to-serosa apposition, the through-and-through suture may
simply transfix the two walls with each thrust, passing back and forth
leaving a loop on each mucosa, and not passing over the cut edges of the bowel.
FIG. 1333. — LATERAL ANASTOMOSIS.
Through-and-through suture continued. By placing the loop on the mucous membrane
side, the inversion of the wound is insured.
A simple and easily extemporized wooden clamp for performing lat-
eral anastomosis or gastroenterostomy, was devised by C. L. Gibson
(Annals of Surg., May, 1915). It is made of the pieces of wood used as
tongue-depressors. These are held together by elastic bands (Fig. 1336).
Lateral implantation (end-to-side anastomosis) may be done by any of the
methods used for end-to-end or lateral anastomosis. After excisions in the
ileocecal region, it has the advantage that the ileum may be implanted into
the colon without the necessity of making another blind end. The simplest
operation is that described above for lateral anastomosis. One bowel is
clamped laterally and the other transversely. An opening is made in the
first, as far as possible from the mesenteric border, and slightly longer than
666 SURGICAL TREATMENT
the diameter of the afferent bowel. A through-and-through suture unites the
wound edges circumferentially, and a musculoserosa suture is applied out-
side of this.
A. H. Gould devised an operation which obviates the danger of contracture
of the opening ("Operations on the Intestines and Stomach"). The small
intestine is closed by a clamp about 8 cm. (3 inches) from its end, and the
large bowel by clamps some distance from the site of operation. The end
of the small bowel to be implanted is split along its antimesenteric side for
1.25 to 2.5 cm (J^j or i inch) (Fig. 1337). The projecting corners are cut
off, leaving an oblique opening. The distal bowel is opened longitudinally
FIG. 1334. — LATERAL ANASTOMOSIS.
The operation is about completed. A few stitches of the outer row remain yet to be taken.
The clamps are loosened.
on its antimesenteric side for about 3.75 cm. (i^ inches). Guides are
placed to invert the edges, and the mesenteric thread is united by a through-
and-through suture (Fig. 1338). Other guides are placed and the suture is
continued the same as that used in simple end-to-end anastomosis. For the
seromuscular suture, which is the outer tier, an interrupted right-angle
suture or the interrupted mattress stitch of Gould is used. A continuous
mattress suture may be employed. The mesentery of the implanted bowel
is sutured to the colon and the peritoneum beyond it.
Anastomosis with mechanical devices is employed less than formerly.
These devices used were recommended by the additional speed which
they contributed to the operation. Each possesses the disadvantage that
it requires special knowledge and experience for its use, and complicates
THE ABDOMEN
667
the surgeon's armamentarium with one more instrument. These things have
served an important function in the development of gastro-intestinal surgery,
and rare occasions still arise when they may be of service.
Anastomosis with a butlon was perfected by J. B. Murphy. The instru-
ment consists of two halves which when pressed together fasten by a spring
FIG. 1335. — LATERAL ANASTOMOSIS COMPLETED.
Section showing inside of bowel.
clutch. They are made both in round and oblong form (Fig. 1340).
For end-to-end anastomosis a purse-string suture is placed in the ends to
be joined. There are two ways of doing this: (i) A simple purse-string is
applied in the outer coats before the bowel is opened. The bowel is then
clamped in four places, and the resection done, 3 mm. (^ inch) from the
FIG. 1336. — ENTERO-ANASTOMOSIS CLAMPS EXTEMPORIZED FROM WOODEN SPATULA.
purse-string. Or (2) the resection is done and an over-and-over suture
applied, passing with each stitch across the cut edge of the bowel. It is im-
portant that the suture in every case embrace the mesenteric angle by a stitch
passed through the mesentery, redoubling upon itself and crossing in the
midmesenteric line. Both of these stitches begin and end at the anti-
668
SURGICAL TREATMENT
FIG. 1337. — END-TO-SIDE ANASTOMOSIS.
Operation of A. H. Gould. Showing first mattress stitch. Trimming off angles of bowel.
FIG. 1338. — END-TO-SIDE ANASTOMOSIS.
Operation of A. H. Gould. The corners of the smaller bowel have been cut off. The
first mattress suture has been tied. Guides have been inserted to control the mesenteric
third of the circumference, and the edges united by an over-and-over stitch. The third
guide has been introduced.
THE ABDOMEN
669
mesenteric border. The first has the advantage that it can be put in without
soiling the field of operation. This is an important point. It possesses the
disadvantage that the mucosa is apt to roll out and unless it is trimmed off
or pressed back may become engaged between the two serosa surfaces. The
first method is more commonly used.
FIG. 1339. — END-TO-SIDE ANASTOMOSIS.
Operation of A. H. Gould. The outer layer of sutures has been applied.
The halves of the button are then grasped by the stem with forceps which
are narrow so as not to bend the circle. The male button, the one with the
smaller stem, is introduced into the proximal gut, and the female button
into the distal gut, just far enough for the edges of the bowel to come down
to the stem (Fig. 1341). The purse-string suture is then tied. Each half
being fixed in a bowel end, the buttons are grasped through the bowel, the
FIG. 1340. — ANASTOMOSIS BUTTONS OF MURPHY.
forceps removed and the two halves pressed together. The mesentery
is then sutured. A few interrupted musculoserosa sutures may be added
(Fig. 1342) although not considered necessary. In this operation care
should be taken that the button fits easily, that the pucker caused by the
purse-string is evenly distributed, that the ends of the suture are cut short,
670
SURGICAL TREATMENT
and that serosa is opposed to serosa as the parts come together. The button
should have been examined and the clutch found to be effective. The
surgeon should hold the two halves as an assistant removes the forceps,
FIG. 1341. — END-TO-END ANASTOMOSIS WITH BUTTON.
The two halves of the button are placed in the bowel ends and each is held by a clamp.
One purse-string has been tied down, the other is ready to be tied.
FIG. 1342. — END-TO-END ANASTOMOSIS WITH BUTTON.
The two halves of the button have been pressed together and the union reinforced with
interrupted sutures
care being taken that they do not slip back into the bowel. If the surgeon
considers applying a serosa suture after the buttons have been pressed
together, this should not be attempted in bowel wall which is so tightly
drawn over the button that the suture threatens to tear out or perforate
THE ABDOMEN 671
the lumen. The button is liberated by pressure necrosis sometime usually
during the second or third week, and passed with the feces.
For lateral implantation, lateral approximation and lateral anastomosis with
buttons the same principle is used. The opening is made on the antimes-
enteric side of the bowel (Fig. 1343). When resection has been done, the
mesentery is sutured to adjacent mesentery and peritoneum. An oblong
button may be used for lateral junctions unless the bowel is very small.
Another method of making lateral anastomoses with the Murphy button,
operated from within the bowel, was worked out by American surgeons.
FIG. 1343. — LATERAL ANASTOMOSIS WITH OBLONG BUTTON.
The oblong button is used as the largest round button is inadequate for most lateral unions.
It requires an opening in the bowel somewhere near the two sites of
junction. This opening may be made for the purpose of introducing the
button or it may be a part of another operation. Thus, in gastroenterostomy,
when it is desired to join the two arms of the loop of jejunum, the operation
is proceeded with as follows: after opening the jejunum for the stomach anasto-
mosis and completing half of the suture, the male half of the button is intro-
duced into the proximal arm of the loop, and the female half into the distal
arm. This may be done with forceps or they may simply be dropped in
672
SURGICAL TREATMENT
loosely and manipulated into place. The cylinder of the button is then
pressed tightly against the antimesenteric wall of the bowel. Through the
drumhead thus formed, two small crossing incisions are made, and the cyl-
FIG. 1344. — ENTERO-ENTEROSTOMY WITH BUTTON FROM WITHIN THE BOWEL.
The first half of a gastro-enterostomy has been done, the halves of the button are passed
respectively into each loop of intestine, one is held with a clamp, the other is controlled
from the outside by the fingers. The intestine is cut to allow the passage of the stem
of the button.
inder of the button pressed through. This is done on either side, the buttons
being carefully steadied, and then the two halves are pressed together. No
suture is required (Fig. 1344).
THE ABDOMEN
673
R. Finochietto (Surg., Gyn. and Obst., 1915) devised a simple
method for bloodless aseptic introduction of the button. The viscus is
emptied and the zone of operation occluded. The bowel or stomach wall
is grasped at the place where the opening is to be made with hemostatic
clamps having a long and broad contact surface on each jaw. The clamp
is applied to a fold which is at right angles to the proposed place of incision,
the clamp being placed so that it grasps the proposed place. If a cylin-
FIG. 1345. — BLOODLESS ASEPTIC METHOD OF PLACING ANASTOMOSIS BUTTON.
A fold of bowel wall is grasped with broad hemostatic forceps at the place where the
opening is to be made, the forceps are slowly but tightly closed, and a purse-string suture
is inserted around the clamp.
dric button is to be used, the amount of wall grasped should be equal to
three-fourths of the diameter of the button. If an oblong button is to be
used the grasp of the clamp should be equal to one-half of the long diam-
eter of the button. The forceps are slowly closed and locked. A purse-
string suture is applied around the forceps (Fig. 1345). When the purse-
string is completed, the forceps are removed, and the viscus is opened with
scissors in the crushed line. The button is inserted and the purse-string
suture tied (Fig. 1346).
VOL. 11—43
674
SURGICAL TREATMENT
Anastomosis with the segmented ring is aimed to increase the speed and
facility with which the operation can be done. The ring, devised by F. B.
Harrington (Boston Med. and Surg. Jour., Nov. 6, 1902), is made of hard
aluminum in four segments all held together by a steel bar provided with
a screw thread. The seromuscular purse-string sutures are passed around
the bowel before it is cut and the first part of a surgeon's knot made. No.
2 plain catgut is used. The bowel is divided 3 mm. (% inch) from the purse-
string. A mesenteric mattress stitch is then introduced, as for simple
anastomosis. The ring is then inserted in one end of the bowel, and the purse-
string tied. The mesenteric suture is then tied, the ring inserted in the other
FIG. 1346. — BLOODLESS ASEPTIC METHOD OF PLACING ANASTOMOSIS BUTTON.
The forceps, having crushed an area in the wall of the bowel, are removed; the bowel is
opened with scissors in this area; the button is slipped in, and the purse-string suture
tied.
opening, and the second purse-string tied. The handle emerging at the
antimesenteric side supports the ring. A parallel continuous suture (Gushing)
is then begun close to the handle and carried around the bowel. It is fre-
quently knotted to prevent slipping. When it reaches the handle, the latter
is unscrewed and removed, and the suture made to close the opening.
The ring falls into four pieces which are passed with the feces. These rings
are made in three different sizes. They may be used also for lateral anas-
tomosis. Their value is as mechanical aids to the operation. The sur-
geon who has experience and skill in intestinal anastomosis does not need
these mechanical aids.
THE ABDOMEN 675
Anastomosis with absorbable mechanical devices involves the same prin-
ciples as have already been described. Bobbins of different materials, such
as carrot, turnip, potato, and other digestible substances, have been em-
ployed. A. W. Mayo Robson (Sem. Med., Paris, xii, 485, 1892) perfected a
technic with a bobbin of decalcified bone. This can be sterilized and kept
in alcohol. Bobbins of many sizes and shapes are used. They consist
of simple cylinders with flanged ends (Fig. 1347). Bone plates were first
employed by N. Senn.
In applying such a devise the first steps are the same as for the button
anastomosis. The mesenteric stitch is placed, the bobbin is inserted, and
the purse-string sutures tied. A continuous seromuscular suture is then
applied.
Instead of using a bobbin to be retained, Coffey employed a simple
straight cylinder of potato. The three preliminary mesenteric sutures, are
inserted and the cylinder introduced in the bowel, and transfixed with two
needles which catch overlapping edges of the intestine. This fixes all of the
FIG. 1347. — ANASTOMOSIS WITH AID OF A BOBBIN.
A purse-string suture ties the approximated ends of the bowel to the bobbin. A sero-
muscular suture completes the operation.
structures to be sewed, and the operation proceeds. When the anastomosis
has been completed, the needles are withdrawn, and the cylinder moved away
from the wound and crushed.
Anastomosis with especially devised forceps, clamps, holders and ligatures
has been done in a great variety of ways.
The rubber ligature, devised and first used by F. Bardenheuer and J. M.
Gaston, and perfected by T. A. McGraw, cuts out an opening by pressure
necrosis. It was once applied in gastro-enterostomy and other lateral an-
astomoses. Several sizes were employed. The medium size is 4 mm. (%Q
inch) in diameter, and the smaller size is 3 mm. (^ inch); these are to be
preferred. McLean (Jour. Mich. Med. Soc., Detroit, ii, 550, 1903) devised
a needle for carrying the ligature which holds the latter by a sliding
ferrule. A needle is placed on each end of the ligature. Clamps for oc-
cluding the intestine are not used. The two viscera are placed side by
side and fixed by the first half of the seromuscular suture as for lateral
anastomosis. The ligature is placed in such a position that it shall make
a necrosis opening similar in length and position to that made by the in-
cision in the ordinary operation fpage 663). The needle is made to pierce
the wall of the bowel at a right angle, care being taken that the mucous
676
SURGICAL TREATMEN
membrane has been penetrated. The needle is then passed along inside of
the bowel for 7 or 8 cm. (3 inches), and then caused to penetrate the wall
and emerge at as near a right angle as possible. The needle is drawn out
with a pair of artery forceps, until half of the ligature remains unsoiled. As
the needle and ligature emerge they are wiped off with a piece of gauze and
painted with tincture of iodin. The clean end is held to put the rubber on
the stretch as it passes along. The same is done in the adjacent coil (Fig.
1348). A piece of strong silk is laid between the two ends and the ligature tied
in a half knot. The silk is then tied tightly about the half knot to keep it
from slipping. As the rubber ligature is being drawn up for tying, the handle
of a pair of anatomic forceps should press back the line of suture to prevent
its compression (Fig. 1349). The second half of the knot is tied and secured
FIG. 1348. — LATERAL ANASTOMOSIS WITH THE RUBBER LIGATURE.
The first row of seromuscular sutures has been placed. The rubber ligature has been
introduced. Note needles of McLean.
by the silk ligature. The rubber should be tied as tightly as possible to
insure cutting through, otherwise two holes will be cut and the ligature left
transfixed by a bridge between them. The ends are then cut short. The
seromuscular suture is continued in front of the ligature. This last half
of the suture should be done with interrupted stitches (Fig. 1350). The
ligature requires four or five days to cut through.
A clamp method devised by E. W. Andrews (Jour. Am. Med. Assoc.,
May 1 6, 1908) employs a clamp, each blade of which is pointed, and which
is plunged into the bowel. The blades are closed and thus act as a
clamp while the suturing proceeds, when the suture is completed the last
loop is left loose, the blades of the clamp are firmly locked, and a chisel-pointed
knife is slid along two grooves between the blades. This cuts the two
bowel walls. A cautery blade follows this. The clamp is then withdrawn,
and the suture tied.
THE ABDOMEN
677
A pair of knitting needles were used by V. and V. W. Pleth (Am. Jour, of
Surg., July, 1909). The bowels are laid side by side, two rows of sutures
inserted posteriorly, and a long steel knitting needle inserted in and out
of each loop of bowel a distance equal to that of the desired opening. A
long narrow forceps is then applied between the needles and the sutures
back of both needles, grasping four thicknesses of bowel. The actual cautery
is then used to burn through both bowel loops along the needles until the
latter are released. The suture next to the opening is then completed, the
loop next to the handle of the forceps not being pulled in place until the
forceps are removed. The outside suture is then completed.
FIG. 1349. — LATERAL ANASTOMOSIS WITH THE RUBBER LIGATURE.
The ligature is being tied. The handle of a pair of forceps presses back the seromus-
cular suture line to prevent its compression. The silk ligature is ready to be tied about
the first turn of the knot.
Intestinal Exclusion. — Excluding of some part of the intestine from carry-
ing intestinal contents is accomplished by making anastomosis in such a way
as to "short-circuit" the intestinal current. These operations are done
for irremovable obstruction, for the purpose of securing rest for some diseased
segment of the bowel, or for purposes of drainage. Tuberculosis of the intes-
tine, ulcers, enterovaginal fistula, enterocystic fistula and intractable colitis
represent some of the non-obstructive conditions for which the operation is
done. Lateral anastomosis, lateral implantation, and end-to-end anastomo-
sis are used. Besides enteroanastomosis there are essentiallv two forms of
678
SURGICAL TREATMENT
FIG. 1350. — LATERAL ANASTOMOSIS WITH THE RUBBER LIGATURE.
The rubber ligature has been tied, the ends cut off, and the second half of the seromus-
cular suture started on the left. In the middle is shown the intestine puckered by the tied
ligature. The two cut ends of the ligature are seen. At the right is seen the posterior
row of seromuscular sutures. (After Gould.)
FIG. 1351. — INTESTINAL EXCLUSION BY RECTOCECAL ANASTOMOSIS.
This gives direct drainage from cecum to rectum and excludes the great intestinal loop.
THE ABDOMEN 679
exclusion unilateral and bilateral. In the first, it is possible for intestinal
contents to pass back into the excluded segment; in the second, the ex-
cluded segment is divided at both ends and entirely disconnected from the in-
FIG. 1352. — INTESTINAL EXCLUSION BY ILEOSIGMOIDOSTOMY.
This gives direct drainage from ileum to sigmoid, but has the disadvantage that some
intestinal contents pass the anastomosis and enter the cecum.
PIG. 1353. — INTESTINAL EXCLUSION BY ILEOSIGMOIDOSTOMY AND OCCLUSION OF ILEUM
DISTAL TO THE ANASTOMOSIS.
testinal canal. In unilateral and bilateral exclusion, the excluded ends
should be brought out as intestinal fistulge for drainage. Exceptions
680
SURGICAL TREATMENT
FIG. 1354. — INTESTINAL EXCLUSION BY ILEOSIGMOID END-TO-SIDE ANASTOMOSIS.
The stump of the ileum is fixed in a button-hole wound in the abdominal wall. A, drainage
tube is passed through the rectum above the anastomosis.
FIG. 1355. — INTESTINAL EXCLUSION BY ILEOSIGMOIDOSTOMY.
The stump of the ileum and of the sigmoid are attached at openings m the abdominal
wall. A tube is placed in the rectum above the anastomosis. This is the best of these
procedures.
THE ABDOMEN
681
may_ be made to this, but it is the safest practice. The only part of the
intestine where regurgitation is not apt to take place is at the ileocecal
valve (Figs. 1351, 1352, 1353, 1354 and 1355).
After resection of a segment of colon the remaining segment may be
excluded. Wherever this is done the excluded segment should be provided
with fistulous openings for irrigation. This is no great inconvenience to
the patient as the secretion from the empty bowel is very slight. It may
be washed through every day with warm water and thus kept clean. Ex-
cluding the colon for chronic stasis is an easier and safer operation than
resection, and it may help preserve the omentum (see page 645).
FIG. 1356. — EXCLUSION OF BOWEL BY Mucous MEMBRANE CONSTRICTION.
The seromuscularis is incised and separated from the mucosa by blunt dissection.
Operations for closing the lumen of the intestine are performed, where
exclusion of a portion of the bowel is desired. Such operations are done
at the pylorus in connection with gastroenterostomy, and in the intestine
between the points of an entero-enterostomy (see Formation of a Blind End,
page 662).
Purse-string suture of the bowel after dividing it transversely is the sim-
plest and easiest method. It is possible to make this an aspetic operation,
by ligating the bowel tightly, dividing it with the thermocautery, sterilizing
the mucous membrane of the stump; and burying the stump with a purse-
string suture.
682 SURGICAL TREATMENT
Transverse closure of the divided bowel is done with an over-and-over
suture. Two layers of suture are usually applied. The division of the
bowel is made parallel with the clamp which is applied transversely. Before
applying the sutures the stump of mucous membrane beyond the clamp is
sterilized.
Submuscularis-mucous-membrane occlusion is performed without dividing
the bowel. Only the mucous membrane tube is occluded. A longitudinal
incision is made in the bowel which passes through all of the coats except
the mucous membrane. With a stroke of the knife on either side, the line
of cleavage between the muscularis and the mucosa is discovered. The
wound is then grasped with the fingers and the muscularis everted (Fig.
FIG. 1357. — EXCLUSION OF BOWEL BY Mucous MEMBRANE CONSTRICTION.
Forceps are passed under the isolated tube of mucous membrane between the mesenteric
vessels.
1356). As this is done the mucous membrane tube presents in the opening.
By continuing the eversion of the muscularis, it is easy with or without a
few strokes of the knife completely to isolate the mucous membrane tube.
If the operation is done between two mesenteric arteries the muscularis
may be peeled away from the mucosa without using a knife (Fig. 1357).
At this stage of the operation A. A. Straus (Jour. Am. Med. Assoc.,
Jan. 22, 1916) used a strip of fascia, taken from the anterior sheath of the
rectus muscle, from the transversalis fascia, or from the outer side of the
thigh. This piece of fascia, cut like a ribbon, is passed around the mucous
membrane tube. One end of the fascia transplant is sewed to the mucous
membrane tube with four or five interrupted sutures. Even traction is
made on the other end and it is carried around the tube tightly enough to
cause its complete collapse and occlusion, and sewed with interrupted sutures
THE ABDOMEN
683
to complete the circle. The free end is sewed, with a third row of interrupted
sutures (Fig. 1358). The occluded mucous tube is then dropped back, and
the serosa-muscularis wound closed with a running chain suture which
catches the band of fascia as it passes along.
Enterostomy.- — The formation of an intestinal fistula or artificial anus may
be done with the view of making it temporary or permanent. Such openings
may be required to relieve obstruction or for the purpose of drainage or
treatment. Jejunostomy is usually done for the purpose of introducing
nourishment below the site of a disease. Low ileostomy and colostomy are
done usually to relieve obstruction, the opening being made above the disease.
When an opening for artificial anus is made it should be as low in the
bowel as possible. The lower in the abdominal wall the opening is made the
greater is the possibility of hernia. The operations which will be described
PIG. 1358.— EXCLUSION OF BOWEL BY Mucous MEMBRANE CONSTRICTION.
A transplant of fascia has been sewed around the tube of mucosa. The seromuscularis
is being closed. The needle catches also the wrapping of fascia.
are those done deliberately and not as emergency expedients when the first
coil of intestine that presents is opened.
A temporary intestinal fistula is one which is to be closed after it has
served a temporary purpose. Such a fistula in the lower part of the ileum
is made as follows: A lateral intramuscular opening is made over the cecum
through an incision (page 504) 5 to 7.5 cm. (2 to 3 inches) in length. The
incision should be about 4 cm. (i^ inches) from the outer end of Poupart's
ligament and parallel to it. The cecum is the guide to the end of the ileum.
The obstruction is found and the bowel above it brought into the wound.
If the obstruction cannot be identified any distended coil of intestine in the
cecal region may be used. The gut should be placed in the general direction
which it naturally occupies. Only the side farthest from the mesentery
should project into the wound. Four fixation sutures are passed through the
684
SURGICAL TREATMENT
outer coats of the bowel, two laterally and two at the ends, embracing a space
about 2 cm. (^ inch) wide and 4 cm. (i% inches) long. These sutures are
passed through the peritoneum and all the layers of the abdominal wall.
The peritoneum is then sewed to the bowel with a continuous suture, leaving
an elliptic knuckle presenting. The muscle and fascia of the wound are
then closed down to the opening and the skin sewed to the elliptic bowel area
as the peritoneum had been. If the intestine is not to be opened at once,
the peritoneal suture may be omitted or the peritoneum and skin may be
sewed together. It is best to make the opening two or three days later when
the peritoneum has become well adherent. If the opening is to be made at
once, a purse-string suture should have been placed in the ellipse and after
FIG. 1359. — ENTEROSTOMY.
Construction of fecal fistula for drainage of intestine. The bowel is sutured to the
abdominal wound; purse-string suture has been inserted; dotted line shows site of incision
for opening into which tube is to be inserted. The incision through the peritoneum is
about 5 cm. (2 inches) long, and the incision in the bowel about 2 cm. (^ inch) long.
the gut has been sewed to the skin the wound should be painted with com-
pound tincture of benzoin varnish, the opening should be made within this
suture, a tube of good size quickly inserted, and the purse-string tied down
upon it. The circle made by the purse-string should be about 13 mm.
(3^ inch) in diameter. The wound should be protected from soiling. The
tube conveys away the intestinal contents (Fig. 1359). After a few days
the tube may be removed. Unless there is obstruction below, this fistula
tends to close spontaneously.
Sometimes these operations must be done after an abdominal section.
If done soon afterward the wound of the abdominal wall may be reopened.
When this is done little or no anesthetic need be used. For immediate
opening of the bowel a segment may be freed of gas and closed in two places
THE ABDOMEN 685
by rubber-covered clamps. A purse-string suture is applied opposite the
mesentery. A No. 12 soft rubber catheter is inserted as soon as the bowel
is punctured, and the purse-string tied. A second purse-string should be
applied, the clamps removed, and the bowel stitched to the abdominal
wall.
Any of the methods used in gastrostomy may be employed for making an
intestinal fistula. If it is desired that the fistula should close promptly
after removing the catheter, the bowel may be incised longitudinally through
the seromuscular coats and the catheter buried in the wall of the intestine
after the method devised by Coff ey for implanting the ureter into the bowel.
C. W. Mayo passed the catheter through the omentum for security and to
favor early closure of the fistula.
A temporary colostomy is made in the same manner. The feature of the
temporary fistula is that only the side of the gut is made fast. No spur is
formed. In these operations, intestinal contents pass on beyond the fistula,
and if there is obstruction the distal arm should be washed out frequently.
If it is desired that intestinal contents should not pass beyond the fistula,
a spur or two distinct openings should be made, as described for carcinoma
(page 582), for intestinal obstruction (page 595), and anterior sigmoidos-
tomy (page 689).
A permanent intestinal fistula in the lower small intestine should not be
made, unless (i) the entire colon requires to be removed or (2) is the seat of
disease which occludes it. An anastomosis of the ileum with the rectum or
colon below the disease is the operation of choice in either of these con-
ditions. The large intestine has important functions and should not lightly
be sacrificed. When such a fistula is made, the operation is done the same
as in the colon.
Colostomy is preferably done in the left inguinal region in the sigmoid
flexure. This is inguinal sigmoidostomy . When obstruction is located above
the sigmoid, an intestinal exclusion, connecting the gut above the disease
with the gut below the disease, is to be preferred to a higher colostomy.
Thus, for irremovable obstruction of the cecum or ascending colon, an end-to-
side implantation of the ileum just below the disease is to be preferred to the
formation of a fecal fistula above the disease. The exceptions to this are:
(i) in acute conditions a temporary fistula above the disease may be neces-
sary to save the patient's life; and (2) in some cases the formation of a fistula
may be preferred because of the greater immediate operative hazard of entero-
anastomosis.
Colostomy which is to be at all permanent should make use of the sepa-
rated muscle fibers of the abdominal wall for sphincteric action. For this
reason the operation should be done through the oblique or the rectus mus-
cles. Ryall (Lancet, London, July 3, 1909) secured transverse fibers from
the rectus by splitting off a bundle from either side, and carrying one across
below and one above the bowel.
The performance of enterostomy for the relief of acute obstruction must
often be carried out as the most simple and expeditious operation possible.
Often the patient is in an extremely depressed condition, and relief from
intestinal distention, toxemia, and shock must be secured promptly. This
condition often prevails after an abdominal operation. The patient should
be removed to the operating room, but if psychic depression from fear is
threatened by such a procedure the operation may be carried out with the
patient remaining in bed. Under local anesthesia the wound should be
opened, the patient understanding that a dressing is to be done; or the abdo-
men opened on the right side if there is no definite knowledge as to the loca-
686 SURGICAL TREATMENT
tion of the obstruction. The distended coil of intestine which comes into the
wound will be above the obstruction. If it is colon, so much the better.
The lower the opening in the bowel is made, the better is the promise of
success. If the patient's condition is desperate no time should be given to
selecting the lowest place. The very first coil of intestine that presents
should be seized. A purse-string suture should be applied opposite the
mesentery, making a circle about 2 cm. (% inch) in diameter. The bowel
should be steadied by holding the suture with two clamps. Towels should
be placed about it to prevent soiling the environment. At this point skill
and cooperation are required. The bowel should be held in such a position
that the fluid contents are farthest from the purse-string. A rubber or glass
tube of fully i cm. (% inch) in diameter should be in readiness. The bowel
should be lifted up by catching it with forceps within the purse-string circle
and quickly opened by snipping a fold with scissors or by a quick puncture
with a sharp knife.
At once, as the cut is made, the assistant slips the tube into the intestine
and ties down the purse-string suture while gas is escaping but before the
fluid contents of the bowel have reached the opening. This should be done
so nicely that the environment is not soiled. The opening made in the
bowel need be only about half the size of the tube as the tube should stretch
the opening and fit tightly. The omentum should be drawn down about the
tube, a strip of gauze placed over the wound in the intestine and lead out
beside the tube, and the rest of the abdominal wound closed. It is not neces-
sary to stitch the bowel to the abdominal wall. The end of the rubber tube
may be attached to the skin by an adhesive strip. The fistula usually closes
promptly when the tube is removed.
This operation is capable of saving life by giving immediate relief to the
obstruction. The subsequent steps must depend upon the location of the
fistula and the nature of the obstruction. If the fistula is above the middle
of the ileum the patient will soon suffer with inanition if all of the contents
flow out. If it is in the lower ileum or colon it may continue to discharge
without harm. Usually the purpose of the tube is to save the patient
from death from obstruction. When the emergency has passed the tube is
removed and the sinus permitted to close.
Left inguinal colostomy is done through the anterior abdominal wall.
An 'incision 5 or 6 cm. (2 or 2^ inches) long, parallel with Poupart's liga-
ment, is made. This incision crosses at right angles an imaginary line, drawn
from the umbilicus to the left anterior superior spine of the ileum; its center
is a little below this line, and it is placed about 4 cm. (i^ inches) internal
to the iliac spine. The abdomen is opened by the intramuscular method
(page 504). A finger is introduced into the left iliac fossa. It follows
the inside of the abdominal wall, passes to the outer side of the sigmoid, and
then, sweeping inward across the sigmoid mesocolon, engages the bowel and
brings it into the wound. The sigmoid is recognized by its longitudinal
bands, sacculations, appendices epiploicae, and by its long mesocolon.
The direction of the bowel should be determined. This is not difficult if
the mesocolon is followed as described above. In this way the bowel is
brought out without being twisted, and its distal part is below. It should
be drawn downward and distal bowel passed on below until stopped from
further traction by its mesocolon. The object of pulling down the bowel as
far as it will go, is that there should not be sagging bowel above to permit
hernia of the attached loop.
If a temporary fecal fistula is to be made, two traction sutures, about 4.5
cm. (1^4 inches) apart, are introduced through the outer coats in the longi-
THE ABDOMEN 687
tudinal band farthest from the mesentery. These sutures lift the bowel into
the wound. It is then made fast by one or two sutures on either side which
pass through peritoneum and muscle of the abdominal wall. A figure-of-
eight silkworm-gut suture or two at either extremity of the wound close it
down to the bowel. The two guides continue to hold up the bowel while it is
sewed fast to the skin, leaving about half of its circumference exposed at the
middle of the wound. This exposes an elliptic area. The two guides,
having been passed through the skin on either side, are then tied across the
wound next to the bowel. If the bowel must be opened at once a purse-string
circle is placed in the middle of the ellipse, a longitudinal incision made, a
large glass tube inserted, and the purse-string tied about it. After adhesions
have developed the tube may be removed. If there is no emergency, the
bowel need not be opened until one or two days later; in which event a longi-
tudinal incision is made through its wall about 2 cm. (% inch) long.
FIG. 1360. — COLOSTOMY.
The. bowel is supported on a glass rod passed through the mesdcolon. The dotted
lines show lines of suture to hold the two arms of the loop together to form a spur. The
suture line should be shown farther from the mesocolon.
Such a fistula as this has the disadvantages that it discharges almost
constantly, and the bowel between the fistula and the obstruction contains
stagnant fecal material, which should be kept washed out to make the
patient comfortable. For these reasons, it is usually best to plan a permanent
fistula, even for temporary cases, unless the emergency makes the above
operation more desirable.
For making a permanent fecal fistula (artificial anus), a loop of sigmoid is
drawn out of the wound until the upper end is taut. A small opening is
made in the mesentery near the bowel and a glass rod or similar support
passed through to hold up the bowel. The two arms of the gut are then
united on the outer side by a U-shaped line of suture (Fig. 1360). This is a
continuous suture of catgut introduced with a curved needle. When it is
pulled up tightly the two surfaces of bowel lie closely together, and a spur is
formed by apposition of the bowel surfaces on the outer side of the mesocolon.
688
SURGICAL TREATMENT
One end of this suture is passed through the edge of the parietal perito-
neum in the middle of the wound on the outer side, and tied. Another
suture catches the parietal peritoneum to the mesocolon near the rod on
the other side. The excess of abdominal wound is then closed at either end
FIG. 1361. — COLOSTOMY.
The union for the spur has been made, the bowel dropped back and sewed to the margin
of the wound.
FIG. 1362. — COLOSTOMY.
Projecting^loop has been cut off. The glass rod is still left under a bridge of intestine to
give support.
by one or two sutures, the suture nearest to the bowel catching it also, and
holding up into the wound a well-relaxed loop of sigmoid. The extruded
bowel is then fastened to the skin by a continuous suture (Fig. 1361).
THE ABDOMEN 689
Gauze is placed between the rod and the skin. If necessary a glass tube is
at once fastened into the bowel.
If there is no urgency, the bowel is not sewed to the skin; the rod and the
four stay sutures keep it in place. Vaselin is not used lest it prevent
adhesions. The bowel is covered with rubber protective, and a wall of
pads laid about it to prevent pressure. After adhesions have formed, in
three or four days, or preferably after a week, the projecting bowel is cut off
(Fig. 1362). Bleeding may require a running suture around the cut edge,
usually no suture is needed. The bridge between is left to be supported
by the rod for a week, when the rod is removed. This constitutes high
inguinal sigmoidoslomy.
The spur in this operation causes all the contents of the upper bowel
limb to escape to the outer world, although some discharged material will
drop into the lower limb. This may be prevented by closing it, as is some-
times done at the original operation, and dropping it back into the abdomen.
FIG. 1363. — COLOSTOMY.
Diagram showing method of supporting loop of bowel by a suture through the mesentery.
The spur also facilitates closure of the fistula, if at any time such an
operation is desired. If there is a possibility that the opening may be only
temporary, a smaller loop of gut should be left outside, and opened by a
longitudinal incision.
By passing a suture through the mesocolon and fastening it to the abdomi-
nal wall on either side of the wound, the glass rod may be dispensed with.
The incision should not be longer than 5 cm. (2 inches). The skin is freed
for 2.5 cm. (i inch) from the edge of the wound with a few strokes of the
knife. The bowel is brought up. A strong chromic catgut suture is then
passed backward through the whole thickness of the abdominal wall, excepting
the skin, about 2 cm. (% inch) from the edge of the wound, then through
the mesocolon about 2.5 cm. (i inch) from the bowel, thence forward through
the abdominal wall as far as the skin on the other side, across through the
mesentery again, to be tied at the place of beginning (Fig. 1363). No
other sutures need be used if the operation is done in two stages. Local
anesthesia suffices. The bowel is opened longitudinally. The suture should
VOL. II — 14
690
SURGICAL TREATMENT
be placed about one-third of the distance from the lower end of the wound, in
order to squeeze the lower more than the upper bowel.
The elimination of the sigmoid as a fecal reservoir means that feces are apt
to discharge at frequent intervals. The opening, through the fibers of the
abdominal muscles, gives some sphincteric control. In order to give better
control to the artificial anus, various modifications of the simple operations
have been made.
A low inguinal sigmoidostomy is done through the same incision as the
above, about 4 cm. (i% inches) long. The distal part of the bowel is drawn
out as far as it will come. This leaves the upper part of the sigmoid in the
abdomen. The bowel is then surrounded by a purse-string suture at the
level at] which the distal part leaves the abdominal cavity. Two clamps
are placed on the bowel above the suture. The bowel is divided between
the clamps, and the mucous membrane sterilized with phenol. The upper
FIG. 1364. — ANTERIOR SIGMOIDOSTOMY BY THE FLAP METHOD.
Skin incised and flap turned back.
stump is simply covered with gauze. The distal stump is closed by a
through-and-through suture, the clamp removed and the bowel inverted by
tying the purse-string. It is fastened to the lower angle of the wound by
one or two stitches through the peritoneum. The upper stump is then
made more mobile by freeing it a little if this can be done without sacri-
ficing its blood supply. It is left hanging out of the wound. The skin is
then undermined for 4 or 5 cm. (i J£ or 2 inches) external to the wound, and
a second opening through the skin made just above the crest of the ileum.
The bowel with its clamp is then passed beneath the bridge of skin. It is
fixed to the peritoneum of the first wound by a few stitches. This wound
is then sutured, the muscles being permitted to close about the gut. The
free end is sewed to the skin of the second wound.
If the abdominal muscles do not have sufficient sphincter action to insure
continence, a compressing pad, worn on a belt over the skin between the
THE ABDOMEN
691
FIG. 1365. — ANTERIOR SIGMOIDOSTOMY BY THE FLAP METHOD.
The flap of skin and fascia has been turned back, the loop of sigmoid drawn out, the meso-
colon split, and the rectus muscle sewed together behind the intestine.
FIG. 1366. — ANTERIOR SIGMOIDOSTOMY BY THE FLAP METHOD.
The flap has been sewed back in place under the loop of intestine. A glass tube for drainage
may be introduced if immediate relief of obstruction is called for.
692
SURGICAL TREATMENT
two wounds, will give control of the bowel. In the event of the sigmoid
having a short mesentery, the artificial anus may be made in the first incision;
*
'
1 v _^
FIG. 1367. — ANTERIOR SIGMOIDOSTOMY BY THE FLAP METHOD.
The bowel has been amputated.
FlG. 1368. COLOSTOMY BY THE FLAP METHOD.
Diagram of the operation for securing compression of the bowel by the muscles of the
abdominal wall in order to maintain fecal control. The bowel is shown external to the
abdomen. Note lines of division of skin and fascia and of rectus muscle.
and by rotating the bowel upon its long axis through half a circle, after the
method of Gersuny, a sphincter effect may be secured.
THE ABDOMEN
693
An anterior sigmoidostomy, between the fibers of the rectus muscle, has
been devised by Mixter, Wier, Audry and others. An incision is begun on a
level with the umbilicus, in front of the junction of the outer and middle
thirds of the left rectus muscle. This is about 7.5 cm. (3 inches) from the
umbilicus. It passes downward about 5 cm. (2 inches), thence marks out
a flap toward the median line about 4 cm. (i^ inches) long with a base 5 cm.
(2 inches) broad, and passes downward for 5 cm. (2 inches) in the same
direction as the beginning vertical incision. This incision passes through
skin, fascia and the anterior sheath of the rectus muscle (Fig. 1364). The
flap is dissected up, turned outward, the fibers of the rectus separated,
and the abdomen opened. Care should be taken to spare the nerves passing
FlG. 1369. COLOSTOMY BY THE FLAP METHOD.
Operation for carrying a loop of bowel through an opening in the oblique muscles in order
to secure compression after the method of Gant.
from without to the inner fibers of the rectus by retracting them upward
and downward. The sigmoid is brought out, with its upper segment pulled
taut to prevent prolapse. Its mesentery is split at right angles to the long
axis of the bowel for about 5 cm. (2 inches). The middle portion of the
rectus, its posterior sheath, and peritoneum are united behind the gut with
three figure-of-eight sutures of chromicized catgut (Fig. 1365). The skin-
fascia flap is then brought through the cleft in the mesocolon and sewed back
in place by two layers of sutures. This leaves the loop of sigmoid arching
over the skin from one end of the wound to the other.
If immediate opening of the bowel is necessary, a circular purse-string
suture is introduced and a large glass tube (Fig. 1366) inserted. To prevent
694
SURGICAL TREATMENT
adhesions to the dressing, the bowel may be covered with vaselin or dusted
with zinc oxid powder and covered with rubber protective tissue. After
five days or a week the bowel loop is cut off at either end about 6 mm. (%
inch) from the skin. Bleeding from the edges is checked by a continuous
over-and-over stitch through the wall of the intestine, if necessary. If for
any reason the bowel is cut away earlier than this or the patient's resistance
is poor, a few stitches should fasten it to the skin. This leaves the two
bowel openings separated by 5 cm. (2 inches), each is compressed by the
rectus muscle, and the distal limb can be washed out or otherwise treated
(Fig. 1367).
Another operation for securing muscular control of the bowel is carried out
through a straight incision, but the bowel is brought through the muscle at
an opening 4 cm. to the side of the skin and peritoneal opening. This causes
FIG. 1370. — OPERATION OF BRINSMADE FOR MAKING A CONTROLLABLE ARTIFICIAL ANUS.
the bowel to make a loop in emerging between the fibers of the muscle
(Fig. 1368).
The operation of Gant carries the loop of bowel through an opening in
the oblique muscle in order to secure muscular compression (Fig. 1369).
An operation devised by W. B. Brinsmade (Trans. Am. Surg. Assoc., 1916)
and highly recommended by him is carried out as follows: The abdomen is
opened through a transverse suprapubic incision. The sigmoid having been
divided a second small incision is made through the skin about 6 cm. (2^
inches) above the first incision to the left of the median line. A passage is
made by blunt dissection between the fibers of the rectus and in front of the
transversalis fascia. The proximal end of the bowel is drawn up through
this passage and fastened by a few sutures to the peritoneum and to the skin
at the place of exit (Fig. 1370).
THE ABDOMEN
695
For the collection of fecal discharges from a colostomy which has been done
without the creation of a sphincteric control, or in which the discharges may
come away unexpectedly, cups and sacks have been constructed to be worn
constantly and held over the opening by belts and bands. H. B. Delatour
(Med. Record, Nov. 15, 1913) devised such an apparatus of hard rubber,
which has attached to it a removable rubber bag (Fig. 1371). This may be
worn by the patient who is about on his feet.
Lumbar colostomy has little to recommend it. It is employed in order to
avoid traversing the peritoneum; and is aimed usually to open the descending
colon. The position of the descending colon is represented by a line, passing
directly upward from a point 1.3 cm. (^ inch) posterior to the middle of
the crest of the ileum, to the twelfth rib. This line marks the outer border of
the quadratus lumborum muscle. An incision 10 cm. (4 inches) long, pass-
ing obliquely downward and forward has its middle crossing the middle of
FIG. 1371. — COLOSTOMY APPARATUS WITH FECAL RECEPTACLE DEVISED BY DELATOUR
this line. The fibers of the latissimus dorsi, external and internal oblique,
are divided. The twelfth dorsal nerve is spared. The border of the quad-
ratus lumborum is exposed. The trans versalis muscle and fascia are divided,
and the subperitoneal connective tissue uncovered. The kidney is pressed
upward. If the distended colon does not bulge into the wound, the finger
should loosen the connective tissue toward the psoas muscle, and the patient
be turned so that the wound is rotated downward. The gut may be cleared,
grasped with blunt forceps, brought toward the surface, and sutured in
the wound. If the colon has a short mesentery, it may be divided; if this
cannot *be done the bowel may be divided; or if this is not possible, a
transperitoneal operation must be done.
Jejunostomy. — This operation is done high in the jejunum. It may be
used as a means of treating diseases of the stomach and duodenum which
require rest or freedom from the irritation of food and the digestive proc-
esses. Through the Jejunostomy tube food may be poured into the jejunum.
696 SURGICAL TREATMENT
By allowing the patient to take water by the mouth, the digestive juices are
diluted in cases of ulcer. A. W. Mayo Robson (British Med. Jour., Jan. 6,
1912) recommended jejunostomy, as useful in the following conditions: (i)
Widespread cancer of the stomach too advanced for gastrostomy. By
securing complete rest to the stomach, it stops hemorrhage, relieves pain,
diminishes the size of the tumor and prolongs life very considerably. (2) In
general cicatricial contraction of the stomach, due to the swallowing of
caustic fluids, in which the stomach has been so far damaged that it no longer
performs its functions or even allows of the passage onward of food. (3) In
chronic ulcer of the stomach giving rise to hemorrhage, pain or vomiting and
to malnutrition; and where the patient is too ill to bear partial gastrectomy,
which can, however, be subsequently done if thought needful after the pa-
FIG. 1372 — JEJUNOSTOMY.
A rubber tube has been passed through a small punctured opening in the jejunum.
The tube is placed along the outer surface of the bowel and sutures placed in such a manner
as to envelop the tube in peritoneum. The sutures are passed through the parietal
peritoneum.
tient's condition has been restored by adequate feeding. (4) In some cases
of chronic duodenal ulcer, associated with hyperchlorhydria, in which there
may be a fear of jejunal ulcer subsequently developing if gastroenterostomy
be performed. (5) In certain cases of duodenal ulcer in very stout subjects
in which it is extremely difficult to perform a gastro-enterostomy and in
which violent hemorrhage has only recently occurred and may be again
excited by dragging on the stomach. (6) In jejunal or gastrojejunal ulcer
where the patient is thought to be too ill to bear one of the extensive opera-
tions previously mentioned; or where, the disease being slight, it is thought
that the complete rest of the stomach and upper jejunum that can be given
by a jejunostomy will at the same time relieve the hyperchlorhydria and cure
the ulcer. Neumann has suggested the operation for hyperchlorhydria alone.
THE ABDOMEN
697
(7) In recurring hematemesis failing to yield to ordinary treatment and where
on exploration no ulcer or other removable cause can be discovered. (8) In
persistent vomiting threatening life, as in the severe and sometimes fatal
vomiting of pregnancy, where no food whatever can be retained in the stom-
ach. To these may be added: (9) Sloughing conditions and ulcerationof the
esophagus associated with gastritis. (10) Other conditions in which gastro-
enterostomy is urgently indicated but cannot be done on account of adhe-
sions, infection or other local reasons, (n) Cases in which the general
condition of the patient is too low to tolerate gastro-enterostomy, but rapid
jejunostomy may be done.
The operation is best done by the same method as that which Witzel
applied to gastrostomy. A small rubber catheter is inserted through a small
FIG. 1373. — JEJUNOSTOMY WITH ENTERO-ENTEROSTOMY.
An entero-anastomosis has been done and the rubber tube introduced into the summit
of the loop which is made fast to the anterior abdominal wall. The tube passes into the
distal arm of the loop.
opening on the convex side, and pushed into the bowel in a distal direction.
It is then infolded as is done for gastrostomy for about 3 cm. ( i Y± inch) . The
bowel should not be kinked or a spur formed. It should be sewed only to the
peritoneum. This is to insure free passage onward for the duodenal juices.
The line of sutures for burying the catheter is fastened to the anterior abdom-
inal wall (Fig. 1372).
Robson short-circuited a loop of jejunum by entero-anastomosis (7.5 to
10 cm. (3 or 4 inches) from the summit of the loop; a small catheter is then
introduced in a purse-string at the summit and passed into the distal arm
beyond the anastomosis; and the fistula with the tube is then sewed to the
skin (Fig. 1373). If a still shorter operation is indicated the tube may be
introduced and the bowel sewed to the peritoneum, without an anastomosis
698
SURGICAL TREATMENT
being made. Maydyl cut the bowel completely across, and implanted the
proximal end into the side of the bowel below the distal end. The latter is
then sewed to the skin (Fig. 1374).
These operations are done through the rectus muscle, just above the level
of the umbilicus, on the left side. The catheter is No. 12 F. Fine linen
suture may be used. The opening is made 30 or 45 cm. (12 or 18 inches)
from the duodenum. The catheter must be kept in or the opening will close.
If it comes out it must be replaced. Liquid feeding may be begun at once.
FIG. 1374. — JEJUNOSTOMY WITH LATERAL IMPLANTATION.
The jejunum is divided. The cut end of the distal limb is implanted in the abdomina
wall. The cut end of the proximal limb is implanted in the distal limb by end-to-side
anastomosis.
THE STOMACH
Anatomy. — The stomach lies in the epigastric and left hypochondriac regions. Above
and in front are the diaphragm, left and quadrate lobes of the liver, anterior abdominal
wall, and cartilages of seventh, eighth and ninth ribs. Below and behind are the dia-
phragm, great vessels, spleen, pancreas, fourth portion of duodenum, splenic flexure of
colon, and transverse colon and its mesocolon. The cardiac end or fundus reaches as high
as the sixth left chondrosternal articulation, which is on a level with the fifth rib in the
mammary line. It rests against the summit of the diaphragm above and behind the apex of
the heart.
The cardiac orifice of the stomach is on a level with the seventh left chondrosternal articu-
lation about 2.5 cm. (i inch) from the sternum. This is the level to the left of the body of
the tenth dorsal vertebra and of the tip of the spinous process of the ninth dorsal vertebra.
It is about 2.5 cm. (i inch) below the diaphragm, and about n cm. (4^ inches) behind the
anterior wall of the abdomen.
The pylorus is on a level with the bony ends of the seventh ribs, the eleventh or twelfth
dorsal spinous process and 5 to 7.5 cm. (2 or 3 inches) below the sterno-ensiform joint.
THE ABDOMEN
699
It lies slightly to the right of the median line. These relations are subject to great variations
(Fig. 1375).
The stomach is covered everywhere with peritoneum excepting at the borders of the
greater and lesser curvatures and at the triangular areas at either end. It is attached to
the diaphragm by the esophagus, and to the posterior abdominal wall by the duodenum.
The fundus is attached to the diaphragm by the gastrophrenic ligament, and to the spleen
by the gastrosplenic omentum; the lesser curvature is connected to the liver by the gastro-
hepatic omentum; the pylorus and duodenum are connected to the liver by the duodeno-
hepatic ligament; and the great omentum connects the greater curvature to the transverse
colon and other structures to which it may adhere.
The structure of the wall of the stomach is similar to that of the intestine (page 621). It
has the same coats. All except the peritoneal coats are thicker. The muscular coat,
besides having longitudinal and circular fibers, has a layer of oblique fibers. This makes
the wall of the stomach much thicker than that of the intestine.
FIG. 1375. — THE STOMACH.
Showing the relations of the stomach and the adjacent organs. .4, Left gastric artery;
B, hepatic artery; C, hepatic duct; D, common bile-duct; E, portal vein; F, coelic axis; G.
splenic artery; H, spleen. Note shape of stomach as revealed by x-ray.
The greater curvature crosses the abdomen about 4 cm. (i% inches) above the level of
the navel. The lesser curvature crosses in front of the first lumbar vertebra. The ante-
rior wall of the stomach lies in contact with the anterior abdominal wall. This is a triangu-
lar area, having a transverse base line about 6.5 cm. (2^ inches) above the navel. The
sides of the triangle measure about 13 cm. (5 inches) each.
The lymphatics of the stomach lead toward the greater and lesser curvatures, where are
located between the folds of the greater and lesser omenta numerous lymph nodes. These
are collected chiefly along the third of the greater curvature nearest to the pylorus, and
along the lesser curvature. From these regions, the lymph vessels pass to the celiac
glands lying along the aorta. The glands of the greater curvature lie along the right gastro-
epiploic artery. They are numerous around the pylorus, whence they pass to the liver and
pancreas. The glands of the lesser curvature lie along the coronary artery from the pylorus
700
SURGICAL TREATMENT
to the esophagus. The tendency of carcinoma is to grow toward these gland collections at
the curvatures, and not toward the duodenum (Fig. 1376).
The nerves of the stomach are from the terminal branches of the pneumogastric and from
the sympathetic branches of the solar plexus. The connection of the sympathetic nerves
with the seventh, eighth and ninth dorsal spinal nerves gives the epigastric and shoulder
manifestations of stomach disease. The intimate sympathetic connections of the stomach
make this organ a centre of reflex disturbances referred from every region of the body.
Exposure of the stomach is secured through the incisions in the upper
abdomen already described (page 504). The anterior wall of the stomach
is easily brought into view. It is recognized by its thickness, compared
with that of the intestine, by its being continuous with the great omen-
turn below, by the gastrohepatic omentum passing upward, and by its pink-
ish-white opaque appearance. The fundus is best reached by an incision
to the left of the median line.
Exposure of the posterior wall requires division of the great omentum as
it hangs from the greater curvature. This is easily done by making a rent
in it between its blood-vessels, and ligating any vessels which may require
it. This operation gives access to the lesser peritoneal cavity between the
FIG. 1376. — LYMPHATICS OF STOMACH.
Showing lymphatic currents whereby cancer of the stomach is carried toward the lymphatic
nodules. Dotted lines show incisions for partial gastrectomy.
stomach and transverse colon. Better access is secured by lifting up the
omentum and dissecting it from the colon.
Gastric lavage (washing out the inside of the stomach) is employed to
empty the stomach of its contents especially when the contents are of morbid
character. The distance from the incisor teeth to the cardiac entrance of
the stomach, by way of the esophagus in the average adult, is between 38
and 46 cm. (15 and 18 inches). For washing out the stomach the tube should
pass 5 or 8 cm. (2 or 3 inches) beyond the cardia. The cardia is provided
with a valve which prevents regurgitation of food but does not hinder the
passage of objects from above downward. The most useful tube is made of
soft rubber in the form of a catheter, and is called stomach tube. It should
have two openings at the lower end. The usual stomach tube is about 1.3
to 1.8 cm. (% to % inch) in diameter and 63 to 75 cm. (25 to 30 inches)
long. Such a tube is capable of reaching to the pylorus.
The stomach tube may be introduced with the patient sitting, or lying
on the side or back. Before introducing a tube, false teeth should be re-
moved. The patient should hold a basin to catch the copious flow of saliva
which the tube excites. He should be instructed to breathe rapidly through
THE ABDOMEN 701
the mouth, not to strain or retch, to allow the saliva to flow out of the mouth,
and not to grasp the tube. He should be told to raise the hand as a signal
if he desires the operation discontinued or interrupted.
The centra-indications for lavage are acute inflammations of the esopha-
gus, ulcer of stomach with symptoms of peritoneal irritation, advanced
disease of heart or lungs, aneurism of the aorta, or advanced cirrhosis of the
liver.
The surgeon should wash his hands in the presence of the patient. The
patient should take a swallow of water, the tube should be taken from a
basin of warm water in which it had been immersed, and the end passed
over the tongue to the entrance of the esophagus. The patient should
then be instructed to swallow, and as the first muscular effort at swallowing
is made, the tube is pushed gently downward into the esophagus. It is
then slid along until it enters the stomach. If any obstruction is met the
tube should be halted. It should glide into the esophagus and stomach as
though it were being swallowed. The surgeon should not think that it
must be pushed in (see Esophageal Bougie, page 433).
In cases of cardiospasm there may be difficulty in passing the cardia.
It may be necessary to allow some warmed olive oil to flow into the tube,
or to use a silk woven tube which is stiffer than the soft rubber. Force
should never be employed. All manipulations should be gentle.
When the tube has entered the stomach, warm water may be poured in by
means of a funnel at the upper end. At first not more than 250 c.c. (^ pint)
should be introduced. Then the upper end of the tube should be lowered
below the level of the stomach over a vessel and the fluid allowed to siphon
out. Following this 250 to 1000 c.c. may be poured in at a time, as the con-
dition of the stomach warrants. It may be necessary to connect a longer
tube to the stomach tube to bring the outlet lower than the level of the stom-
ach. So much fluid that the patient has a sense of uncomfortable disten-
tion should not be poured in.
Instead of plain warm water, salt solution or boric acid solution may be
used for special conditions. Usually plain water is best. The irrigation
may continue until the fluid returns clear. The removal of the tube is easy.
Rarely cocainization of the pharynx may be necessary at the beginning
of the first operation. Patients soon become accustomed to the tube and
pass it themselves. The hands should be washed always before the operation.
Lavage is a most useful measure in the treatment of intestinal intoxica-
tions in which intestinal contents are regurgitated into the stomach. It is
most useful in intractable vomiting of intestinal toxic origin. In acute dilata-
tion of the stomach, of course, the contents are allowed to run out before
water is poured in.
Duodenal lavage is practised by the gastroenterologists. The skillful
operator can pass a tube, by way of the mouth, esophagus and stomach,
into the duodenum. This permits of irrigation and treatment of the duo-
denum. The tube used is preferably of smaller caliber than the ordinary
stomach tube. Through such a tube food may be introduced and enteric
feeding practised. J. T. Pilcher (Long Island Med. Jour., June, 1914)
advocated this measure as practicable in the treatment of certain cases of
ulcer of the stomach.
Continuous gastric lavage is useful in cases of toxemia of peritonitis
or intestinal obstruction, and in persistent vomiting. The tube used is of
the type employed for duodenal irrigation. It should be of small caliber
with a bulbous enlargement at the end. It should be introduced in the stom-
ach, and fastened to the chin by adhesive plaster. Connected with the
702 SURGICAL TREATMENT
stomach tube should be another tube passing down to a vessel below the
level of the bed. The end of this tube should be under water. After the
patient's stomach has been washed out the tube is left in place. By keeping
the end under water, siphon action is secured and as fast as the duodenum
pours fluid into the stomach it runs out through the tube. At frequent
intervals the stomach may be washed out with soda solution or other fluid.
Patients tolerate it well. A. B. Kanavel (Surg., Gynec. and Obst, October,
1916) who advocated this method, employed it in connection with continu-
ous hypodermoclysis. The method may be used with continuous procto-
clysis. Actual continuous irrigation may be practised by using a double
tube, having one opening 8 cm. (3 inches) from the other, and permitting
water to flow in and out of the stomach continuously.
Wounds and Rupture of the Stomach.- — Perforations of the stomach are
treated the same as in the intestine (page 566).
Inflammations. — Gastritis due to caustics, such as is caused by swallowing
caustic fluids, must be treated according to the nature of the poison. Empty-
ing the stomach, administering antidotes, and diluting the poison should
be practised at once. Ulcer and scar contractions should be prevented
as much as possible by (i) asepticity and by (2) prohibiting food by mouth.
The mouth should be cleansed, antiseptic washes used and only sterile
substances taken into the mouth (see Preparation for Operations on the
Intestine, page 564, for methods for gastro-intestinal asepsis). At first
food should not be given by mouth; the patient should have nutrient
enemata. After a few days sterile fluids may be given by mouth. So long as
epigastric pain and tenderness are present, solid food is best not given.
In cases with ulceration or sloughing of the mucous membrane of the mouth,
esophagus, and stomach, it is often best to make a high fistula in the jeju-
num, for feeding purposes. Through this the patient may be fed foods which
have been treated with salivary and gastric ferments. Such a fistula should
be made in the antimesenteric side of the bowel, after the method of a gastros-
tomy (pages 683 to 697).
Phlegmonous gastritis (suppuration in the stomach wall), because of the
difficulty of diagnosis, is not apt to have surgical treatment promptly applied.
Operation should be done, the stomach exposed, and the phlegmon incised.
Diffuse cellulitis of the stomach wall is best treated by incisions down to the
submucosa and drainage, just as for cellulitis elsewhere. R. W. Westbrook
(Long Island Med. Jour., N. Y., December, 1916) operated upon such a case of
a very acute type by incision and drainage.
Tuberculosis and syphilis of the stomach should be treated as elsewhere.
Cirrhosis of the stomach (plastic linitis) should receive internal treatment.
When contracture of the stomach, pain, tenderness and vomiting, cause
emaciation, operation is indicated. Gastroenterostomy has given relief.
Often these cases are not true cirrhosis, but diffuse carcinoma. If gastrec-
tomy cannot be done, and gastroenterostomy is not advisable, the patient
may be given immediate relief by jejunostomy (page 697).
Perigastric adhesions which bind the stomach and give rise to symptoms,
especially pain, should be divided and the stomach permitted to drop into
normal position. When the adhesions are firm, care must be taken in their
division, and after they have been divided, an inspection should be made
for perforation. This is important because a large proportion of these cases
have ulcer of the stomach or duodenum as the cause of the adhesions,
and often the adhesions represent a plastic deposit which closed a perforation.
Such perforations may be very small and not easily discovered. They should
THE ABDOMEN 703
be closed with a suture. If it is believed that an ulcer still exists, gastro-
enterostomy should be done.
To prevent the reformation of adhesions, an edge of omentum may be
caught with a couple of sutures so that it is interposed between the previously
adherent surfaces. While this does not really prevent adhesions, it does
interpose tissue which is freely movable and capable of making a very loose
connection. Other expedients for preventing adhesions have been discussed
(see Peritoneal Adhesions, pages 515, 520 and 600).
Tumors of the Stomach. — Benign tumors of the stomach are uncommon.
Adenoma, when sessile, should be excised and the wound closed. When the
pylorus is involved the tumor may be removed by an incision placed in the
direction of the axis of the bowel so that it can be closed transversely in order
not to restrict the lumen. In the case of a larger tumor, pylorectomy may
be required. Pedunculated tumors may be ligated and cut off. Such tumors
may occlude the pylorus, and care should be taken to recognize them before
an unnecessary pylorectomy or gastroenterostomy is done. Myoma should
be removed. Unless this is done the tumor mayjeach a large size. Lipoma
should be treated the same. Cysts should receive the same treatment as in
other parts of the body. All benign tumors, even though they do not cause
pain or obstruction, may give rise to ulceration of the mucous membrane
and hemorrhage, and for this reason their removal is indicated.
Sarcoma of the stomach appears in several varieties. The treatment
consists in wide extirpation. Partial or complete gastrectomy must be done.
Carcinoma of the stomach is amenable to surgical treatment and can
be cured, when recognized early enough. Perfection in treatment must be
aimed at because of the great prevalence of the disease; nearly one- third
of all cancers occur in the stomach. Extirpation of the'part of the stomach
bearing the disease offers the only hope. Unlike the outer parts of the body,
carcinoma developing in the stomach cannot be palpated at an early
stage. Its presence can only be suspected at first. Patients, who during the
cancer period, have loss of appetite, food stagnation in the stomach, gastric
discomfort, and loss of weight, or the other less characteristic signs, should be
subjected to stomach examination. If there is a diminution of digestive
power, absence of free hydrochloric acid, food remnants found remaining
longer than twelve hours, carcinoma should be suspected, and an exploratory
operation done. Remnants of food are found in over 50 per cent, of cases.
This is the most important indication for operation next to tumor.
The surgeon should not wait until the diagnosis can be made without
question, for at that stage the disease is rarely curable. In the present state
of diagnostic power, operation to be successful must be undertaken in the
presence of some considerable doubt as to the diagnosis. If no tumor can
be palpated and the diagnosis is not positive, the operation should be begun
as an exploration. This can be done under local anesthesia. Everything
for major operation should be ready. An opening through the abdominal
wall, large enough to admit one or two fingers, is made in the epigastrium,
opening the peritoneum to the left of the suspensory ligament of the liver.
This permits palpation of the stomach and liver. If operable carcinoma is
found, the operation necessary for its relief proceeds at once. If no carcinoma
is found an opening large enough to admit the whole hand, and even to
permit inspection, must be made in order to clear up questions of doubt.
If still the disease cannot be discovered, surgery has registered a triumph;
for the patient would have had the benefit of early operation had cancer
been present. Diagnosis of the absence of cancer, in the presence of suspi-
cious symptoms, is more useful to the patient than operation for cancer;
704 SURGICAL TREATMENT
and the surgeon should find more satisfaction in the patient's good fortune
in being without cancer than in his own skill in confirming a diagnosis of
that disease.
If inoperable disease is found, the wound may be closed, and the patient
soon returned home. If the wound must be enlarged to admit the hand,
general anesthesia will be required.
In cases in which a tumor is present which is easily felt through the ab-
dominal wall, operation should not be denied the patient. If it is found that
it cannot be removed, relief may be given by a gastroenterostomy. If so
much of the stomach is involved that this cannot be done, jejunostomy may
be employed to prolong life and secure relief from hunger. Incurable growths
in the cardiac end of the stomach may be given relief by gastrostomy which
will prevent the patient from starving to death.
The operations, then, depend upon the stage of the disease. If the
disease is still confined to the stomach wall, gastrectomy (partial or complete),
sufficiently wide to clear the growth, is to be done. If the disease occludes
the pylorus (partially or completely), if ulcerations or stagnation of food are
present, gastroenterostomy is to be done provided the growth has extended
beyond the possibilities of extirpation and provided there is enough healthy
stomach wall proximal to the disease for the operation. If the extent of
the disease is so great that neither of these operations can be done, je-
junostomy is indicated. Gastrostomy is indicated in incurable growths in
the region of the cardiac orifice.
It can rarely be said that the condition of the patient is so bad that op-
eration could not be borne. None of these operations is so hard for the
patient to bear as carcinoma of the stomach is. The palliative operations
(gastroenterostomy, gastrostomy, jejunostomy) can all be done under
local anesthesia, if needs be; and, if the suffering from inanition is serious,
food may be given at once. The depression from these operations need not
be considerable.
The only curative operation (partial or complete gastrectomy) is not a
much more serious matter. The disease is so infinitely more serious that in
all cases, in which the operation offers any hope, it should be undertaken.
Without operation, the disease terminates fatally in about a year from the
onset of symptoms. With gastro-enterostomy life is prolonged about three
months. Gastrectomy, if followed by recurrence, prolongs life about
twelve months. The operative mortality in the hands of the average surgeon,
following gastro-enterostomy for cancer, is about 15 per cent. Partial gas-
trectomy gives about the same mortality. In the hands of the highly skill-
ful and experienced operators the figures are lower than this; in the hands of
the less skillful they are higher. Death is from shock, peritonitis, or
pneumonia.
Recurrence takes place in the majority of cases after gastrectomy; but
even though it does, the patient has been relieved of an ulcerating, sepsis-
breeding tumor, and life is prolonged and made more comfortable. Many
surgeons are favoring gastrectomy even as a palliative measure, especially
since its mortality is not much greater in this disease than that of
gastro-enterostomy.
In performing gastrectomy, not only the primary cancer but the lymph-
nodes, first in the line of lymphatic drainage, should be removed. This is
a most important consideration of the operation and the surgeon should have
well in mind their location.
In cases suffering with obstruction to the exit of food from the stomach,
toxemia from fermentation of gastric contents, and inanition, gastro-enteros-
THE ABDOMEN 705
tomy may be done; and after two or three weeks when the general condition
has improved, partial gastrectomy may be performed.
It may be said that the surgical treatment of cancer of the stomach is as
satisfactory and successful as that of cancer in other parts of the body. It
will be more satisfactory when surgeons are willing to operate before a
positive diagnosis is waited for. Positive diagnosis is not often made in
time to guarantee a cure of the disease by operation. Operation should
be done before the signs due to cancer itself are manifest. The indications
for operation should be based on the functional disturbances which a beginning
cancer produces.
The presence of a palpable tumor is not a sign of hopelessness in all cases.
If the tumor is movable the case may be a very hopeful one. If the tumor
is associated with early obstruction, meaning that it is at the pylorus, it may
not have advanced very far; and a surgical cure may be hoped for. The fact
that 75 per cent, of cancers of the stomach are at the pylorus makes early
diagnosis more possible. Tumor and the symptoms of obstruction are_the
signs which indicate operation in many cases.
Unfortunately cancer of the body of the stomach, not involving the
orifices, is rarely diagnosed early enough for a curative operation. Cancer of
the cardiac orifice causes early obstruction, but its complete removal is
more difficult than cancer of the pylorus.
The patients who are saved are largely in the category of those operated
upon as an exploratory measure with only a tentative diagnosis. Patients
submitted to exploratory operation under present conditions, W. J. Mayo
says, with a probable diagnosis of cancer of the stomach, have a little over
one chance in three of a radical operation being done at all, a little less than
one chance in three of a palliative operation, and about one chance in three
that the operation will be merely an exploration and nothing more.
In some cases the transverse mesocolon will be found involved in an other-
wise hopeful case. Under such circumstances resection of the mesocolon
should be added to the stomach operation. In other cases resection of a
portion of colon may be necessary. The same may be said of the pancreas.
The involved part of the pancreas may be removed, the stump of the duo-
denum closed with suture, and the closed end of the duodenum planted into
the defect from which the pancreatic tissue was removed.
The means for restoring the continuity of the gastro-intestinal tract must
depend upon the conditions in each case. Usually after removal of part of
the stomach, the next step best taken is closure of the duodenum and stomach
and the performance of an independent posterior gastrojejunostomy. If the
remaining portion of the stomach is small, anterior gastroenterostomy may
be done without making a new stomach opening.
It is well to consider doing a gastrojejunostomy as the first step in the
operation if the patient is suffering from extreme malnutrition. After two
or three weeks, when the patient is in better condition, the resection of the
cancerous stomach may be done more safely. This method is rarely in-
dicated because the risk of doing the complete operation at one stage is not
much greater.
In certain doubtful cases gastrojejunostomy may be done. Such cases
are tumor of the pylorus of doubtful character. If the tumor is inflammatory,
it will subside; if malignant, secondary operation may be done. Some
ulcers may be doubtful in their etiology; in such cases the palliative operation
may be performed.
Gastrostomy is useful in cancer of the region of the cardiac orifice, which
is not amenable to cure and which causes or threatens obstruction. Even
VOL. 11—45
706 SURGICAL TREATMENT
when obstruction is not threatened, it is often desirable to do a gastrostomy,
placing the tube in such a position that it may easily be passed through the
pylorus. With such an operation it is possible at feedings to pass the tube
into the duodenum, and thus practise intestinal feeding, leaving the stomach
at rest. Food that has been subjected to ptyalin, pepsin and hydrochloric
acid digestion is injected into the duodenum. The stomach may be entirely
protected from contact with food. It may be washed out through the tube
and treated with medicated solutions. By this method it is possible to keep
the patient well nourished, an ulcerating cancer clean and the stomach
free from fermentation.
In such cases jejunostomy is often useful instead of gastrostomy; but it
is especially in inoperable cancer of the body of the stomach in which gastro-
enterostomy cannot be done, that it is called for. This operation gives
rest to the stomach.
At the Mayo clinic cancer of the pyloric end of the stomach is recognized
sufficiently early to do a resection of the stomach in fully 50 per cent, of the
cases. The mortality of operation is about 10 per cent. In cases in which
early diagnosis is made and operation done while the patient is in good con-
dition the mortality is kept below 5 per cent. Of the cases which survive
operation, 25 per cent, enjoy apparent immunity from recurrence for five
years, and 38 per cent, remain well for three years. Few patients who
recover from the operation have less than a year of relief.
Cancer infection, transplanted upon a raw surface or upon the peritoneum,
must be guarded against in all operations for abdominal cancer. Rough
handling should be avoided, and cancerous tissue when exposed should be
kept covered with gauze pads. A knife which has cut through cancerous
tissue should be sterilized before it is used to cut healthy tissue.
Inoperable abdominal carcinoma should be recognized before the abdomi-
nal incision is enlarged. The first incision should be long enough to admit
only the exploring fingers. If it is then found that operation is not indicated,
the small abdominal wound should be closed, the dressing reinforced with
adhesive plaster, and the patient gotten up out of bed in a few days. The
inoperable case that is operated upon and then kept in bed for a week or
two has little hope of ever getting up again.
Hour-glass Stomach. — When the disease is due to ulcer, perigastritis
or other benign condition, and gives rise to symptoms, operative treatment
is indicated. These cases are not always simple, and an examination should
always be made for other constrictions. Stenosis of the pylorus may exist at
the same time, and demand pyloroplasty, pylorectomy or gastro-enterostomy
in connection with the operation for the hour-glass stomach. It is important
that a gastroplasty alone shall not be done in a case in which there is obstruc-
tion beyond.
Gastroplasty gives the best results in cases in which there is no ulcer,
in which the constriction is near the center of the stomach, and the pylorus
is not obstructed. This operation is curative. Dilatation of a stricture
in these cases is not apt to give permanent results.
In cases of extreme constriction, gastrogastrostomy is sometimes done.
For hour-glass stomach, combined with pyloric stenosis, a gastro-enteros-
tomy, with an opening from each sac into the jejunum, was recommended by
Weir and Foote (Medical Press, 1896).
In cases with ulceration present, the ulcerated wall of the stomach may
be excised as a part of the pyloroplasty. This gives an opportunity to
observe the patency of the pylorus. Such ulcerations may show distinct
marks of malignancy, and a wider and curative operation may be done.
THE ABDOMEN
707
FIG. 1377. — GASTROPLASTY FOR HOUR-GLASS STOMACH.
The dotted line shows the place of the seromuscular suture. The stomach is incised
along the heavy line. The posterior half of the suture is applied before the incision is
made.
FIG. 1378. — GASTROPLASTY FOR HOUR-GLASS STOMACH.
Clamps are placed by making a small opening in the great and small omenta. The
posterior seromuscular suture has been applied. The through-and-through suture is being
introduced.
708
SURGICAL TREATMENT
FIG. 1379. — GASTROPLASTY FOR HOUR-GLASS STOMACH.
Showing result after operation.
i
FIG. 1380. — HOUR-GLASS STOMACH TREATED BY CONVERTING TRANSVERSE INCISION INTO
A VERTICAL INCISION.
Transverse incision has been made and a hemostatic clamp applied in the middle of each
lip of the wound.
THE ABDOMEN
709
In order to make no mistakes, the whole stomach from cardia to pylorus
should be inspected, as it might happen that gastro-enterostomy may be done
at the distal pouch, a proximal pouch not being recognized. The surgeon
should bear in mind that there may be more than two sacculations.
Gastroplasty for hour-glass stomach is best performed after the method
of simple lateral enteroanastomosis with two layers of sutures. Clamps are
applied as for resection of the middle portion of the stomach. The first
half of a continuous seromuscular suture is applied with a curved needle,
connecting the two sacks to be united just posterior to their nearest points
(Fig. 1377). An incision, having the form of an inverted U, is then made
through the wall of the stomach, and its edges united throughout by a
continuous suture (Fig. 1378). When the through-and- through suture has
\
FIG. 1381. — HOUR-GLASS STOMACH TREATED BY CLOSING TRANSVERSE WOUND VERTICALLY .
The wound is in position to be sewed.
been completed, the anterior half of the seromuscular suture is taken in hand
and finished. By carrying the sutures and incision to the bottom of the two
sacks, the continuity of the greater curvature is restored without inter-
ruption (Fig. 1379). If adhesions interfere, the use of clamps may be
omitted.
In cases in which the contracture sulcus is less marked, gastroplasty by a
transverse incision, closed vertically, may be done. A transverse fold of
stomach, above the sulcus, is grasped by a clamp, and an incision made
through the wall parallel with the lesser curvature. A small hemostat is
applied in the middle of each lip of the wound and one at either extremity,
not grasping mucosa (Fig. 1380). The stomach clamp is then removed, the
first two hemostats separated from one another as far as possible, and the
710
SURGICAL TREATMENT
stomach clamp reapplied at right angle to its first position. The four
hemostats in the hands of two assistants help to adjust the incision in line.
The wound is sutured in such a way that the two extremities of the incision
are brought together, and the middle of each lip becomes the extremity
(Fig. 1381). The hemostats are removed, the redundant mucous membrane
is trimmed off, and the edges of the wound united by a through-and-through
suture. When this is completed the clamp is removed, to be sure that
bleeding has been controlled, and an outer seromuscular suture inserted.
For cases in which there is pyloric stenosis of an intractable character,
gastroenterostomy with an opening from each sac into the jejunum, as
advised by Weir and Foote, is to be recommended. This operation is of
especial value in cases with ulceration of such a character, as to preclude
excision (Fig. 1382).
Gastroptosis. — This condition should not be regarded as surgical until
medical and hygienic treatment have failed (see Enteroptosis, page 616).
In most cases, operation is not required. Correction of the faults of bad
FIG. 1382. — HOUR-GLASS STOMACH TREATED BY DOUBLE GASTROJEJUNOSTOMY.
living usually suffices for a cure. Abdominal massage and gymnastic
exercises to strengthen the muscles of the abdominal wall are sometimes
required. The avoidance of excessive fatigue and badly fitting clothes is
important. Intrinsic diseases of the stomach, such as catarrh, pyloric
stenosis, and atony, should receive their especial treatment. The patient
should be fattened, if lean. Small meals more frequently are better than
large meals.
Cases not amenable to the above measures may have their symptoms
relieved by wearing a broad band across the abdomen to make backward
pressure. Adhesive plaster strapping is used for this purpose. These
expedients are not to be employed to the exclusion of exercises in cases
in which there is hope of restoring the natural tone of the parts, as they
are not curative but palliative, and tend to weaken the muscles which they
supplement.
In women who have not had children, the abdominal walls are so firm
THE ABDOMEN
711
that pads and bandages cannot be made to exert enough pressure to affect
the prolapsed viscera. The majority of cases in women who have borne
children can be helped by a pressure pad. The pressure must be widely
distributed over the hypogastrium; and it must be strong and constant.
Such a pad may be made by a truss-maker; it should have a steel-spring
belt on either side and a counter-pressure pad at the back (Figs. 1383 and
1384).
The pad should be applied as the patient lies on her back with the head
of the bed lowered. The pelvis should be elevated to cause the abdominal
contents to fall toward the diaphragm. The patient should take the exer-
cises which strengthen the abdominal muscles. The pad need not be worn
at night, but should be adjusted before the patient arises.
If these methods fail gastropexy is indicated. It should always be borne
in mind that prolapse of the liver, kidneys and intestines, one or more, is
FIG. 1383. FIG. i.
FIG. 1383. — GASTROPTOSIS PAD (FRONT VIEW).
FIG. 1384. — GASTROPTOSIS PAD (REAR VIEW).
84.
apt to be associated with gastroptosis and require treatment at the same
time (see Enteroptosis, Hepatoptosis, and Nephroptosis; also Adhesive
Plaster Strapping of Abdomen, page 520, Fig. 1197).
Gastropexy, for supporting the prolapsed stomach, may be done by one
of several methods. The best of these consists in shortening the sitspensory
ligament of the stomach. This operation was suggested by H. D. Beyea
(Univ. Penn. Med. Bull., February, 1903; Am. Med., viii, 1904). The
abdomen is opened by an incision 7.5 cm. (3 inches) long in the median
line, midway between the ensiform and the navel. The lesser curvature
of rthe stomach and the lower surface of the liver are exposed. The gastro-
phrenic and gastrohepatic ligaments are then shortened by means of four
or five rows of continuous sutures, throwing the ligament into folds. The
sutures extend from the cardia to the pylorus, involve only the suspensory
ligament, and when tied elevate the stomach as high as possible (Fig. 1385).
Although the gastrohepatic omentum is thin and delicate, its folding in this
712
SURGICAL TREATMENT
manner is sufficient to hold up the stomach. The results of this operation
have been most gratifying.
Duret sewed the upper part of the anterior wall of the stomach to the
peritoneum of the anterior abdominal wall. Coffey sewed to the abdominal
wall about 2.5 cm. (i inch) above the umbilicus, a transverse line of great
omentum just below the stomach.
In some cases with dilatation, atony and hematemesis, gastro-enterostomy
is required, but usually the operation of Beyea may be depended upon to
cure these symptoms.
The operation done by T. Rovsing is as follows: Three strong silk sutures
are passed in and out through the serosa of the anterior wall of the stomach
FIG. 1385. — OPERATION FOR GASTROPTOSIS.
The first 'layer of sutures has been inserted. The second and third layers are in process
of application.
parallel with the lesser curvature. The upper thread is just below the lesser
curvature. The others are about 2 cm. (•% inch) apart. The regions of the
greater curvature and pylorus are not included. The serosa between the
threads, the parietal peritoneum and the under surface of the liver to which
it is desired that the stomach should adhere, are scarified with the point of a
knife. The sutures are then passed through the entire thickness of the
abdominal wall. The left ends are brought out at the rib margin, and the
right ends about 3 cm. (i*4 inches) to the right of the median line (Fig. 1386).
The abdominal wound is then closed, and the silk sutures are tied over a glass
plate which is a little broader than the scarified stomach surface and which lies
on a gauze pad between it and the skin. This holds the stomach surface
flatly to the abdominal wall. The threads are removed at the end of four
weeks (Fig. 1387).
Hepatopexy should be done at the same time if necessary. If the left
1 obe of the liver is greatly hypertrophied, it must be removed to prevent press-
THE ABDOMEN
713
ing down upon the stomach. Nephropexy must also be done if necessary.
Gastro-enterostomy does these patients more harm than good. If enterop-
tosis is present, it also must be remedied, as there is no comfort in having one's
stomach hung up in the attic while his bowels are left lying on the basement
floor.
It happens in some of these cases, particularly in nulliparous women, that
the hypogastric region is so constricted that it is difficult to press the stomach
up in place. In these it becomes necessary to enlarge the hypogastric
region of the abdomen. This was done by Rovsing by splitting the recti
muscles and turning inward as a muscular flap a segment of the anterior part
of the bellies of the muscle together with the anterior sheath. The anterior
sheath in the new wall segment is brought to lie upon the peritoneum (Fig.
1388).
Method of Rovsing.
FIG. 1386. — GASTROPEXY.
The stomach sutures are applied, the ends passing through the
abdominal wall.
In all cases in which the gastrocolic ligament is elongated, permitting' sag-
ging of the transverse colon, it should be shortened. This is much better than
doing a colopexy. The shortening is a very simple matter and is accom-
plished by turning up the colon and carrying six or eight rows of plicating
sutures along the posterior surface of the gastrocolic ligament. The sutures
should catch the greater curvature of the stomach (Fig. 1389).
Dilatation of the Stomach. — Chronic atonic dilatation, not due to obstruc-
tion at the outlet of the stomach, should receive medical and hygienic treat-
ment. Rarely these measures fail. When they do, gastroplication or
gastro-enterostomy may be resorted to. The first is an operation practically
without risk and is worthy of trial. Gastro-enterostomy gives drainage
714 SURGICAL TREATMENT
of the stomach, puts an end to stagnation, and permits the restoration
of the normal functions.
G astro plication consists in suturing the anterior wall of the stomach into
one or more folds to take up the relaxed structures. The posterior wall is not
sutured. Care shoul d be taken that the sutures do not come near enough to
the orifices of the stomach to cause obstruction. These operations were
developed by Bircher and Weir. The stomach wall may be thrown into
multiple folds (Fig. 1390) or one fold (Fig. 1391).
The stomach is exposed by a median incision between the ensiform and
the navel. Sutures of chromicized catgut are passed through the seromuscu-
lar coats so as to cause folds parallel with the long axis of the stomach. In
aggravated cases, having a greatly relaxed posterior wall, Gould favored gas-
tro-enterostomy in connection with gastroplication.
FIG. 1387. — GASTROPEXY.
The wound is dressed and the sutures have been passed and tied over a gauze-covered glass
plate.
Acute dilatation of the stomach, not due to pyloric obstruction, should be
treated the same as acute post-operative dilatation (see page 615).
Foreign Bodies in the Stomach. — A single foreign body small enough to
pass through the esophagus will usually pass through the pylorus and the
intestinal canal. Such bodies sometimes require to be removed by opera-
tion because of cicatricial narrowing of the pylorus. Another class of bodies
is made up of impacted masses of small articles, which become felted together
into a ball of such size that it can only be removed by gastrotomy (see Gas-
trotomy, page 730). Such bodies should not be confused with tumor.
When a foreign body is known to be passing through the bowel, the feces
should be examined to determine its exit, and the surgeon should be prepared
to operate for acute intestinal obstruction, should it become lodged (Fig.
I392)-
Bodies with sharp points or edges are more serious. A needle should not
715
be permitted to pass through the gastrointestinal tract, but having been
located by the x-ray should be removed by gastrotomy or gastroscopy.
Pins are much less dangerous because the head usually goes first. If, how-
ever, the x-ray shows that the pin is not moving forward it should be re-
moved. A sharp object, such as a tack, a pin, a sharp-edged piece of bone,
metal or glass, which is small enough to pass through the pylorus may be
treated by administering 7 to 15 Gm. (2 to 4 drams) of absorbent cotton,
shredded out and drunk in glass of milk. If this is followed in an hour or so
by a saline laxative the foreign body will usually be passed enveloped in the
cotton. Or the cotton may be followed by some coarse food, such as pota-
toes, lettuce or spinach, to further envelop the foreign body.
FIG. 1388. — METHOD OF ENLARGING THE ABDOMINAL WALL.
This method of Rovsing, for enlarging the abdominal wall by turning inward flaps from
the recti muscles, is applicable to cases of virginal ptosis with tight muscles.
Volvulus of the Stomach. — If there is great distention, the stomach should
be emptied and washed out through a stomach tube. If the tube cannot
be passed, the distention must be treated after opening the abdomen. If
the greatly distended stomach cannot be replaced it must be aspirated and
emptied. The condition demands immediate laparotomy and untwisting of
the stomach supports. To prevent recurrence, shortening of the gastro-
hepatic omentum, as for gastroptosis, should be done.
Stenosis of the Cardiac Orifice.- — When due to cicatricial contracture, the
treatment is the same as that of stricture of the esophagus (page 433) (see
Cancer of the Esophagus, page 445; Operations on the Lower End of the
Esophagus, pages 459, 756). Tumors of the cardiac end of the stomach are
716 SURGICAL TREATMENT
to be treated by resection of the diseased segment and anastomosis of the
esophagus to the remaining part of the stomach. Gastrostomy or jejunos-
tomy is a last resort to prevent starvation (see Cancer of Cardia, page 756).
Cardiospasm should be treated by removal of the cause. Otherwise the
same treatment as for spasm of the esophagus is indicated (see Spasm of
Esophagus, page 442).
These cases may be relieved by operation as for stenosis. Dilatation
proves effective in most cases. It is best done by means of the rubber dilating
bag. This method has been worked out most successfully by H. S. Plummer
(Northwestern Lancet, September, 1906). The method is simpler and more
effective than gastrotomy or the introduction of dilating forceps from below.
Mechanical stretching is the operation of choice. Some cases refuse to yield
FIG. 1389. — SHORTENING THE GASTROCOLIC LIGAMENT FOR GASTROPTOSIS.
This operation is to be preferred above gastropexy. The shape of the stomach here shown
is that which is determined by radiography.
to treatment by stretching, and other operation becomes necessary. W.
Meyer (Am. Jour. Surg., June, 1912) in such a case opened the thorax, iso-
lated the two pneumogastric nerves, and in doing so tore away the fine
branches going to the esophagus. The dilated esophagus was reduced in
size by esophagoplication. The patient was cured. He also performed
cardioplasty successfully for intractable cases.
To approach the cardia for operation at the diaphragm, a median incision
is made from the ensiform cartilage to the umbilicus. This is joined by a
transverse incision about 2.5 cm. (i inch) above the umbilicus extending to
the tip of the ninth rib. The ninth, eighth and seventh ribs are divided near
their cartilages through short incisions through the skin, a separate incision
being made for each rib. The pleura should not be opened. The triangular
flap of abdomen and chest wall is turned upward and outward. The left
THE ABDOMEN
717
lobe of the liver is drawn downward and to the right and the left lateral liga-
ment of the liver is divided. This frees the liver from the diaphragm and
exposes the region of the cardiac orifice. By drawing the stomach downward
and to the left the esophagus may be drawn down through the diaphragm. By
incising the diaphragm toward the right from the esophageal orifice the
esophagus may be liberated and its lower end drawn into the abdomen.
Pyloric Stenosis. — Congenital atresia of the pylorus proves fatal because
of the difficulty of recognizing the condition in time to apply successful
treatment. If recognized early pyloroplasty or gastroenterostomy may save
life.
Pyloric stenosis of infancy (wrongly called congenital hypertrophic steno-
sis), usually occurring in infants a few weeks old, should be treated at first
by washing out the stomach once or twice a day with sterile water. For
irrigation bicarbonate of soda solution 1:160 is useful. The water should
have a temperature of 44°C. (ii2°F.). The nourishment should be breast
milk. If this cannot be had, peptonized milk, diluted with an equal amount
FIG. 1390. — GASTROPLICATION.
Showing method of reducing the size of the stomach by pleating its anterior wall.
of water, may be used. The feeding should be limited to the amount the
child can take without having nausea. Usually from 30 to 90 c.c. (i to 3
ounces) may be given every three or four hours. Sterilized water may be
given between feedings. Some children should not have this much. Hypo-
dermoclysis may be indicated in some. The child's weight should be
watched. Many of these cases have probably been confused with some
other condition. The tumor of the pyloric muscle cannot be cured by medi-
cal means, and if any cases have recovered they have represented a mild form
of hypertrophy.
Drugs are probably of no use, although opium has been extolled in doses of
from 0.0015 to 0.003 c-c- (Mo to ^o minim) of the tincture, shortly before
each feeding, as a means of relaxing the pylorus. Cases not yielding to treat-
ment by irrigation, medication and careful feeding should be operated upon.
In the pronounced cases operation should be done at once. It is possible
that the cases that yield to medical treatment are cases of spasm, and not
organic stenosis.
The operations of most service are pylorotomy, pyloroplasty, pylorodio-
sis and gastro-enterostomy. Simple longitudinal incision through all of the
718
SURGICAL TREATMENT
FIG. 1391. — GASTROPLICATION.
For convenience the sutures are applied over a sound or staff which is withdrawn when the
suturing is completed.
FIG. 1392. — FOREIGN BODIES REMOVED FROM THE STOMACH BY THE AUTHOR AT A SINGLE
OPERATION.
THE ABDOMEN 719
pyloric structures except the mucous membrane is effective and safe without
suture. This seems to give as good results as closing the wound trans-
versely. Pylorectomy is rarely justifiable. Stretching the pylorus gives
the lowest operative mortality and the best immediate results, but the per-
manence of the results are not so dependable.
The pyloroplastic operation of Finney would seem to be indicated in some
cases. Nicoll (Glasgow Med. Jour., April, 1906) made a V-shaped incision
and closed it as a Y by a single row of sutures. Of six infants, from six to
ten weeks old, operated upon by this method, five recovered and remained
apparently cured. This would not seem applicable to the dense indurated
swellings.
S. Stillman (Jour. Amer. Med. Assoc., Nov., 6, 1909) reported 12 cases
treated medically, with 6 deaths, and 10 cases treated by gastro-enterostomy,
with 2 deaths. The cases operated upon are healthy children. The cases
which survived medical treatment are not all well.
The surgeon should perform whichever operation seems best adapted to
the individual case.
The disease has a mortality of about 50 per cent, in unoperated cases.
If the disease is purely spasmodic at first, medical treatment may be suffi-
cient. When actual hypertrophy of the pyloric muscularis develops, it is
probable that medical treatment will not suffice. Still these children recover ;
and there seems to be no connection between the stenosis of infancy and
that of later life. It is probable that the patients that recover without
operation, ultimately recover completely.
The operative treatment is dangerous because the patients are very young
and poorly nourished. Operation should be done if the vomiting does not
abate. The persistence of the vomiting means loss of weight, dilatation of
the stomach, and cessation of fecal movements. When operation is done
hypodermoclysis is most important for getting fluids into the body. The
patient should be kept quiet, and given 4 c.c. (i dram) of castor oil at the
end of the first twenty-four or thirty-six hours. Breast milk should be started
as soon after operation as the child can take it. Very small doses should
be given every two hours, at first 8 c.c. (2 drams), according to L. E. Holt.
This should be gradually increased, alternating with boiled water. The
head of the bed is kept elevated.
As to whether medical treatment or operation shall be adopted should
depend on the severity of the symptoms.
The operation formerly done for this condition has been posterior
gastro-enterostomy. In the hands of skilled surgeons the mortality of opera-
tion has been reduced to 14 per cent. It is doubtful whether this is the best
operation for this disease, to be adopted as a routine procedure. Simple in-
cision down to the mucous membrane has given good results, and may be
found sufficient for many cases. A. A. Straus (Jour. Am. Med. Assoc., Oct.
30, 1915) amplified this procedure into a plastic operation. He
made a longitudinal incision through all the pyloric structures except the
mucous membrane, and freed the mucous membrane from the muscularis.
Blunt scissors may be passed between the muscularis and the mucosa and
by blunt dissection the whole circumference of the mucous membrane tube
isolated. This is done more quickly than gastro-enterostomy, and appar-
ently gives as good results. The pyloric wound should be covered with an
edge of omentum.
It should be borne in mind that in true hypertrophic stenosis of infancy,
there is an actual tumor of the pyloric muscularis, which cannot be cured by
medical treatment. The condition is not one of muscular spasm. The
720 SURGICAL TREATMENT
mortality from medical treatment is somewhere between 80 and 100 per cent.
C. L. Scudder (Annals of Surg., 1914, vol. 59) reported a mortality of 14
per cent, following gastro-enterostomy.
Acquired hypertrophic stenosis in adults, not associated with ulcer or scar
tissue, occurs in young adults, and is amenable to pyloroplasty or gastro-
enterostomy. Operation should be preceded by a period of treatment by
gastric lavage (see Pyloroplasty, page 740).
Carcinoma, or other tumor of the pylorus, is treated by resection (see
Pylorectomy, page 747).
Cicatricial stenosis, commonly following ulcer, is best treated by gastro-
enterostomy. Pyloroplasty may be done in some cases. Resection of the
pylorus is indicated if there is induration without external adhesions. In
skilled hands the ideal treatment is resection of the pylorus and pyloroplasty
or gastroduodenostomy.
Spasmodic Stenosis. — There are cases of persistent vomiting no cause for
which can be discovered clinically. These cases have been relieved by
stretching the pylorus. It has been assumed that there was some pyloric
spasm or stenosis and upon this theory the stomach has been exposed; often
it has been difficult to say whether a lesion was present or not; but after
performing gastrotomy, passing a dilator through the opening, and through
the pylorus, dilating, and then suturing the small gastrotomy wound, the
patients have been found to be cured. The simple operation of stretching
the pylorus has sufficed.
Before operating on the pylorus, the surgeon should be sure that the
vomiting is not due to angulation or other obstruction in the bowel. He
should particularly guard against the mistake of performing gastroenteros-
tomy, under the assumption of obstruction due to an intestinal lesion.
Ulcer of the Stomach. — The causative factor should be sought for and
eliminated. The primary focus of infection may be at the root of a tooth, in
infected adenoids, nasal sinuses, or in some other part of the body. It is
possible that an infected appendix, Fallopian tube, gall-bladder, or anal
fissure may be the nidus requiring attention. Old ulcers with calloused beds
and constantly recurring symptoms, situated near the pylorus, should be
treated by resection or other operation. Excision is the operation of choice
and in all cases should be done when possible. In many instances the
refusal of the patient, the physical condition of the patient, or other circum-
stances over which the surgeon has no control make operation impossible or
compel its postponement. Under such circumstances palliative treatment
becomes necessary.
Nonoperative treatment is indicated also in young ulcers with little in-
duration. The treatment formulated by F. Smithies (Am. Jour. Med. Sci.,
1917) provides for rest of the stomach. The patient should be kept quietly
in bed. No food should be taken by mouth for three to seven days. This
period is determined by the subsidence of gastric spasm. By chewing paraffin
wax for fifteen minutes every hour hunger and thirst are allayed. Rectal
feedings are given during the fasting period. From 500 to 1000 calories
of nutrient mixture are given every twenty-four hours. This may be secured
by using 30 c.c. (i ounce) of 50 per cent, alcohol, and 30 Gm. of glucose in
normal salt solution to make 240 c.c. of fluid. This is given at body tem-
perature by the drop method. If rectal feeding for several days is neces-
sary, proteids also should be used (see Nutrient Enemata, page 620). A little
tincture of opium may be added to the first enema. From the fourth to
the seventh day mouth feeding may be begun.
THE ABDOMEN 721
Large doses of alkalies increase the acid secretion and are not to be recom-
mended. If an alkali is employed frequent small doses of milk of magnesia
or calcined magnesia are best. Usually 0.3 to 0.6 Gm. (5 to 10 grains) of
calcined magnesia every two or three hours suffice. Alkalies and lavage
are not desirable and should be used only when especially called for. It is
doubtful if such medicines as oils, bismuth, and iron have any curative
value.
Most cases are capable of being healed by nonoperative treatment. If
patients are given rest, quiet and freedom from worry, the natural tendency
of the disease seems to be toward recovery. There are two principal
methods of internal treatment: That of W. von Leube consists in rest in
bed, medication, saline laxatives, heat to the epigastrium, prohibition of
food by mouth until blood has disappeared from the stools and then gradual
administration of fluid food. That of Lenhartz consists in rest in bed for
at least four weeks, feeding from the beginning with steadily increasing
quantities of beaten-up eggs and milk to neutralize or fix the acid gastric
juice, ice-bag to the epigastrium, addition of fine solid food to the dietary
after the first week and the administration of bismuth and iron.
A mixture may be made having a proportion of 45 c.c. (i^ ounces)
of cream, 120 c.c. (4 ounces) of milk, and one egg. This is given every hour
from 7 a.m. till 7 p.m. in doses of 15 c.c. (4 drams). The dosage is increased
15 c.c. (4 drams) every day. When the quantity at each feeding reaches
90 c.c. (3 ounces) the dose is not further increased for five days. At the end
of the first week, a soft boiled egg and 30 Gm. (i ounce) of strained oatmeal
may be given twice daily, at 7 a.m. and at 7 p.m., and at i p.m. 30 Gm. (i
ounce) of broiled scraped beef and the same amount of well-cooked rice.
From the tenth to the fifteenth day, the food should consist of 90 c.c. (3
ounces) of the egg-milk mixture at 9 and n a.m. and 3 and 5 p.m.; and
60 Gm. (2 ounces) of strained oatmeal with cream and glucose, and one or
two thin slices of dry bread, and two soft eggs at 7 a.m. and at 7 p.m.;
and chopped chicken or scraped beef, dry bread and rice at i p.m. From
the fifteenth day to the end of the second month, small meals 3 times daily
should be eaten. An egg and a glass of milk should be taken between
meals and at bed time. This is practically the dietary advised by
S. Harris (Southern Med. Jour., November, 1916). It may be begun
two days after a hemorrhage. It is a highly useful regimen after gastro-
enterostomy.
A method of feeding in gastric and duodenal ulcers advocated by W. J.
Stone (Jour. Am. Med. Assoc., Sept. 30, 1916) met hyperacidity by a
restriction of carbohydrate diet. Neutral sodium citrate, 0.2 Gm. (3 grains),
is given with every 30 c.c. (i ounce) of milk to prevent the formation of
curds. Albumin water is made of the white of one egg, in 500 c.c. (i pint)
of water, and is best flavored with orange, grape or lemon juice, but no
sugar should be used. Custard should be made with but little sugar. Puree
is made of peas, spinach or corn. Broth may be made of chicken, oysters or
clams. Bacon should be broiled crisp, and the tough edge and cartilage
removed. If the patient is badly in need of fluids, proctoclysis may be given.
Retention of food in the stomach should be treated by gastric lavage. The
following feeding schedule is followed:
VOL. 11—46
722 SURGICAL TREATMENT
Day Food: amount and frequency A.M. P. M.
ist Milk, 2 ounces, every two hours 6 8
Albumin water, 3 ounces, every two hours 7 Q
2d Milk, 2 ounces; cream, i ounce, every two hours 6 8
Albumin water; 3 ounces, every two hours 7
3d Milk and cream as above, every two hours 6
Albumin water, as above, every two hours ; 7
One soft boiled egg, with feeding at 7
4th Milk and cream as above 6 8
Albumin water as above 7 Q
One egg as above, with feeding at 7 7
Soft, well cooked cereal, 3 ounces, with feeding at 8 2
5th Milk and cream as above 6 8
Albumin water as above 7 q
One egg as above, with feeding at 7 i and 7
Cereal as above with feeding at 8 2
Puree, 3 ounces, with feeding at 12 M. 6
6th Milk and cream as above ; 6 8
Albumin water as above i 7 9
One egg with 2 slices bacon, with feeding at 7 i and 7
Cereal as above, with feeding at 8 2 and 8
Puree as above, with feeding at 12 M. 6
7th Repeat above and 3 ounces broth, with feeding at 10 4
8th Same as seventh, and broth with feeding at 10 4 and 10
Qth to 1 4th Same as eighth and M slice toast with three feedings. Cus-
tard, 3 ounces, may be substituted for one or two milk
or albumin water feedings if desired
Ferric chlorid i per cent, solution introduced through a stomach tube,
and the same drug in gelatin lozenges have been used. Olive oil, linseed
oil, and oil of sweet almonds have their advocates. Some medical authorities
regard the mechanical activities of the stomach as being of more importance
than the chemical in ulcer of the stomach, and permit only foods which are
finely divided and macerated. Hyperchlorhydria may be reduced and con-
trolled by regulating the intake of sodium chloride.
Hyperchlorhydria, which is a common feature of the disease, is amenable
to medical treatment. Even though it be attended by pyloric spasm the
case does not require surgical treatment unless motor disturbances are
pronounced.
Operative treatment is called for in cases in which (i) despite medical
treatment the symptoms of ulcer continue to cause distress or interfere with
the patient's efficiency; (2) perforation occurs; (3) physical signs of food
stagnation, dilatation, hour-glass contracture, or adhesions supervene;
or (4) hemorrhage, as shown by occult blood in the feces, by hematemesis,
or intractable anemia, persists. This means that cases which do not yield
to palliative treatment should be operated upon.
The histories of most cases which come for surgical relief show that they
have been too long deferred. Spasm of the pylorus, hyperchlorhydria,
dilatation of the stomach, atony of the stomach, cicatricial contractures,
hour-glass stomach, perforation, perigastric adhesions, cancer and a
train of constitutional ills represent some of the conditions which may
supervene if ulcer is left to run its course. To check the disease, when non-
surgical measures have failed, excision of the ulcer or gastro-enterostomy or
both should be employed.
In dealing with ulcer of the stomach and duodenum, there are two
definite forms of gastro-enterostomy. One is gastrojejunostomy; the other
is gastroduodenostomy. Gastroduodenostomy in these diseases is best
THE ABDOMEN 723
performed as a pyloroplasty. This means that the duodenum and stomach
are connected by a larger opening than the natural pyloric opening. This
operation gives access for the removal of duodenal or pyloric ulcers, and is
properly speaking a gastro-enterostomy. When gastro-enterostomy is
spoken of in this work in connection with gastric or duodenal ulcer, pyloro-
plasty is meant to be preferred if the ulcer is near the pylorus.
Operation offers relief to so large a proportion of cases — about 90 per
cent, of those operated upon — and the hazard of gastro-enterostomy has been
reduced to so low a degree — i or 2 per cent, mortality in skilled hands —
that even the cases which may be relieved by a tedious course of medical
treatment are justified in electing operation. Unfortunately the mortality
in the hands of the average surgeon is 6 to 8 per cent. ; and when combined
with resection it is 10 to 15 per cent.
Although the modern methods of diagnosis enable the surgeon to judge
beforehand the location of the ulcer, still the operation should be regarded as
diagnostic until the ulcer is discovered. Old ulcers may be recognized by
the induration of the stomach wall, but recent ulcers may elude recognition.
If the ulcer is at the pylorus, and especially if associated with thickening
of the wall, resection of the ulcer and tumor is indicated. Some surgeons
even in these cases prefer to do gastro-enterostomy alone, which is less hazard-
ous. If the ulcerated area is surrounded by adhesions, which would make
resection difficult, gastro-enterostomy alone is usually done, although
resection is the ideal operation. If the ulcer is not at the pylorus, simple
resection of the ulcerated part of the stomach wall, and closure of the wound
is indicated, without gastro-enterostomy, provided the surgeon feels satis-
fied there is no other ulcer, and the pyloric drainage of the stomach is per-
fectly adequate. This is often difficult to determine, and it is for this
reason, therefore, that gastro-enterostomy may wisely be added to the
resection.
While medical treatment may be expected to cure most cases of gastric
ulcer, the cure is always doubtful for we know that commonly after such ulcers
cease to give symptoms the ulcer, from a surgical standpoint, is still unhealed.
It is therefore difficult to say when surgical treatment is indicated. In
view of the uncertainty of medical treatment, the fact that cancer of the
stomach is most prone to develop in ulcers, and the excellent results of op-
erative treatment, operation may be said to be justified in all cases in which
there are no positive contraindications. It is not advised that every gastric
ulcer should be treated by operation, but surgical treatment should be
applied in the cases not clearly cured by faithful medical treatment. The
fact that we have evidence that at least 75 per cent, of stomach cancers de-
velop in the beds of old ulcers is the reason for regarding all ulcers of the
stomach as surgical disease and justifies their resection.
Ulcer near the pylorus, which is apt to be swollen and edematous, should
not be mistaken for cancer. The fact that the swelling is so great that it
can even be felt through the abdominal wall should not lead the surgeon to
operate as for cancer.
Excision of the ulcer-bearing area is the operation of choice and especially
in pyloric ulcers. This usually is best treated by a partial excision of the
stomach wall, followed by pyloroplasty. In smaller ulcers an elliptical
resection should be done, and the wound in the stomach closed as for
gastrotomy.
The ulcer should be removed or destroyed in all cases operated upon for
ulcer of the stomach, unless there is some pressing contraindication against
its removal.
724
SURGICAL TREATMENT
Ulcers of other parts of the stomach than the pylorus are best treated by
excision. In many cases gastro-enterostomy also seems indicated because,
if only excision of the ulcer is done, the diseased condition of stomach func-
tion seems not to be relieved, the wound may fail to heal properly, and
later gastro-enterostomy may become necessary.
D. C. Balfour successfully treated ulcers of the lesser curvature with the
actual cautery (Surg., Gyn. and Obst, vol. 19, p. 528, 1914). The peritoneum
is dissected from the bed of the ulcer, and the cautery at a cherry red, is
caused to burn out the ulcer, thus producing an artificial perforation into the
stomach. The opening is closed with sutures, and the peritoneum sutured
over all. At the lesser curvature the gastrohepatic omentum would naturally
constitute the covering peritoneum. This operation should be followed by
gastrojejunostomy or pyloroplasty for the sake of better gastric drainage.
FIG. 1393. — TRANSGASTRIC EXCISION OF ULCER OF THE POSTERIOR WALL OF THE STOMACH.
The anterior wall has been incised and retracted. The ulcer is seen on the posterior wall.
The dotted line indicates the line of incision for its removal.
Resection of the part of the stomach bearing the ulcer should be practised
in the case of large or old indurated ulcers. Ulcers of the posterior wall of
the stomach may be approached through an incision in the anterior wall
(Fig. 1393), thus making a transgastric operation. After resecting the ulcer
the two stomach wounds are closed (Figs. 1394 and 1395).
Excision of much of the stomach may be followed by direct anastomosis of
the remaining part with the jejunum or duodenum. Even though excision
is done, gastro-enterostomy also is often desirable. It gives rest to the
stomach, secures drainage, relieves hyperchlorhydria, and cures ulcers which
may not be capable of discovery for excision.
W. J. Mayo's results showed that by gastro-enterostomy alone, it was
possible to secure permanent recovery in 80 per cent, of the cases in which
medical treatment had failed; and that in nearly to per cent, more, improve-
ment can be secured. His later figures showed improvement or cure in 98
per cent, of cases following gastrojejunostomy and excision or infolding of the
ulcer.
The treatment of the complications resulting from gastric ulcer are each
discussed separately (see Perforations of the Stomach, page 725; Gastric
THE ABDOMEN
725
Hemorrhage, page 727; Pyloric Stenosis, page 717; Operations on the
Stomach, page 730).
About 80 per cent, of ulcers of the stomach are at the pylorus. The
pylorus and duodenum are usually easily mobilized, and excision of the ulcer-
FIG. 1394. — CLOSING WOUND IN POSTERIOR WALL OF STOMACH AFTER EXCISION OF ULCER.
bearing area is not difficult. This may be done as a pylorectomy or as a
pyloroplasty after the method of Finney. This course is in most cases pref-
erable to gastrojejunostomy.
FIG. 1395. — WOUNDS OF STOMACH CLOSED AFTER TRANSGASTRIC EXCISION OF ULCER OF
POSTERIOR WALL OF STOMACH.
In cases in which immediate relief is called for in a patient who has become
much reduced by disease and suffering, or if adhesions are present which
would make pylorectomy or pyloroplasty difficult, then gastrojejunostomy
may be regarded as the operation of choice.
726 SURGICAL TREATMENT
Pylorectomy or pyloroplasty may then be done later. After a weak
patient has grown strong, it may be done to remove the ulcer and close the
gastrojejunostomy openings. In the presence of adhesions it may be done to
remove the ulcerated area after the gastrojejunostomy has proved its effi-
cacy. And it may be done in cases in which the symptoms of ulcer have not
been relieved by gastrojejunostomy.
The advisability of operating in two stages on weak patients should
always be considered whether the operation is to be done for ulcer or for
cancer.
Perforating ulcer of the stomach should be treated the same as perforating
ulcer of the intestine (page 566). The abdomen should be opened at once,
as soon as possible after the condition is recognized or suspected, and the per-
foration closed. Every hour that elapses after perforation the prognosis
becomes more grave. Delay is unjustifiable. It is a serious error to tempo-
rize because shock is present, hoping to get the patient into better condition
for operation. The danger of peritonitis is greater than that of shock. It is
also a serious error to temporize in cases in which the symptoms are not pro-
nounced, waiting until the condition more positively manifests itself. It is
true that slow perforation may become sealed over by plastic exudate, and
spreading peritonitis not occur. Many such cases, as disclosed by peri-
gastric adhesions, heal spontaneously. But the possibility of fatal or serious
peritonitis is so great that every case of perforation should be sutured.
Mayo operated upon 543 cases of ulcer of the duodenum and stomach
during a consecutive period. Of these, 27 were perforating. All the cases
of acute perforation treated by simple suture, excepting one, recovered.
Cases operated upon during the first twelve hours should be expected to
recover. The mortality increases with the lapse of time. The mortality of
the acute cases operated upon is not less than 50 per cent, in all hands
because of the loon average delay between perforation and operation.
Operation for perforating gastric ulcer should be done through a lo-cm.
(4-inch) median incision above the umbilicus. Fluid is removed; and if
the perforation does not come at once into sight, an inspection of the anterior
wall of the stomach is made, beginning with the pyloric end. If the perfora-
tion is not found in the anterior wall, the posterior wall should be exposed.
This may be done by making a rent through the great omentum between the
stomach and transverse colon; or the omentum and the colon may be lifted
up and the opening made through the transverse mesocolon. The soiled
peritoneum should be cleansed, and the opening closed with two layers of
sutures, first a through-and-through suture, and then a serosa suture of linen.
If the soiling of the peritoneum has been considerable, as may occur in the
case of a large perforation after a meal, the peritoneum should be irrigated
and the abdomen closed with drainage. If the soiling has been slight or has
involved but a small area, irrigation and drainage may be dispensed with.
The resection of a perforated ulcer is not called for. Mayo has called atten-
tion to the fact that perforation cures the ulcer. As soon as perforation
takes place, the main question is not of ulcer but of peritonitis.
The further treatment is that of peritonitis. When peritonitis has super-
vened, that condition should receive active attention. Ileus may have to be
met later and foci of suppuration may require to be drained (see Peritonitis,
page 546).
Some surgeons have advocated gastro-enterostomy after closure of the
ulcer. This may be done, if the ulcer has long resisted medical treatment, if
the mechanical and chemical function has been much altered, and if the con-
dition of the patient will easily permit of prolonging the operation. If a
THE ABDOMEN 727
diffuse peritoneal infection has occurred, anastomosis should not be done.
Gastro-enterostomy is indicated more in the chronic cases with the perforation
closed by plastic exudate and a persistence of the symptoms of ulcer.
J. B. Deaver and many other surgeons excise the ulcer, close the wound,
and perform posterior gastro-enterostomy. This treatment gives highly
satisfactory results. Excision is always advisable because of the danger of
cancer developing in the bed of gastric ulcer. So far as gastro-enterostomy is
concerned, it is indicated only for the relief of pyloric obstruction and
defective stomach drainage (see Gastric Ulcer, page 720).
Perigastric abscess from perforation of the stomach depends for its loca-
tion upon whether the perforation is in the anterior or posterior wall. Ante-
rior perforation may give abscess anywhere between the anterior abdominal
wall and the stomach; it can usually be drained by incision through the
abdominal wall; or it may extend over the liver and be reached by the inci-
sion described for subphrenic abscess (page 553). Perforation of the
posterior wall infects the lesser peritoneal cavity; and the abscess may require
to be reached through the thorax, or through the anterior abdominal wall and
the anterior layer of the gastrocolic omentum (page 780).
Hemorrhage of the Stomach. — If it could be known that hemorrhage is
arterial, then operation should be done at once. Capillary hemorrhage
should not require to be controlled by operation. Nearly 100 per cent, of
cases of obvious hemorrhage are arrested without operation, and it may be
assumed that these represent capillary bleeding. A large number have
loss of a smaller amount of blood, which is to be discovered only by chemical
examination of the stools. It may be stated that the great majority of cases
of hemorrhage need not be operated upon. Rest, the withholding of gastric
feeding, ice, adrenalin chlorid, or astringents introduced through the
stomach tube, and morphin hypodermatically, are the most effective
expedients.
Adrenalin is, perhaps the most useful agent. It must be given at intervals
of not more than an hour. The first doses may be 2 c.c. (30 minims) of a
i : 1000 solution. The measures for increasing the coagulability of the blood
should also be used (see Hemorrhage, Vol. I, page 334).
A simple hemorrhage, either large or small, should not call for operation
unless an ulcer has been known to exist. In old chronic cases, operation is
indicated at the first hemorrhage, as it not only is aimed to control the
bleeding but it gives an opportunity to cure the ulcer at the same time.
Recurrent bleeding which persists despite treatment, even when no history
of ulcer has been obtained, should receive surgical treatment.
In any case every effort should be made to secure the arrest of the hem-
orrhage before operating in order to operate in a quiescent stage if possible.
Operation in a stage of extreme and recent acute anemia is very hazardous,
but often not so hazardous as the continuation of the bleeding. It should
also be borne in mind that a complicating carcinomatous degeneration may
be present. This should be suspected if after the hemorrhage has stopped,
every attempt to feed solid food is followed by bleeding.
There are few conditions in which decision may be more difficult.
Whether operation shall be done must depend upon the general conditions,
the surgical skill that can be secured, the resistance of the patient, and gen-
eral facilities for operations and postoperative care.
After operating the surgeon cannot always be sure that his operation
was of benefit or harm.
A middle-aged man without history of ulcer, vomited blood twice and was suffering with
acute anemia. While I was at his bedside, it could be seen plainly that his stomach again
728 SURGICAL TREATMENT
was filling with blood. I sent him to the hospital and operated as a last desperate measure
five hours after the first hemorrhage. He had vomited a large quantity of blood when he
went on the table, and was profoundly anemic. Upon opening the stomach no ulcer or
bleeding point could be found. Three suspicious-looking spots were surrounded with a
suture. No further bleeding took place; and the man had remained entirely well fifteen
years later. It can not be known whether this operation was of any service; it probably was
not.
T. Rovsing (Jour. Amer. Med. Assoc., Oct. 24, 1908, page 1476) suc-
cessfully employed gastroscopy and diaphanoscopy for purposes of trans-
illumination of the stomach as an aid to operation. With an electric light
in the stomach introduced through the esophagus or through a very small
puncture in the stomach wall, bleeding and the vessel from which it is tak-
ing place can be seen by the shadow through the stomach; and a sunken
suture may be passed around the vessel. The ordinary cystoscope has been
employed for this purpose by L. Kraft (Hospitalstidende, No. 20; May 19,
1909).
Operation for gastric hemorrhage must be regarded as being at first diag-
nostic. Some surgeons are strongly in favor of gastro-enterostomy alone,
claiming that it relieves the condition which causes the hemorrhage. As
an operative procedure, this operation is no more hazardous than gastrot-
omy, search for the bleeding point and ligation. It may be said, on one
hand, that gastro-enterostomy has not always been followed by cessation
of bleeding, and, on the other hand, that simple ligation has been followed
by recurrence of hemorrhage because it did not cure the ulcer. Judgment
is required.
A bleeding artery in an old ulcer should surely be ligated; and, if the con-
dition of the patient will permit, it is best that the ulcer be excised. If
excision is not done the healing of the ulcer will be facilitated by gastro-
enterostomy. The surgeon must decide for each case which is the more
important. If the condition of the patient will permit, after checking the hem-
orrhage, the operative treatment as for ulcer should be proceeded with
if ulcer is present. If the hemorrhage has stopped, the ulcer should be
dealt with. If the bleeding is continuing at the time of operation, direct
hemostasis is the more important.
If bleeding is not going on, it will often be difficult to determine where
it came from; and after a futile search, or ligation of suspected foci, hemor-
rhage may recur. The bleeding may have come from the duodenum.
Gastro-enterostomy has more to offer for the majority of cases than attempts
at direct ligation, if no active bleeding is seen.
The technic of operation begins with exposure of the stomach by a lo-cm.
(4-inch) incision above the umbilicus. As a rule it is undesirable to wash
out the stomach lest bleeding be excited. The anterior surface of the stom-
ach should be scrutinized with a good light for evidences of ulcer. An area
of induration, discoloration or puckering should be sought. If the outward
signs of ulcer are discovered, it may be assumed that this is the site of hem-
orrhage. If the condition of the patient will permit, the ulcer should be
excised (page 723).
If the patient's condition is bad and a short operation is essential, then
simple ligation may be done without opening the stomach. This may be
accomplished by observing through the serosa the vessel which goes to the
ulcer. A curved needle may be passed under it and the vessel tied. If no
vessel can be identified as the main supply of the ulcer, a continuous suture
through the whole thickness of the stomach wall may be applied in such a
manner as to sew together the raw surface without exposing it. This suture
should be applied tightly in such a direction as to embrace the blood-vessels,
THE ABDOMEN
729
and after being tied should be covered by a second layer of serosa sutures.
This is the operation of emergency, not of choice.
If no sign of ulcer is to be seen through the peritoneum, and direct treat-
ment of the hemorrhage is to be undertaken, the stomach should be drawn
forward, surrounded by protecting pads and opened. An incision in the
long axis of the stomach in the middle of its anterior wall gives the best view.
This wound should be held open by forceps grasping its edges. With the
aid of good light, or an electric light introduced through the wound, the
interior of the stomach should be inspected. To facilitate examination of the
posterior wall a slit may be made in the omentum just below the stomach,
and four fingers passed through it. The fingers behind the stomach may
press forward into the wound for inspection the various parts of the mucous
FIG. 1396. — METHOD OF LOCATING ULCER OR BLEEDING POINT ON POSTERIOR WALL OF
STOMACH.
The stomach is incised anteriorly; an opening is made in the great omentum just
below the stomach and two fingers passed behind it. These two fingers press the posterior
wall of the stomach forward into the wound. A large area of the mucous membrane of the
posterior wall may thus be brought under inspection through a small anterior wound.
membrane of the posterior wall (Fig. 1396). The duodenum should be
examined not only externally but it may be invaginated through the pylorus,
if no ulcer can be found in the stomach.
If a bleeding point is discovered it should be caught with a broad-nosed
clamp and ligated. The mucous membrane is very friable and will be cut
through if the ligature is tied too tightly. The thermocautery may be used.
An ulcer should be excised. An ulcer at the pylorus, if small, may be excised
and the wound closed transversely so as to prevent narrowing of the lumen.
A larger ulcer is best treated by pylorectomy, the main object being to pre-
vent cancer. If the induration or adhesions are too extensive or if the con-
730 SURGICAL TREATMENT
dition of the patient does not warrant pylorectomy, the bleeding point may
be ligated and gastro-enterostomy performed.
The gastrotomy wound should be closed with two layers of sutures, a
through-and-through suture closing the opening, and a seromuscular outside
suture.
In all operations for hemorrhage preparations for the treatment of acute
anemia should go on with the preparations for operation. If an infusion is
needed it should be in readiness, and as soon as the bleeding opening has
been closed the infusion should begin (Vol. I, page 346).
To recapitulate: (i) In desperate cases the bleeding ulcer may be dis-
covered and the supplying vessel tied by passing a ligature with a needle
through the stomach wall without opening the stomach. (2) If ulcer can-
not be discovered externally and uncontrolled bleeding is going on, gastrot-
omy may reveal the bleeding point. (3) If the condition of the patient war-
rants it, the bleeding ulcer should be excised. (4) If the patient's condition
is still good, gastroduodenostomy (pyloroplasty) or gastrojejunostomy may
be added to the excision if indicated.
Gastric Tetany. — The treatment consists in relieving the causative
disease if it can be discovered. Pyloric stenosis, hour-glass stomach, cancer,
or any other condition producing stagnation of stomach contents or hyper-
chlorhydria should have applied to it its special treatment. I have reported
a case cured by the removal of foreign bodies from the stomach (Annals of
Surgery, December, 1904).
Lavage of the stomach may be depended upon to give temporary relief
but success will not follow unless the washing is continued until the fluid
returns clear. A sedative or even a general anesthetic may be required for
the operation. Gastro-enterostomy, providing drainage of the stomach,
may be depended upon as the most effective treatment. This operation
has not failed to give relief in a large number of cases.
OPERATIONS ON THE STOMACH
Gastrotomy. — This operation consists in opening the stomach by an inci-
sion. It is usually best that the stomach be washed out before operation.
The stomach is exposed by an incision above the umbilicus, and inspected
with reference to the condition demanding operation. The surrounding
structures are protected. The least bleeding will be caused by the incision
if it is made about midway between the greater and lesser curvatures in the
line with the long axis of the stomach. This incision will be made toward the
pylorus, the cardia, or in the middle of the stomach, depending upon the re-
gion to be exposed. After the object of the operation has been accomplished
the incision is closed with two layers of sutures — a through-and-through
suture approximating the edges of the wound, and an outer seromuscular
suture — the same as employed for closing wounds of the intestine (page 626).
Gastrostomy. — This operation consists in making a permanent opening in
the anterior wall of the stomach for purposes of feeding or treatment. It is
employed especially in cases of obstruction of the esophagus. Many
operations have been devised and modified. It is desirable that the orifice
shall be made tight enough so that it shall not allow the escape of stomach
contents upon the skin to produce irritation. The simple compression
between the fibers of the rectus muscle is not enough of a sphincter action to
close the opening. The operation must often be modified according to the
mobility of the anterior stomach wall and according to the permanence
desired.
THE ABDOMEN
731
Gastrostomy by means of an external flap was devised by H. H. Janeway
(personal communication). The operation may be done under local anes-
thetic through a 4 cm. (i>£ inch) incision. The incision is made parallel
with the fibers of the rectus muscle over the inner third of the left rectus
3 or 4 cm. belew the costal cartilage. A wedge of stomach is pulled out
through the wound by means of two clamps. An incision, 3 or 4 cm. long
(Fig. 13960), is made between the two clamps and two shorter incisions,
1.5 or 2 cm. long, are carried from the end of this toward the greater curva-
ture. A flap is thus formed which is folded into a tube. The wound is closed
without reducing the transverse dimension of the stomach, and in such a
manner that the line of suture is continuous with that which closes the tube.
H.J.5.
FIG. 13963. — GASTROSTOMY, METHOD OF JANEWAY.
I, The U-shaped incision is made on the anterior wall of the stomach. This forms a
flap EGFC. 2, The flap EGFC is turned down. Its nourishment is from the
artery of the greater curvature. 3, The point A is grasped and drawn upward. The side
D E G is united with the side B C F. This closes the stomach %vound and forms the
tube of stomach-wall. 4, Showing stomach through abdominal wound. When the opera-
tion is completed, an elongated tube is formed, the transverse dimension of the stomach
is not reduced, and when the tube is compressed by the fibers of the rectus muscle leakage
is prevented.
The base of this artificial canal is sewed to the parietal peritoneum and
posterior sheath of the rectus. The apex is sewed to the skin. When this
operation is well done the patient is not obliged to wear a tube, the opening will
not close nor leak, and the interior of the stomach may be examined at any
time with the gastroscope.
Gastrostomy through an internal cone is done by the method devised by E.
J. Senn. It is the most simple of the operations. A vertical incision about
5 cm. (2 inches) long is made over the outer third of the left rectus muscle. It
begins about 2 cm. (% inch) below the costal margin. The fibers of the rectus
are separated bluntly, care being taken not to divide the nerves passing to
the inner two- thirds of the muscle. The peritoneum is opened. The stomach
may be small and shrunken. The colon should be retracted downward,
732
SURGICAL TREATMENT
FIG. 1397. — GASTROSTOMY, METHOD OF SENN.
Showing sutures inserted and catheter introduced. The stomach here indicated has the
shape disclosed by x-ray examinations.
FIG. 1398. — GASTROSTOMY, METHOD OF SENN.
Showing purse-string sutures tied.
THE ABDOMEN
733
and the stomach brought forward into the wound. The point to be opened
should be about midway between the lesser curvatures at the cardiac end of
the stomach. A purse-string suture is applied with a diameter of about
2 cm. (% inch). The ends of the suture are left long for tying. Outside of
this a second, third and a fourth purse-string suture are placed. These
sutures should be about 6 mm. (^ inch) apart. The diameter of the outer
circle is about 5.7 cm. (2% inches). If haste is necessary three purse-strings
about i cm. (f& inch) apart may be placed. The circle should not be any
smaller than this. Having placed these seromuscular sutures, an opening is
made in the center of the circle, and a No. 14 or 16 French catheter introduced.
The opening should be made with a narrow sharp knife and should be small
enough to make the tube fit snugly (Fig. 1397). The tube should be passed
into the stomach about 5 cm. (2 inches). The inner purse-string is then tied
FIG. 1399. — GASTROSTOMY, METHOD OF KADER.
The stomach-wall is inverted by two rows of sutures.
down as the tube is pushed in. Each purse-string is tied successively and
the ends cut. The ends of the outer suture after being tied are then tied
about the tube to prevent it from slipping. All of these sutures should be
tied rather tightly. They invert an area of the stomach wall and the tube
appears inside of the stomach at the apex of a cone.
The stomach is then fixed by two sutures, one above and one below the
tube, passed through the peritoneum and posterior sheath of the rectus
(Fig. 1398). These are tied and the peritoneum and other structures su-
tured as usual.
The tube which is fixed in the stomach is cut so as to leave about 7.5 cm.
(3 inches) outside of the body. This is clamped. When it is desired to feed
the patient, a second tube is connected with it, and fluid poured in through
a funnel. In about ten days the tube will be found to be loose. It may then
734 SURGICAL TREATMENT
be removed and a clean one introduced. A tube should be left in constantly,
otherwise the opening is apt to become permanently contracted.
Water, milk, eggs, broths, porridges and soups may 'be fed in this way.
Some patients prefer to masticate their food and feed themselves through the
tube. The mouth and teeth should be kept well cleansed.
The method of Kader for performing this operation consists in making a
fold instead of a cone, the stomach wall being inverted by two rows of sutures
(Fig. 1399).
Gastrostomy through an external cone is done by a modification of the
method of Franck. An incision 7.5 cm. (3 inches) long is made parallel to
the left costal border and about 4 cm. (i^ inches) from it. The upper end
of the incision is near the median line. The rectus fibers are separated
vertically by blunt dissection and the peritoneum opened. A second in-
FIG. 1400. — GASTROSTOMY.
Modification of method of Franck. A cone of stomach is drawn out through a second
small wound in the abdominal wall and sewed fast.
cision 2 cm. (% inch) long is made parallel to the first about 2.5 cm. (i inch)
above the costal margin, and carried through the skin and superficial fascia.
The skin between the two incisions is undermined. The stomach at the
cardiac end is picked up and pulled out far enough to reach the smaller open-
ing, and fixed to the peritoneum and fascia by four sutures. The apex of
the part grasped is then drawn under the skin to emerge at the smaller open-
ing (Fig. 1400). This forms a cone with its apex at the small opening
and its base at the larger. The apex is fixed to the fascia and skin by four
sutures. The opening of the stomach may be made after a day or two, or
a purse-string suture may be introduced and a catheter inserted at once.
This operation is an unnecessary complication of what should be a simple
procedure. It violates the surgical principle that, an operation to accomplish
THE ABDOMEN
735
FIG. 1401. — GASTROSTOMY. OPERATION OF WITZEL.
FIG. 1402. — GASTROSTOMY. OPERATION OF WITZEL.
Tube inserted and sutures tied.
736
SURGICAL TREATMENT
its purpose should disturb the natural arrangement of structures as little as
possible.
Gastrostomy by canalization of the stomach wall is done after the principle
of Witzel. The stomach is exposed by a lo-cm. (4-inch) incision between the
fibers of the left rectus muscle between the umbilicus and sternum. It is
brought into the wound and a rubber tube or catheter (about 22 French)
is laid upon its anterior wall and buried for 6 or 7 cm. (2^ inches) by a con-
tinuous seromuscular suture. This should be in the middle of its anterior
wall, the tube lying in the direction of the long axis of the stomach. At the
upper end of this line of suture an opening, just large enough to admit the
tube, is made through the stomach wall (Fig. 1401). The end of the tube is
FIG. 1403. — GASTROSTOMY.
Operation of Witzel completed. The tube lies in the stomach and is clamped to prevent
the escape of stomach contents.
then introduced into the stomach, and this part of the tube and opening
covered in with about four interrupted sutures, which should have been
introduced before the opening is made (Fig. 1402). Gould has called at-
tention to the desirability of having the stomach opening toward the cardia.
The tube may be buried by two rows of sutures if it is thought best. Many
surgeons perform this operation with the tube passing in the direction of
the pylorus — downward instead of upward. By using a larger tube, 25 or
30 French, a larger variety of food can be given.
The stomach is fixed to the abdominal wall by sutures passed through the
seromuscular coats in the region of the tube and through the peritoneum and
deep fascia. To prevent the stomach dropping away from the wound two
of these sutures should pass through the anterior sheath of the rectus. The
THE ABDOMEN 737
tube emerges at the part of the wound where it lies most easily, and the
abdomen is closed in the usual way.
The tube should project for about 5 cm. (2 inches) within the stomach, and
be fixed by one of the abdominal wall sutures so that it cannot slip out for
about a week. It should be clamped to prevent the escape of stomach
contents (Fig. 1403). After a week it may be removed, and then introduced
only for feeding. If too long an interval is allowed between the times of
passage of the tube, the canal may be expected to close.
Patients upon whom gastrostomy is done are usually much in need of
nourishment. For this reason in undernourished patients the tube when it
is first introduced should be passed immediately on through the pylorus
into the duodenum. After it has been fixed and the operation completed
FIG. 1404. — PYLORODIOSIS.
The pylorus is stretched by pressing the finger through it from the stomach toward the
duodenum.
the patient may be given food which has been predigested with pepsin and
hydrochloric acid. This may be done at once without fear of placing strain
on the sutures. It may be left in the duodenum several days if necessary.
The technic for the application of purse-string sutures is given under
Intestinal Sutures, page 626; and Vol. I, page 201.
Pylorodiosis consists in enlarging the outlet of the stomach by stretching.
In malignant or cicatricial stricture this operation may give temporary relief.
In some cases of spasm of the pylorus it is a useful procedure. Its field
of application is small, and it is by no means without danger. Rupture of
the duodenum and fatal peritonitis have been attributed to the operation.
Serious bleeding may take place from the mucous membrane.
The operation of Lor eta opens the stomach about 5 cm. (2 inches) from the
VOL. 11—47
738
SURGICAL TREATMENT
pylorus by an incision midway between the two curvatures and parallel
with them. A bougie, finger or other dilating instrument is passed into the
constricted pylorus while the hand steadies the parts. The dilation is
FIG. 1405. — PYLOROPLASTY. FIRST STAGE.
Stomach clamped for operation. Showing line of incision.
FIG. 1406. — PYLOROPLASTY. SECOND STAGE.
The lips of the wound are grasped at the middle with clamps and drawn apart until
the direction of the wound is changed into that of a wound at right angles to the original
incision. In this position it is sewed.
carried up to a little more than the normal size of the pylorus, if it seem safe.
The wound is closed by two layers of sutures.
The operation of Hahn does not involve incision of the parts. The pylorus
is grasped with the left hand, the tip of a gloved finger of the right hand
THE ABDOMEN
739
FIG. 1407. — PYLOROPLASTY. THIRD STAGE.
Result after wound has been closed with two layers of sutures — a through-and-through
suture and a seromuscular suture.
FIG. 1408. — FREEING THE DUODENUM FOR PYLOROPLASTY OR OTHER OPERATION RE-
QUIRING GREATER MOBILITY.
Showing incision in peritoneum just external to duodenum and dissection of inner flap.
740
SURGICAL TREATMENT
engages the wall of the stomach some distance away, and presses it into the
pylorus (Fig. 1404). The fold of stomach to be pressed in should be not too
near the pylorus. At first the little finger may be used. Care should be
taken to engage the center of the pyloric opening and to press to the right
and backward. This is one of the operations in which a cotton glove may
with advantage be worn on the left hand. Not more than two fingers
should be introduced.
Pyloroplasty is indicated as the operation of choice in (i) simple pyloric
stenosis; it is of value in treating (2) ruptured pyloric or duodenal ulcer;
it is indicated in the treatment of (3) pylorospasm in cases in which no definite
cause can be found; and it serves all the purposes of gastroenterostomy in
dealing with (4) ulcers of the stomach and duodenum, which are near the pylo-
rus, and at the same time it permits dealing directly with the ulcer.
Pyloroplasty by a single incision is done according to the method of Hein-
eke and Mikulicz. The abdomen is opened by an incision between the ster-
FIG. 1409. — PYLOROPLASTY. OPERATION OF FINNEY. FIRST STAGE.
Showing position of traction sutures as the first step in the no-clamp operation.
num and navel. Adhesions about the pylorus are separated and clamps
applied above and below, about 7.5 cm. (3 inches) from the stricture.
The upper clamp is applied to the stomach with the posterior blade penetra-
ting the gastrocolic omentum. An incision, about 2 cm. (% inch) long, fol-
lowing the natural curve of the canal, is made in front of the pylorus from the
stomach to the duodenum. The interior of the pylorus is then inspected,
and the incision is carried in either direction until healthy stomach and duo-
denum appear at its extremities. Redundant mucous membrane is cut away.
The incision may be 5 cm. (2 inches) long (Fig. 1405). The middle of each
lip is then grasped with narrow forceps, and drawn apart as far as possible.
This causes the ends of the incision to approach (Fig. 1406). The wound
is then sutured in this position, at a right angle to the original incision,
with two layers of sutures as for gastrotomy (Fig. 1407).
For stenosis the incision may be as long as 7.5 cm. (3 inches). The
center should be at the pylorus.
This operation is done for benign contractures, such as follow pyloric
THE ABDOMEN
741
ulcer. If there is much thickening, the operation may be difficult, and a dia-
mond-shaped resection may be necessary in order to secure good approxima-
tion of the wound. Mayo has called attention to the fact that dense adhe-
sions commonly follow the operation, which fix the pylorus in an abnormally
high position. The operation should not be done if active ulceration and
inflammation are present; nor can it be done where dense adhesions fix the
pylorus. Moynihan regards it as an unsatisfactory operation. Most
surgeons are agreed that it has a field in cases of narrow constriction, with a
FIG. 1410. — PYLOROPLASTY. OPERATION OF FIXXEY. SECOXD STAGE.
The pyloric, duodenal and gastric traction sutures have been applied, and the posterior
seromuscular suture is in process of application.
healed mucosa, and without dense perigastric adhesions. Of the cases oper-
ated upon by this method, about one-third have required subsequent opera-
tions for the relief of pyloric obstruction. This has been largely because the
incision was too short.
Pyloroplasty combined with gastroduodenostomy is an operation devised by
J. M. T. Finney (Bulletin Johns Hopkins Hosp., July, 1902). It is one of the
most useful operations in gastric surgery, and is destined to play a larger
role than has yet been its lot. An incision is made to the right of the median
742
SURGICAL TREATMENT
line, its lower end at the level of the navel. It should be about 10 cm.
(4 inches) long, and the pyloric region exposed. Adhesions should be divided.
In order to give the duodenum greater mobility, so that it may be displaced
inward, the peritoneum lying to the outer side of the descending part should
be divided. This incision to the right of the duodenum divides vertically
the delicate layer of peritoneum in front of the right kidney as it is about to
FIG. 1411. — PYLOROPLASTY. OPERATION OF FINNEY. THIRD STAGE.
Thev posterior seromuscular suture has been applied. The anterior layer of mattress
sutures is to be retracted by hooks.
pass to form the upper layer of the transverse mesocolon at the hepatic
flexure. The incision ends above at the entrance to the foramen of Winslow.
The duodenum may now be drawn inward, being raised from the vertebral
column and the great vessels. If further relaxation is necessary the incision
may be carried downward through the upper layer of the transverse meso-
colon, and upward to divide the anterior peritoneal layer of the extreme
THE ABDOMEN 743
right edge of the gastrohepatic omentum. This latter division is carried
across the suspensory ligament of the pylorus (Fig. 1408). At first it may
seem that the pylorus and duodenum are so fixed that the operation cannot
be done, but by division of the peritoneum and careful blunt dissection the
operation becomes easily possible.
After about 7 or 8 cm. (3 inches) of duodenum have been freed sufficiently
to permit the duodenum to be placed against the pyloric end of the stomach,
'
FIG. 1412. — PYLOROPLASTY. OPERATION OF FINNEY. FOURTH STAGE
The anterior row of seromuscular mattress sutures are retracted above and below and the
stomach and duodenum incised.
a suture to be used for traction is applied in the upper wall of the pylorus.
A second traction suture is placed in the anterior wall of the stomach and a
third suture in the anterior wall of the duodenum (Fig. 1409). These
last two sutures should be at points equidistant from the duodenal suture
(about 12 cm.) and mark the lower ends of the duodenal and gastric incisions
respectively. Traction is then made upward on the pyloric suture and down-
ward on the two other sutures. The two folds are brought together and su-
744
SURGICAL TREATMENT
tured as for lateral anastomosis with a continuous suture. Silk is commonly
used (Fig. 1410).
After the posterior suture has been completed and tied, the anterior
layer of seromuscular sutures is inserted. This should be a row of inter-
rupted mattress sutures which are not tied but hooked out of the way with
an aneurism needle above and below (Fig. 1411).
The incisions in the stomach and duodenum are then made. The opening
planned for should be about 10 cm. (4 inches) long. These are the same
incisions as for lateral anastomosis excepting that they are connected above
FIG. 1413. — PYLOROPLASTY. OPERATION OF FINNEY. FIFTH STAGE.
Through-and-through suture in process of application.
at the pylorus (Fig. 1412). Hemorrhage is checked. The redundant mu-
cous membrane is trimmed off. Ulcers are looked for and if present excised.
The two edges of the spur are sewed together by a continuous through-
and-through suture of catgut starting at the pylorus and continuing to the
base (Fig. 1413). From this point it continues to unite the front of the
opening ending at the pylorus. (Finney omits this anterior suture.) It
should be interrupted at intervals by a tie. Chromicized catgut is used
for the suture which passes through the mucous membrane. The
THE ABDOMEN
745
seromuscular mattress sutures are then tied completing the anastomosis
(Fig. 1414). If a complete anterior through-and-through suture has not
been applied there should be added to the anterior serosa suture a second
layer of continuous sutures (Fig. 1415).
FIG. 1414. — PYLOROPLASTY. OPERATION OF FINNEY. SIXTH STAGE.
Completion of operation by tying mattress sutures.
A
FIG. 1415. — PYLOROPLASTY. OPERATION OF FINNEY.
Diagram showing result of operation. A, Before operation; B, after operation.
This operation may be done with clamps as employed in lateral anastomo-
sis. The operation with clamps has the advantage that the parts are more
firmly held and bleeding during the operation is not a factor (Figs. 1416 and
1417).
746
SURGICAL TREATMENT
FIG. 1416. — PYLOROPLASTY WITH CLAMPS.
The stomach and duodenum are each grasped by the clamps.
PIG. 1417. — PYLOROPLASTY WITH CLAMPS.
The posterior seromuscular and through-and-through sutures have been applied. The
anterior through-and-through suture is in process of application.
THE ABDOMEN
747
Moynihan used an angular clamp (Fig. 1418) which gives more room and
better apposition. He advised the operation in cases in which pyloric
spasm is a prominent symptom, and where an ulcer is located near
the pylorus. He regards gastro-enterostomy as easier and safer in the
ordinary cases of pyloric stenosis with dilatation and hypertrophy of the
stomach. All of these opinions are probably modified by the fact of greater
experience with gastrojejunostomy. A surgeon who has had as much experi-
ence with this operation as with gastrojejunostomy should find it just as
easily performed.
Gastroduodenostomy was done by Kocher through an oblique incision
beginning at the middle line and passing 4 cm. (i% inches) below and paral-
lel to the right costal border. Everything is divided in this line, excepting
that in muscular patients the transversalis muscle is split. A pad is placed
under the liver and the organ retracted upward. The stomach and colon
are held aside. The thin peritoneum in front of the right kidney is divided
by a vertical incision 4 cm. (i^ inches) external to the
second part of the duodenum. This incision is carried
downward through the upper layer of the transverse meso-
colon as far as the blood-vessels, after the method de-
scribed for pyloroplasty combined with gastroduodenos-
tomy (page 741). By blunt dissection with the finger
passed into this wound, the duodenum is displaced forward
and inward, separating it from the vertebral column, vena
cava and aorta. The clamps for lateral anastomosis are
placed so that the opening in the stomach shall be about
2 cm. (% inch) from the greater curvature parallel to it,
and as near the pylorus as the disease will permit. The
opening in the duodenum should be made on its anterior
surface. The technic is the same as for lateral anastomosis
of the intestines (Fig. 1419).
Pylorectomy is done for carcinoma of the pylorus, in
cases in which a cure of the disease seems possible. It may
be done for ulcer in cases in which gastro-enterostomy can-
not be accomplished with facility, and in which the area
of ulceration and induration is extensive. When done for
carcinoma, the lymphatic relations should be borne in mind
(see Anatomy of Stomach, page 698).
A small incision is made midway between the ensiform
cartilage and the umbilicus. Two fingers are introduced,
and if the disease is found to be inoperable the wound is closed. If opera-
tion is decided upon, the wound is enlarged up to 10 or 13 cm. (4 or 5
inches). The gastrohepatic omen turn is doubly tied close to the liver for a
sufficient distance and cut between the ligatures. This frees and exposes
the pyloric end of the stomach.
The control of hemorrhage is the next step. The four blood-vessels
supplying the pylorus should be tied. The gastric artery is tied doubly and
cut about 2.5 cm. (i inch) below the cardiac orifice as it courses to the lesser
curvature between the layers of the lesser omentum. The superior pyloric,
coming from the hepatic artery, is doubly tied and divided. By passing
the fingers beneath the pylorus the gastrocolic omentum is raised from
the transverse mesocolon, and ligation of the right gastro-epiploic or the
gastroduodenal artery is accomplished. The left gastro-epiploic is then
tied at the point to which the resection is to be carried; and the gastrocolic
omentum is tied and divided. In ligating the gastroduodenal artery and the
FIG. 1418. —
ANGULAR CLAMP
OF MOYNIHAN FOR
PYLOROPLASTY.
748
SURGICAL TREATMENT
gastrocolic omentum the structures should be lifted forward in order to
avoid the middle colic artery which passes beneath the transverse mesocolon
(Fig. 1420).
FIG. 1419. — GASTRODUODENOSTOMY.
The posterior seromuscular suture has been applied. The dotted lines show the places
of incision. Note that the duodenum has been mobilized by incision and dissection of the
peritoneum external to it.
FIG. 1420. — PYLORECTOMY. FIRST STAGE OF OPERATION.
The gastrohepatic omentum has been tied and cut. Dotted lines show places of incision.
The duodenum is doubly clamped and divided between with the cautery.
A running suture is applied through the distal stump and tied. The clamp
THE ABDOMEN
is removed. A purse-string suture, applied 2 cm.
of the stump is tied down to invert the free end.
749
inch) below the end
FIG. 1421. — PYLORECTOMY. OMENTA TIED AND CUT. ALL CLAMPS IN PLACE READY FOR
THE RESECTION.
Distal stump of duodenum has been closed.
FIG. 1422. — PYLORECTOMY. RESECTION HAS BEEN DONE.
All clamps have been removed except last stomach clamp. Continuous suture applied
to cut edge of stomach.
A long rubber-covered stomach clamp is then caused to grasp the stomach
between the point at which the gastric artery was tied and the point of
ligation of the left gastro-epiploic. This clamp should not be closed so tightly
750
SURGICAL TREATMENT
as to damage the tissues. A second clamp, which need not be covered, is
applied on the tumor side. The stomach is then divided with the cautery
or scissors i cm. (^ inch) from the upper clamp. It is well to catch the edge
of the stomach in several places with toothed forceps as it is divided, to
prevent the retraction of its edges through the jaws of the clamp (Fig. 1421).
The pyloric segment of the stomach, held by a clamp at each end is removed.
The edge of the stomach remaining is then sewed over-and-over with a
continuous suture from the greater to the lesser curvature and thence back
again to the starting point and the ends of the suture tied. This suture
passes through all the coats of the stomach, and prevents bleeding as well
as leakage (Fig. 1422).
The clamp is then removed, and any point that bleeds is caught and tied.
A continuous suture, involving only the seromuscular layers, is then applied
FIG. 1423. — PYLORECTOMY. OPERATION ABOUT COMPLETED.
Posterior gastroenterostomy shown in dotted lines.
sufficiently far from the first suture to allow easy covering of the free edge.
The operation is then continued by making a posterior gastrojejunostomy
(Fig. 1423).
Billroth left the duodenum open, reduced the size of the stomach opening,
and made a direct anastomosis of the duodenum and the lower end of the
stomach (Fig. 1424). The results of this operation at first were not good.
He then tried closing both viscera and doing gastrojejunostomy in the
ordinary way. This latter operation has given the best results, although
in suitable cases in which the operation can be done without tension, the
end-to-end anastomosis is now employed by some surgeons with much
success.
W. J. Mayo preferred the gastro-enterostomy, as there is no tension and
the operation is done with uninjured tissues. The posterior operation is done
if the patient's condition is good. If haste is necessary, anterior gastro-
jejunostomy is indicated. If great haste is necessary the anastomosis may
be done with a button.
THE ABDOMEN
751
Gould showed that the tendency of the mucous membrane to project
may be obviated by cutting the stomach wall obliquely so that more of the
mucosa is cut away than the seromuscularis. Drainage should only be
used if there has been accidental soiling of the wound (for After-treatment,
see page 776).
Resection of the pyloric end of the stomach (partial gastrectomy and
pylorectomy) in the hands of experienced surgeons gives a mortality of 8 or 10
per cent. Assuming a growth, the center of which is in the last third of the
stomach close to the middle third on the anterior wall at the lesser curvature,
the operation should consist of resection of the distal half of the stomach.
The technic of operation as practised by W. J. Mayo and described by him
(Jour. Am. Med. Assoc., May 14, 1910) is as follows:
The lesser peritoneal cavity is opened through the gastrohepatic omentum.
The superior pyloric artery is ligated in two places as far as possible from
the duodenum and cut between the ligatures. The superior border of the
FIG. 1424. — PYLORECTOMY WITH END-TO-END ANASTOMOSIS OF STOMACH AND DUODENUM
duodenum is thus freed for a distance of 4 or 5 cm. (i}^ or 2 inches). The
object of this step is to include the glands which lie beside the artery. It
should be remembered that the common bile duct lies close to the artery and
must not be injured.
Adhesions of the stomach or duodenum to the liver should be separated.
The stomach should be drawn downward and to the right and the gastric
artery caught and ligated close to the celiac axis. This artery is best tied
by passing a ligature in a needle and tying securely. The anterior and
posterior gastric branches should be caught and tied so that the fat and
glands and distal part of the vessel can be dissected free from the upper part
of the lesser curvature, exposing a space 3 cm. (i J£ inches) in extent next to
the cardiac orifice. This dissection should be made very carefully because
of the probable involvement of this region. The whole of the lesser curvature
right up to the cardia should be included in the resection.
The greater curvature should be examined for the lymphatic glands.
Even when not carcinomatous these glands are usually visible. Double
ligatures should be tied about the left gastro-epiploic vessels to the left of
752
SURGICAL TREATMENT
the glands and cut between. The anterior and posterior gastric vessels
should be tied as they pass from the stomach. The greater curvature should
thus be cleared or a distance of at least 3 cm. (i^ inches). The trans-
verse colon is drawn into view so that the middle colic artery can be examined
at intervals to avoid injury, and the gastro-epiploic vessels tied with the
gastrocolic omentum in sections from left to right sufficiently close to the
transverse colon to leave the glands lying on the vessels of the greater curva-
ture by a good margin. If it be found that the avascular area, which lies
in the circle of the middle colic vessel and the posterior layer of the mesocolic
peritoneum, is attached to the growth, the attached peritoneum may be cut
out and removed with the growth. The opening thus made in the transverse
mesocolon may be used later through which to make the gastrojejunostomy.
As the dissection proceeds to the right, the middle colic artery is exposed
and traced to its origin in the superior mesenteric artery just at the lower
FIG. 1425. — PARTIAL GASTRECTOMY.
The vessels have been tied and the omenta divided.
edge of the pancreas, otherwise it may be accidentally injured. Mayo states
that Kronlein has shown that in three out of four cases obliteration of the
middle colic vessel will lead to gangrene of a portion of the transverse colon
and necessitate a coincident resection.
The next step in the operation is removal of the inferior gastroduodenal
glands which lie below and to the right of the pylorus about the head of the
pancreas and in the curve of the duodenum. The gastrocolic omentum is
tied in sections close to the transverse colon, the fat and glands are lifted up
from over the head of the pancreas, and the blood-vessels, anastomosing
with the branches of the superior pancreatoduodenal artery, are tied. Sepa-
ration is continued upward, clearing the inferior border of the duodenum
for at least 5 cm. (2 inches) until the gastroduodenal artery is reached in
the groove between the head of the pancreas and the duodenum behind
the pylorus. Division of these vessels allows raising in one piece all this
group of glands (Fig. 1425).
THE ABDOMEN
753
Next the posterior surface of the upper duodenum is separated from the
pancreas. If the pancreas is adherent to the gastric growth, a piece is
shaved off, allowing it to remain attached to the growth by adhesions. In
some cases it becomes necessary to remove more or less of the pancreatic
structure. If the involvement is extensive Mayo thinks it is better to leave
this part of the operation until the stomach is either cut across and separated
from the duodenum, or the line of stomach section on the cardiac side is
finished and the stomach turned over in order that this portion of the dis-
section may be completed under inspection. If such injuries to the pancreas
are properly cared for, he has not found that they give rise to serious conse-
quences. As a rule these operations are more serious as they become exten-
sive but he has not found any special mortality due to operable pancreatic
complication. The method of treating such an injury to the pancreas is
FIG. 1426. — PARTIAL GASTRECTOMY.
Clamps are placed to isolate the segment to be resected.
to cover it as far as practicable with the sheath and posterior peritoneum,
and after completely closing the end of the duodenum, if possible, the stump
of the duodenum should be buried in the wounded surface of the pancreas.
It will usually be found that the duodenum beyond the pylorus is not
involved to any considerable extent, but to make sure it is best to remove
about 2.5 cm. (i inch) of it. Compression forceps are placed next to the
pylorus, and 1.3 cm. (^ inch) below this clamps are placed on the duo-
denum. The duodenum is divided between, and both raw surfaces cauter-
ized with the actual cautery. The pyloric end of the stomach is then
turned over on the left side of the patient. The stump of the duodenum
is sutured with a continuous catgut suture. The clamp is removed. About
2 cm. (% inch) below this a purse-string suture is placed about the duo-
denum, the ends of the catgut strands are cut short and the duodenal stump
VOL. 11—48
754
SURGICAL TREATMENT
invaginated in a manner similar to the stump of an appendix in appen-
dectomy. A second suture is now placed on the duodenum; behind, it
catches the pancreatic sheath so that the stump may be buried against the
head of the pancreas. Finally the stumps of the adjacent tied gastrocolic
and gastrohepatic omenta are so adjusted by fine sutures as to give further
protection. The field of operation is searched for bleeding points and
protected with gauze.
Next the stomach is drawn to the right and holding clamps placed from
the space cleared on the greater curvature to the space cleared on the lesser
curvature. When the stomach is cut across these clamps sometimes slip
near the cardia and the stomach retracts. To prevent this Mayo uses a
pair of bayonet holding clamps which are placed on the proximal side from
above downward, grasping the upper part of the stomach halfway across. A
FIG. 1427. — PARTIAL GASTRECTOMY WITH ANTERIOR GASTRO-ENTEROSTOMY.
The pyloric end of the stomach has been removed, the duodenum closed and the jejunum
anastomosed anteriorly to the stomach.
clamp is now placed distally to prevent leakage from the end to be amputated,
and the stomach divided between. The divided proximal gastric surface is
cauterized with the actual cautery and the stomach turned in by a continu-
ous chromic catgut suture beginning on the greater curvature. This suture
is applied quite tightly. It starts on the mucous surface, passes through
all the coats to the peritoneum and back on the opposite side through all
the coats to the mucous membrane, and is then tied and the end cut.
The suture now passes through all the coats from the mucous to the peri-
toneal coat and begins on the opposite side by passing through all the coats
from the peritoneum to the mucous and then back on the same side from the
mucous to the peritoneum. This is repeated on alternate sides until one-
THE ABDOMEN
755
half or two-thirds of the stomach is closed. The cut margins now approach
the transverse holding clamp so closely that inversion can not be accom-
plished. This clamp is removed and the bayonet clamp, which grasps the
upper part of the stomach to the left of the cardia, is depended on during
the completion of the suture. A half dozen mattress tension sutures of
medium-sized linen are now placed, turning in the catgut row, and over this
a continuous suture of fine linen is applied (Fig. 1426).
Continuity of the gastro-intestinal canal is best secured by a posterior
gastrojejunostomy with the jejunum passing to the left and as short as will
FIG. 1428. — GASTROJEJUNOSTOMY FOLLOWING RESECTION OF PYLORIC END OF STOMACH.
Note that the size of the stomach orifice is reduced by suturing from above.
permit the intestine to reach the stomach without tension. In some cases
the remaining pouch of the stomach is so small that anterior gastrojejun-
ostomy on a 45-cm. (i 8-inch) loop, the jejunum running to the right, can be
done more easily and quickly and has given equally good results in Mayo's
hands (Fig. 1427).
The two-row suture method is preferred in performing gastro-enterostomy.
But in addition to this it is recommended to stitch the intestine to the stom-
ach 2.5 cm. (i inch) above the proximal side with a mattress suture. A
756 SURGICAL TREATMENT
second mattress suture is placed about 2 cm. (% inch) from the distal side,
holding the intestine to the stomach. The object of this is to prevent the
intestine from kinking at the anastomosis. It is possible in some cases
to connect the duodenum directly with the stomach pouch. This can not
often be done in operations for cancer, but it can commonly be practised in
resections for ulcer. Mayo prefers closing the duodenal stump and doing an
independent gastro-enterostomy.
The radical operation for cancer of the pyloric end of the stomach
should begin with removal of the groups of lymphatics adjacent to the dis-
ease, and the ligation of the four vessels. W. J. Mayo proceeded in some
cases after the method of E. Polya (Surg., Gyn. & Obst, xix, 1914). The
diseased segment of the stomach is removed as above described. The
stump of the duodenum is closed. An opening is then made in the transverse
mesocolon and the upper part of the jejunum drawn through the opening.
FIG. 1429. — RESECTION OF CARDIAC END OF STOMACH FOR CANCER.
Showing lines of incision and upward displacement of diaphragm.
The stump of the stomach which is held in a crushing clamp and the raw
edges of which have been cauterized is placed at the side of the loop and
united by the serosa-to-serosa suture of fine silk as is done for gastro-enter-
ostomy (Fig. 1428). If the opening in the stomach is larger than is needed,
it can be reduced as the suture is applied.
Rubber-guarded holding clamps are then applied to the stomach and
intestine, the crushing clamp is removed, the jejunum incised, and the
through-and-through suture of chromicized catgut is applied around the
whole circumference of the opening. The outer serosa suture is then com-
pleted. The anastomosis is then drawn through the opening in the trans-
verse mesentery and the margin of the opening fastened to the wall of the
stomach by a number of sutures.
Resection of the cardia for carcinoma can usually be done entirely through
the abdomen, but in some cases so much of the esophagus is involved that
a thoracic operation for resection of the lower esophagus must be added. For
THE ABDOMEN
757
gaining better access to the vault of the diaphragm, in addition to the
abdominal incision, an incision may be made along the free border of the ribs
on the left side and the seventh costal cartilage divided near the sternum.
(See also operations for gaining access to the lower end of the esophagus,
page 458.) By freeing the esophagus from the diaphragm, it is possible in
many cases to draw it down 3 or 4 cm. (1^4 or i^ inches) or more. As a
matter of fact it is the upward displacement of the diaphragm with re-
tractors that must be counted upon to give access to the esophagus. It is
really easier to pull the stomach up into the thorax than to pull ,the
esophagus down into the abdomen.
When sufficient mobility can be secured and the disease does not extend
high, after the resection the stomach wound may partially be closed and the
esophagus anastomosed at the left end of the stomach (Fig. 1429). Gastros-
FIG. 1430. — RESECTION OF CARDIAC END OF STOMACH COMPLETED.
Gastrostomy has been added and the tube passed into the duodenum.
tomy should be added, and the tube placed in such a position that it can be
passed through the pylorus into the duodenum. After the operation duo-
denal feeding should be practised, and the stomach occasionally cleansed
with sterile water (Fig. 1430).
In a case operated upon by Kiimmell (Verhandl. Deutsch. Gesells. f.
Chir., 1910) there was so much separation after the resection that anastomosis
could not be done. A tube connected with the esophagus was brought out
through the wound for drainage, and a tube connected with the stomach
was used for feeding. Later a single tube was inserted to connect esophagus
and stomach. In a case such as this a loop of intestine may ultimately be
used to complete the connection.
W. Meyer (Annals of Surg., December, 1915) advocated a two- or three-
stage operation. The first operation begins with abdominal exploration with
special reference to examination of the cardia, and closes with gastrostomy.
758
SURGICAL TREATMENT
The second operation consists of excision of the tumor and establishment of
a new exit for the esophagus, either laterally in the axillary line of the chest,
or the whole proximal esophagus may be brought out of the mediastinum
and implanted under the skin down the front of the thorax. This latter
operation may be divided into two operations. This program means a
transpleural operation. The esophagus is reached by subperiosteal resec-
tion of the sixth to the twelfth ribs. By connecting the esophagus, which
is stitched to the skin, with the gastrostomy fistula, by a long tube, the
patient may drink fluids (Fig. 1431).
Ach, of Munich, performed a one-stage operation as follows: Through
a left oblique abdominal incision the cardia is examined. .The esophagus
is then exposed in the left side of the neck (see Cervical Esophagotomy,
page 442), isolated, a tape passed around it, and the wound tamponed.
The tumor is next exposed through the abdomen and isolated from its
surrounding connections. The best exposure is secured by continuing
FIG. 1431. — RESECTION OF CARDIAC END OF STOMACH FOR CANCER.
Showing possibilities of connecting stump of esophagus and stomach by means of an ex-
ternal rubber tube as practised by J. H. Zaaijer of Leiden.
an incision from the epigastrium opposite the eighth left cartilage, downward
and outward to the tip of the eleventh rib, thence upward and backward to the
eighth interspace in the midaxillary line. The eighth, ninth and tenth ribs
are divided in the axillary line, and the costal cartilage of the seventh near
the sternum. The flap is retracted upward, the esophagus clamped and
divided. The ligated esophagus is then dissected free in the posterior
mediastinum, brought out through the neck wound, the esophageal opening
in the diaphragm closed, and the esophagus implanted under the skin at the
left of the sternum. The resection of the stomach is then completed at a safe
distance beyond the disease, the stomach wound closed, and a gastrostomy
done after the method of Witzel, the tube being brought out and later
connected with the extrathoracic esophagus.
For bringing the diaphragm well into view it is desirable that the dorsal
spine should be in strong lordosis. This may be accomplished by placing
sand-bags behind the lower dorsal region or by using an operating table
THE ABDOMEN 759
which is capable of lowering both ends of the spine while remaining fixed at the
center. The extraction of the esophagus is best done by inverting it in
itself.
For further information on the subject the reader is referred to Meyer's
admirable article, cited above.
Resection of gastric ulcer, whether done at the pylorus or elsewhere, is
best accomplished by an incision removing an elliptic piece of the wall of
the stomach. The ellipse should contain the indurated tissue external to
the ulcer. Usually it should have its long axis in the direction of the axis
FIG. 1432. — PARTIAL GASTRECTOMY.
Vessels tied; omenta cut; clamps applied; scissors cutting stomach.
of the stomach. At the pylorus this wound may usually be a part of the
wound needed for pyloroplasty by the method of Finney. After simple
excision the wound should be closed with two layers of sutures as for gastrot-
omy (page 730).
A small ulcer at the pylorus should be excised, and if gastro-enterostomy
is not done the wound should be closed transversely so as to prevent narrow-
ing of the pylorus. After excision of a large ulcer at the pylorus pyloroplasty,
gastroduodenostomy or gastrojejunostomy should be done.
Partial gastrectomy consists in resection of some portion of the stomach
wall. It is applied usually for malignant disease, ulcer or stricture. The
technic is essentially the same as that described above for resection of the
760
SURGICAL TREATMENT
pyloric end of the stomach. Operating for malignant disease, the stomach
is exposed by a median incision as for pylorectomy, and examined. It is
withdrawn from the abdomen, and the lines of resection determined. The
vessels of the greater and lesser omentum running to the part of the stomach
to be resected are doubly ligated. The omentum is divided between these
ligatures. This frees the stomach along its lesser and greater curvatures.
At the ends of the openings in the omenta the vessels of the stomach are
doubly ligated and cut— these are the gastric artery at the lesser curvature
and the epiploic vessels along the greater curvature. Two straight stomach
FIG. 1433. — PARTIAL GASTRECTOMY.
The diseased segment has been removed and. the cut ends approximated. The first
half of the seromuscular suture has been applied. The through-and-through suture has
been begun. Showing method of reducing size of the opening in the cardiac segment.
clamps, about 2.5 cm. (i inch) apart, are then placed on either side of the
diseased part (Fig. 1432).
Gauze pads are passed behind the stomach, and the diseased segment
is cut away close to the two middle clamps. For this purpose scissors or the
cautery knife may be used. Care should be taken not to soil the field of
operation. The cut edges should be wiped clean. Having removed the
resected portion, the free edges of the stomach are then brought together
and placed in position for suturing. The cardiac end is usually larger than
the pyloric end, and should be equalized by partially suturing one end of the
THE ABDOMEN
761
opening. A continuous seromuscular suture is first applied to the posterior
half of the stomach. This suture is tied at the upper and lower ends and left
long. A through-and-through suture of all of the coats of the stomach is
then applied throughout the entire circumference of the openings (Fig. 1433).
Some surgeons apply two such sutures in order to be sure that bleeding is
controlled. Whether one or two are inserted, the suture should be tied or
looped about at frequent intervals to prevent unequal drawing. When the
through-and-through suture is completed, the second or anterior half of the
seromuscular suture should be inserted. The clamps are removed. The
gauze is taken away and the omental openings closed by a few sutures (Fig.
I434)-
FIG. 1434. — PARTIAL GASTRECTOMY.
Showing result of operation.
If reunion
This is partial gastrectomy with reunion of the stomach wall,
cannot be done then gastro-enterostomy is called for.
Total gastrectomy is rarely indicated. When much of the stomach is
involved in disease, the disease usually has spread beyond the stomach,
contraindicating gastrectomy; and if the disease has not so widely extended,
then usually some of the stomach wall can be preserved. The details of the
operation are essentially the same as will be found described under resection
of the pyloric end of the stomach or partial gastrectomy (pages 747 and
751).
The stomach is exposed by median incision. The gastrohepatic omentum
762
SURGICAL TREATMENT
is ligated doubly, from the duodenum to the esophagus, at eight or ten points.
The gastrocolic omentum is similarly ligated along the greater curvature.
The gastrophrenic and gastrosplenic omenta are also divided. The four
main arteries supplying the stomach are ligated and divided as the ligation
of the omenta progresses. These vessels are the gastric, the pyloric, the
gastro-epiploica dextra, and the gastro-epiploica sinistra. Gauze pads are
placed behind the stomach. The duodenum is then clamped with two clamps
and divided between. The stomach is freed up to the esophagus, where
two clamps are placed and the stomach cut away.
If the duodenum can be brought up to the esophagus an end-to-end
anastomosis is made. The duodenum may be freed as described for gastro-
duodenostomy (page 739, Fig. 1408). If the duodenum cannot be brought
up to the esophagus without tension then an anastomosis should be made
between the esophagus and a loop of jejunum, and a jejunojejunostomy done
lower down (Fig. 14340).
Gastro-enterostomy is one of the most useful operations performed on
the stomach. Usually the term is limited to anastomosis of the stomach
FIG. 14340. — DIAGRAM OF RESULT AFTER GASTRECTOMY.
The stomach has been removed; the stump of the duodenum is closed; the jejunum is
divided; the distal stump is united to the esophagus; the proximal stump is connected with
the jejunum at a lower point by end-to-side anastomosis.
and jejunum. When other anastomosis is specified it is given a distinguish-
ing name. The object of the operation is to empty the stomach directly into
the small bowel without the passage of its contents through the pylorus. Its
chief indications are in (i) obstruction at the pylorus, (2) disease of the duo-
denum or pylorus requiring rest and freedom from irritation and in (3)
diseases of the stomach in which better drainage of that viscus is required
than can be secured through the pylorus. The operation of choice is done
by the posterior route.
Posterior gastrojejunostomy is best done between the upper part of the
jejunum and the posterior wall of the stomach, the junction being affected by
making an opening through the transverse mescolon. The incision should
begin about 5 cm. (2 inches) below the ensiform cartilage and extend below
the level of the umbilicus. The abdomen is opened about 2 cm. (% inch)
to the right of the median line, by retracting outward the rectus muscle. The
THE ABDOMEN
763
stomach is lifted forward with the transverse colon and the great omentum
and turned upward over the upper end of the abdominal opening. The
omentum is pressed upward and the lower surface of the transverse meso-
colon exposed (for Anatomy, see pages 503 and 769).
The part of the greater curvature which naturally lies lowest is then
grasped by the fingers of the left hand while the right hand presses the trans-
verse colon upward. Pressure upon the posterior wall of the stomach with
the left hand causes the stomach to press against the superior surface of the
transverse mesocolon and cause the under surface of the mesocolon to bulge
about at its middle. A small vertical incision is made in the mesocolon at
FiG. 1435. G ASTRO -ENTEROSTOMY.
The stomach and intestine have been grasped by clamps, approximated, and the first
layer of seromuscular sutures applied.
this point between the blood-vessels. As soon as the opening has pene-
trated both layers of the mesocolon it is enlarged by stretching up to about
7.5 cm. (3 inches) in length. Pressure upon the stomach with the left hand
causes its posterior wall to present at the rent. It is grasped and drawn well
through the opening.
The stomach is then grasped by a pair of stomach forceps including a
fold for anastomosis. The site of the opening should be planned well toward
the pyloric end, at the most dependent part of the stomach on its posterior
wall. That means that it should pass down nearly to the greater curvature.
764
SURGICAL TREATMENT
The opening should be oblique. Its lowest part should be 5 to 7.5 cm
(2 to 3 inches) to the left of the pylorus.
Mayo's rule is that the opening in the stomach shall begin at a point
2.5 cm. (i inch) above the greater curvature on a line with the longitudinal
portion of the lesser curvature and end at the bottom of the stomach 6.5
cm. (2^2 inches) to the left.
The clamps should be applied so that the tips of the blades point toward
the outer side of the patient's left hip and the handles toward the right
shoulder.
FIG. 1436. — SHOWING LOCATION OF INCISION IN JEJUNUM FOR GASTRO-ENTEROSTOMY
The next step is the identification of the end of the duodenum and the
beginning of the jejunum. This is found by passing the hand along the lower
surface of the root of the transverse mesocolon from left to right. The small
intestine will be found emerging through the mesentery just at the right of
the spinal column. ,By drawing the transverse colon forward out of the
abdomen, and making traction to the right and upward, the beginning of
the jejunum is easily brought into view. It should be picked up and the
portion which naturally lies nearest the opening in the transverse mesocolon
should be selected for anastomosis.
The rule should be to make the anastomosis as near the duodenum as pos-
sible without incurring the danger of tension. There should be an easy
THE ABDOMEN
765
relaxation of the loop. It should be borne in mind that an easy anastomosis,
made while the stomach is turned up, may cause tension when the viscera
drop back into their natural places. The clamp should be applied to the small
intestine, grasping a fold of its free border. The fold exposed between the
jaws of the forceps should be about 7.5 cm. (3 inches) long. The nearest point
of this fold should be 7.5 or 10 cm. (3 or 4 inches) from the beginning of the
jejunum. In some cases the distance between the beginning of the jejunum
and the jejunal incision need be only 6 cm. (2% inches). The intestine
should be clamped so that the opening is made parallel to its long axis and on
the antimesenteric side of the bowel.
The two clamps should then be brought together (or a three-bladed
single clamp should be used), placing the fold of stomach beside that of the
small intestine, and the rest of the stomach, intestines, and omentum re-
turned to the abdomen (Fig. 1435). A small gauze pad is placed behind the
two clamps, and the rest of the peritoneal field is covered with towels. The
first half of the seromuscular suture is applied with a curved needle. The sut-
ure'line should be at least 7.5 cm. (3 inches) long — a continuous suture.
FIG. 1437. — GASTRO-ENTEROSTOMY.
Placing through-and-through suture.
Each end should be tied and left long with a needle on each one. Some sur-
geons prefer to make this row of interrupted sutures. If a continuous suture
is used, the ends should be laid aside when the end is reached to be used later in
making the anterior half of the seromuscular stitch. An incision is now made
with a sharp knife through the seromuscular coats down to the mucous
membrane (Fig. 1436). This incision is made in either viscus, about 7 mm.
(% inch) from the seromuscular suture. It should be about 6 cm. (2^
inches) long. The mucous membrane which puffs out in this incision is
grasped by forceps and a strip cut out so that the mucous edge of the wounds
should be even with the seromuscular edges. Careful placing of flat sponges
should prevent soiling of the field during the opening of the stomach and
bowel.
The next step is the application of a through-and-through suture uniting
766
SURGICAL TREATMENT
the stomach and intestine. This should be started at the middle of the
base line and tied (Fig. 1437). For this suture chromicized catgut should be
used. Linen, silk or other nonabsorbable suture should not be left in the mu-
cous membrane, as it is dangerously apt to invite ulceration at the suture
line (see Gastrojejunal Ulcers, page 580).
The suture is continued around the angle of the openings. When the
angle has been passed, the needle on the other end of the suture is taken
in hand and the suture completed. By this method the knot is tied at
the nearer side of the anastomosis, which is better than tying at the angle
where leakage is most apt to occur. For this suture a straight needle and
No. o chromicized catgut is to be preferred. The suture should be fixed
FIG. 1438. — GASTRO-ENTEROSTOMY.
The operation has been completed, and sutures holding the stomach to the mesocolon are
being applied.
occasionally (every third or fourth stitch) by taking a loop about the thread
in order to prevent puckering.
After completing the through-and-through suture, the wound region
should be sponged off gently, the soiled protectors removed, clean towels
put in place, and the surgeon's hands washed. The second half of the sero-
muscular suture is then completed. A curved needle is best for sewing
about the two corners of the wound. Each end is used to sew about its
respective corner. The two approach on the front and are tied and cut.
The clamps are then unlocked and the wound inspected for bleeding. If
the result is satisfactory, the clamps are removed. An extra suture is
placed at each end of the anastomosis line to take the tension from the
THE ABDOMEN
767
suture. The stomach about 13 mm. (}^ inch) from the suture line, is fas-
tened to the rent in the transverse mesocolon by three or four interrupted
sutures, with the object of closing. the opening to prevent intestine entering
it and producing internal hernia (Fig. 1438). To prevent hernia behind^the
upper loop, it is well to suture the afferent loop of jejunum to the lower sur-
FIG. 1439. — GASTRO-ENTEROSTOMY WITH THREE POSTERIOR Rows OF SUTURES.
The first row has been applied, the seromuscularis has been incised, and the second row
is in process of application. (Method of Mayo.)
face of the transverse mesocolon with about four interrupted sutures as
suggested by Moschcowitz and Wilensky (Surg., Gyn. & Obst., September,
W. J. Mayo modified the operation by placing first an interrupted suture
in the seromuscularis; then the incisions were made down to but not through
PIG. 1440. — GASTRO-ENTEROSTOMY WITH THREE POSTERIOR Rows OF SUTURES.
The third row of sutures, involving only the mucosa, is being placed.
the mucous membrane; an interlocking continuous suture of chromic catgut
was then applied through the seromuscularis and covering the first row of
sutures (Fig. 1439) ; the mucous membrane was then incised; and a continuous
row of plain catgut sutures was applied to the mucous membrane (Fig. 1440.1.
By this method three rows of sutures are applied to the posterior union.
768
SURGICAL TREATMENT
F. T. Stewart (Annals of Surg., September, 1917) operated without
clamps. The incision was made through the seromuscularis, and the vessels
of the stomach and intestine each caught by a pair of clamps. The op-
posite intestinal vessel and the opposite stomach vessel were ligated together
by a single ligature around both clamps. This is done on both the posterior
and the anterior lines of union. These ligatures constitute a part of the union
mechanism.
Most surgeons enter the abdomen through the sheath of the rectus
muscle just to the right of the middle line. The round ligament of the liver
should not be injured. When adhesions are present between the stomach and
the mesocolon entrance into the lesser peritoneal cavity may be difficult
or impossible. Blunt dissection may accomplish exposure of the posterior
wall of the stomach sufficient for the anastomosis; or it may have to be aban-
doned and anterior gastro-enterostomy done instead.
FIG. 1441. — GASTRO-ENTEROSTOMY.
Showing position of bowel and stomach after operation.
Occasionally it is necessary to tie a small vessel in the mesenteric rent.
After picking up the beginning of the jejunum, it is well to make some traction
upon it to draw it out of the duodenojejunal fossa.
Adhesions at the beginning of the jejunum may require to be divided to
give freedom of the bowel.
Some surgeons introduce an extra layer of sutures between the two
just described. Half of this is done after incising the seromuscular coats
and before the mucosa is incised. Some surgeons do not cut away redun-
dant mucous membrane, but, after incising the viscera, proceed at once with
•the through-and-through suture. It is the practice of some operators to
loosen the clamps as soon as the through-and-through suture is completed
in order to discover hemorrhage. If bleeding occurs it should be stopped
by interrupted sutures.
THE ABDOMEN
769
The extra suture, applied at either end of the anastomosis to prevent
kinking and relieve the suture line of tension is important. It is neither
necessary nor wise to make a loop or half turn in the bowel at the anasto-
mosis. It should lie in its natural position (Fig. 1441). The jejunum passes
from right to left, and in this position it should be connected to the stomach
(Fig. 1442).
For the inner suture catgut is preferable because nonabsorbable suture
may hang into the lumen of the bowel for a long time. The through-and-
through mattress suture (Connell) is used by some. For the seromuscular
suture celluloid linen (Pagenstecher), paraffined linen, or silk is to be preferred,
although many surgeons use chromicized catgut.
Posterior anastomosis with the Murphy button may be done by the same
technic as described for entero-anastomosis. It has been quite superseded
by the suture method.
Stomach ....••
.Jejunum
Omentum . . .
FIG. 1442. — POSTERIOR GASTRO-EXTEROSTOMY.
Vertical median section of abdomen showing stomach and intestines. Diagram
W. J. Mayo called attention to the band which connects the jejunum to
mesocolon, and sometimes turns it to the right. This band when prominent
requires to be divided (Fig. 1443).
Anterior gastrojejunostomy is done when the posterior operation cannot
be performed because of the presence of adhesions or abnormally short
mesocolon. It is also to be preferred in obstructive cancer of the pylorus
which cannot be removed. The operation is done speedily and safely; but
for permanent drainage of the stomach it does not serve so well as the pos-
terior operation. The abdomen is opened through the sheath of the right
rectus muscle, and the stomach and transverse colon turned up as for pos-
terior gastro-enterostomy. The beginning of the jejunum is identified and
brought forward in front of the great omentum and colon. The bowel is
followed down to a point which can be brought up to the stomach without
tension. This is usually from 30 to 45 cm. (12 to 18 inches) from its begin-
VOL 11—49
770
SURGICAL TREATMENT
ning. Tension is fatal to the success of the operation. The point selected
is held by an assistant and the stomach, great omentum and colon are re-
turned to the abdomen. The omentum falls mostly to the left side and the
colon behind the loop. As the loop is lifted up to the stomach the anasto-
mosed intestine should have its natural physiologic direction to continue the
peristaltic wave from the stomach to the loop of bowel.
The opening into the stomach should be parallel with the greater curva-
ture and as near the latter as possible. It should be about midway between
the middle of the stomach and the pylorus. The intestine should be opened
opposite the mesenteric attachment. Having determined these points
FIG. 1443. — DIVISION OF MESOCOLIC BAND TO FACILITATE GASTRO-ENTEROSTOMY.
clamps are applied, the openings cut and the same method of suturing used,
as for posterior gastro-enterostomy; or the operation may be done without
clamps. The openings should be 5 to 6.5 cm. (2 to 2% inches) long.
The bowel should be anchored to the stomach by extra sutures. These
sutures should be so applied as to make the attachment about twice the
length required for the anastomosis. The object of this is to prevent rota-
tion of the bowel (Fig. 1444).
The success of the operation is better assured if a jejunojejunostomy is
done to unite the arms of the loop in such a way that the duodenal secre-
tions shall be able to flow on in the intestine without having to mount up to
the summit of the loop 'at the stomach (Fig. 1445).
THE ABDOMEN 771
In this operation unless the proximal loop is made long enough there is
danger of tension which may cause (i) the union to fail, (2) the jejunum to
become obstructed by pressure of the colon or (3) the colon to become ob-
structed by the jejunum. These are the chief reasons for the so-called "vi-
cious circle" which was once common after this operation. To obviate
this the proximal arm must be left relaxed, and with a relaxed proximal
arm the duodenal contents have a long uphill journey before they can pass the
stomach. For this reason lateral entero-anastomosis is indicated. This
may be done very quickly with the Murphy button.
FIG. 1444. — ANTERIOR GASTROJEJCNOSTOMY.
The operation of Roux, called the Y-operation, consists in division of
the bowel, the anastomosis of the distal stump with the stomach, and the
anastomosis of the proximal stump with the distal stump at a convenient
distance below the gastro-enterostomy. The operation is rarely indicated
(Fig. 1446).
Exclusion of the pylorus was once practised much as a routine measure
after gastrojejunostomy. This was done because it was observed that in
many cases a "vicious circle" developed, the duodenal contents passing
back through the anastomosis into the stomach and the stomach contents
passing out through the pylorus. This accident is not apt to occur if the
opening is made large enough, if the jejunum is free from kinks or other
obstruction, if there is accurate union of the margins of mucous membrane,
772
SURGICAL TREATMENT
if the opening is close to the lower border of the stomach, if the distal loop
of the jejunum is placed toward the right side of the median line before
closing the abdomen, if the operation is done without a loop or half turn in
the bowel, and if the proximal arm is not so short that it is compressed or so
long that it sags.
To prevent the vicious circle which follows these errors of technic, ex-
clusion of the pylorus has been practised. It is also done in cases of duodenal
ulcer, treated by gastrojejunostomy, in which it is desired to keep the duo-
denum free from gastric contents. It may be done by simply throwing a band
of fascia about the pylorus and sewing it down tightly (Fig. 1447). Pyloric
exclusion by means of infolding sutures (Fig. 1448) serves for a short time,
but if catgut is used, the permeability of the duodenum is soon restored.
FIG 1445. — ANTERIOR GASTROJEJUNOSTOMY.
Showing diagram of stomach and small intestine.
Simple ligature (Fig. 1449) of catgut soon melts away. To meet this objec-
tion silk and silver wire have been used. These are foreign bodies and highly
objectionable. The sure method is division of the pylorus and suture (Fig.
1450). This is naturally most effective and permanent. Dissection free
of the pyloric mucous membrane through a longitudinal incision, and sepa-
rate ligation and division of the mucous membrane is permanent in its effect
(Fig. 1451). A simple and satisfactory method consists in isolation of the
mucous membrane of the pylorus and constricting it with a band of fascia
taken from the rectus abdominis fascia or from the thigh (Fig. 1452).
Ordinary posterior gastro-enterostomy is not dangerous because if obstruc-
tion occurs at the intestinal kink, the loop of bowel between the pylorus and
the anastomosis has vent into the stomach and the stomach can be washed
THE ABDOMEN
773
out. But if resection or occlusion of the pylorus is done, "duodenal death"
takes place when obstruction occurs. Safer than occlusion of the pylorus
is anastomosis of the amputated stomach with the duodenum.
Reconstruction of Wall of Gastro-intestinal Tract by Transplantation
of Tissue. — After the loss of substance in the wall of the stomach or intestine
following the excision of an ulcer tumor or injured area, it has been customary
to close the wound. If such closure would cause too great a contraction, it
has been customary to perform resection or anastomosis to obviate the diffi-
culty. A. A. Strauss (Jour. Am. Med. Assoc., May 12, 1917) showed that
FIG. 1446. — GASTRO-ENTEROSTOMY BY THE Y-OPERATION.
The bowel is divided, the distal stump is anastomosed with the stomach, and the
proximal stump with the distal bowel at a convenient distance below the gastro-enterostomy.
This is the ideal gastro-enterostomy, but not always the operation of choice.
it is possible in the duodenum, after resection of ulcer, to restore the wall of
the bowel by means of a transplant of fascia. An incision is made through
the right rectus muscle about 13 mm. (^ inch) to the right of the median
line, extending from the ribs to the level of the umbilicus. The ulcer-bearing
area is circumscribed by an elliptic incision through all the coats of the
bowel excepting the mucosa. The grafts are then cut from the abdominal
wall. A clamp is placed on the duodenum and the mucosa is separated from
the muscularis for some distance around the wound. The ulcer is then
excised.
The grafts are applied as follows: A transplant, composed of perito-
neum, transversalis fascia and some adherent rectus muscle is cut from the
inner edge of the wound. This transplant should have about the shape
774
SURGICAL TREATMENT
of the wound to be filled. It should be sewed (Fig. 1453) with fine chromic
catgut to the mucous membrane with the peritoneal surface inside of the
bowel. The anterior sheath of the rectus muscle , is then exposed and an
oval piece with some of the underlying muscle fibers is cut out. This second
FIG. 1447. — PYLORIC EXCLUSION AFTER
GASTRO-ENTEROSTOMY BY MEANS OF A
BAND OF FASCIA.
FIG. 1448. — PYLORIC EXCLUSION BY
MEANS OF INFOLDING SUTURES.
transplant is placed on the first and sewed (Fig. 1454) with interrupted silk
sutures in such a manner that its edges lie between the mucosa and the
muscularis (Fig. 1455). The free edge of the omentum is then sewed over
the whole wound surface.
FIG. 1449. — PYLORIC EXCLUSION BY
MEANS OF SIMPLE LIGATION.
FIG. 1450. — PYLORIC EXCLUSION BY
DIVISION AND SUTURE.
The operation may be simplified by dissecting up the mucosa in such a
manner that only one transplant is needed. The same elliptic incision is
made through the seromuscularis. A straight incision is carried from its
THE ABDOMEN
775
upper end back into the stomach for a distance of 5 cm. (2 inches), and the
mucosa separated from the muscularis. The ulcer is then cut away. A
transverse incision is made through the stomach mucosa and closed longi-
FIG. 1451. — PYLORIC EXCLUSION BY
MEANS OF DOUBLE LIGATION AND DIVISION
OF THE MUCOUS MEMBRANE.
FIG. 1452. — PYLORIC EXCLUSION BY
CONSTRICTION OF Mucous MEMBRANE
WITH BAND OF FASCIA.
tudinally. This so frees the mucosa which can be closed transversely by
suture (Fig. 1456). The transplant of fascia is then set in and sewed to the
seromuscularis (Fig. 1457), and omentum sewed over all.
FIG. 1453. — RECONSTRUCTION OF PYLORUS AFTER EXCISION OF ULCER.
Sewing first graft of fascia to mucous membrane. (Method of Strauss.)
It is possible that in the treatment of ulcer of the duodenum this method
may come to supplant gastro-enterostomy. Strauss claims that it takes^less
skill, causes less shock, and can be done quicker.
776
SURGICAL TREATMENT
The treatment of shock in cases of gastroplasty, pylorectomy, gastrec-
tomy, and gastro-enterostomy is important. The preliminary treatment of
these cases has been described (pages 499, 564). If the patient has not
been able to take sufficient fluids, the body fluids should be increased by the
proctoclysis for two days previous to operation. The washing of the stom-
FIG. 1454. — RECONSTRUCTION OF PYLORUS.
Sewing second transplant to seromuscularis. (Method of Strauss.)
ach is best done on the day before operation. An injection of morphin
should precede the anesthetic. Anesthesia is necessary only for the opening
and closing of the abdominal wall; the morphin narcosis suffices for the most
of the operation.
L
FIG. 1455. — RECONSTRUCTION OF PYLORUS
Diagram showing wound closed by transplants of fascia after excision of ulcer,
graft of fascia: B, second graft of fascia.
A, First
By ligating the vessels supplying the parts to be excised, as a preliminary
step, blood is saved. The shock of operation should be slight if these pre-
cautions are taken and the rest of the peritoneum protected from insult.
THE ABDOMEN
777
After operation the head and shoulders should be raised by four or five
pillows. Rectal alimentation should be instituted. Hot water is given by
mouth after twelve hours in teaspoonful doses. As the patient tolerates
FIG. 1456. — RECONSTRUCTION OF PYLORUS AFTER EXCISION OF ULCER.
Mucous membrane closed. Transverse wound sewed longitudinally. (Method of Slrauss.
-A
FIG. 1457. — PLACING TRANSPLANT OF FASCIA AND MUSCLE IN RECONSTRUCTION OF
PYLORUS.
this, the dose is increased to 30 c.c. (i ounce) every hour. At the end of
thirty-six hours careful experiments with liquid food are begun. (See Post-
operative Treatment of Abdominal Cases, page 529.)
778 SURGICAL TREATMENT
Feeding after Gastro-enterostomy, Pyloroplasty and Intestinal Opera-
tions.— The patient should be placed in a semisitting position, upon being
put to bed after the operation. That means with the trunk nearly vertical.
This position should be continued for several days. Twelve hours after the
operation the patient may take by mouth, water in 4-c.c. (i-dram) doses.
During the first forty-eight hours after operation the patient should take
no food by mouth except water. Immediately after the operation continuous
fluids should be given by the drip method by rectum (proctoclysis). This
should be continued about a week. Plain water, salt solution, or glucose
solution, may be used.
After twenty-four hours the water by mouth may be increased gradually
up to 30 c.c. (i ounce) every two hours. On the second day if fluids are
tolerated 3o-c.c. doses of water may alternate with 4-c.c. (i-dram) doses of
egg-albumin. Then any nourishing liquid may be substituted for the egg-
albumin or water. This means broth, weak tea or whey. The quantity
of water and egg-albumin may be increased gradually until by the eighth
day any liquid, in 6o-c.c. (2-ounce) doses, may be taken every two hours.
This means water, tea, peptonized milk, malted milk, strained soup, strained
orange juice, peach juice, diluted grape juice, albumin water, whey or
strained buttermilk.
On the ninth day the amount of liquid may be increased to 90 c.c. (3
ounces) every two hours. On the tenth day any liquid in i2o-c.c. (4-ounce)
doses. On the eleventh day a soft-boiled egg may be given in addition to the
liquids. On the twelfth day two soft-boiled eggs may be allowed. On the
thirteenth and fourteenth days soft food may be given. They may be such
as soup, soft cereals with cream and invert sugar, custard, and mashed
potato. On the fifteenth and sixteenth days soft restricted diet is allowed.
On the seventeenth and eighteenth days any easily digestible food may be
taken.
After this the diet should be restricted for three months to carefully
selected easily digested foods, which should be taken in moderation. The
patient should avoid hot foods, very cold foods, fried foods, fat soups,
pork, liver, kidney, lobster, crabs, sardines, smoked and preserved meats,
cabbage, cauliflower, radishes, cuctimbers, corn, berries, pastries and
cakes, fresh bread, preserves, strong tea and coffee and alcohol.
Bloody oozing from the wound in the intestine or stomach may take
place in some cases. The temporary paresis which is always present to a
greater or lesser degree causes retention of this blood in the stomach after
gastro-enterostomy. This should be watched for. If the patient does not
vomit it, the stomach should be washed out with small amounts of warm
sterilized water.
The same rules for feeding which apply to gastro-enterostomy, apply also
to intestinal resections, anastomoses and suturing.
THE PANCREAS
Anatomy. — The pancreas lies transversely across the posterior abdominal wall behind the
peritoneum on a level with the first and second lumbar vertebrae. Its right end or head is
embraced by the curving duodenum, and its tapering tail reaches to the hilum of the spleen.
The common bile duct is usually embraced by the tissue of the head as it passes downward.
The splenic artery runs along its upper border. The splenic vein lies behind it. The
main duct of the pancreas (duct of Wirsiing) runs in its substance toward the head, and
empties into the second part of the duodenum in close connection with the common bile
duct. Commonly the two ducts join to form an ampulla (ampulla of Vater) which
empties by a single opening at the apex of a papilla. These two ducts may empty into the
duodenum through separate openings. A second duct (ducts of Santorini) often empties
into one of the above ducts or has a separate mouth in the duodenum (Fig. 1458).
THE ABDOMEN
779
Wounds of the Pancreas.— An infected wound should be provided with
drainage, and spreading pancreatitis should be watched for and guarded
against. Traumatism to the abdomen, resulting in the rupture of other
viscera, should prompt inspection for rupture of the pancreas. Immediate
suture of a rupture should be done. Incised wounds and bullet wounds
should either be sutured or drained or both. In suturing wounds of the pan-
creas the duct should not be occluded. In injuries in the region of the neck,
the superior mesenteric vessels should be protected. When the gland is
crushed or pulpified, hemorrhage should be arrested either by suture or
packing, and drainage provided. Suturing must be done carefully with
fairly heavy catgut as the tissue is friable and easily tears. The natural
approach to the pancreas is through the mid-abdomen, and drainage of
the pancreas is best provided through the route of approach in most cases ;
but as such drainage usually is between the coils of intestine, the feasibility
of posterior drainage through the flank should always be considered.
YE m vmss D
FIG. 1458. — ANATOMIC RELATIONS OF THE PANCREAS.
.4, Superior pancreatic and duodenal artery; B, hepatic artery; C, splenic artery; D,
inferior pancreaticoduodenal artery; E, inferior mesenteric vessels.
Approach to the pancreas is through the mid-abdomen. A sand-bag
should be placed under the back. The abdomen should be opened by a free
incision to the right of the median line above the umbilicus. The pancreas
may be approached by one of four routes, (i) The gastrohepatic route is
through the gastrohepatic omentum above the stomach. It is useful in
thin people with prolapse of the stomach. (2) The gaslrocolic route is
opened by incising the gastrocolic omentum just below the stomach. This
gives free access. A number of ligatures are required. (3) The trans-
mesocolic route is through the mesentery of the transverse colon the same
as for posterior gastro-enterostomy. It provides a circumscribed opening.
(4) The retro-omental route is made by lifting up the apron of the great omen-
tum; incising the serosa of the transverse colon at its line of juncture with
the great omentum; and with the finger, covered with a piece of gauze,
separating the omentum from the bowel throughout the length of the
incision (Fig. 14580).
780
SURGICAL TREATMENT
The retro-omental route gives the best access. The incision may be 13 cm.
(5 inches) long or longer. If care is taken there need be no bleeding. This
route not only gives free access to the pancreas, but is the best means of
approach to the posterior wall of the stomach. It also provides exposure of the
duodenum, especially in its relation to the head of the pancreas.
Drainage of the pancreas, whether after traumatism, operations for tumor
or incision for infections, is important. When the organ is wounded or
incised, pancreatic juice escapes. This juice has the power (i) to digest
plastic exudate and (2) to irritate the peritoneum.. It also causes fat
necrosis. Its presence in the tissues or peritoneum greatly increases the dan-
gers of infection. Bacteria which would otherwise be destroyed, grow in
the presence of this fluid. Drainage may fail to localize infection because
the enzymes of the pancreas break down the plastic barriers.
A good-sized drainage tube surrounded by gauze is the most effective
drainage.
Acute Pancreatitis. — Acute in-
fection may be expected to
terminate fatally in the severe
cases unless relieved by surgical
means. The less acute cases
may result in abscess or local-
ized necrosis of the gland, which
may find spontaneous drainage.
In certain mild cases recovery
may be secured without opera-
tion. If all local irritation is
removed, by washing out the
stomach, by permitting no food
by mouth, and by keeping the
patient quiet the disease may be
expected to subside. The patient
should be carefully studied and
watched.
Usually acute infection de-
mands quick recognition and
i458s.-APPROACHEs TO PANCREAS AND treatment. The omentum will
POSTERIOR WALL OF STOMACH. commonly present the small
I, Gastrohepatic route; 2, gastrocolic route; round, pale yellow or white
3, transmesocolic route; 4, retro-omental route. patches characteristic of fat ne-
crosis. This confirms the diagno-
sis. The pancreas in these cases is intensely congested, the congestion ex-
tending outside of the capsule. The gland should be exposed as above
described, and the intestines walled off. The gland will appear swollen and
purplish in color. Hemorrhagic areas may be present. The important in-
dication is to relieve the tension by incisions into the gland substance. After
such treatment abundant provision for drainage should be made, as above
described. Recovery will depend upon the promptness with which drainage
is secured. Often the capsule will be found so diseased that nothing
further than drainage down to the gland is indicated.
Operation should be done with the least possible traumatism. If jaun-
dice is present, simple drainage of the gall-bladder should be secured.
Cholecystitis and gall-stones will be discovered in connection with some
of these cases. If the condition of the patient will permit, the gall-bladder
should be incised and drained. In some cases the pancreatitis follows the
PANCREAS
DUODENUM
MESOCOLON
TRANSVERSE
COLON
FIG.
THE ABDOMEN 781
occlusion of the ampulla of Vater by a stone, which causes bile to flow back
into the pancreas through the duct of Wirsung and set up pancreatitis.
Examination should be made for stone in the common bile duct. It is
rarely wise to complicate the operation by removal of stone from the ducts
in acute pancreatitis. The condition of the patient will rarely justify its
removal at the first operation.
The surgeon should always be prepared for these cases. The diagnosis
is difficult. But all acute surgical conditions of the upper abdomen should
receive immediate operative treatment. In acute pancreatitis life may be
saved by so doing.
Subacute Pancreatitis. — The less acute forms of infection may give rise
to less violent symptoms, but abscess or gangrene may result and require
operative relief. The bulging pancreas is exposed by dissecting bluntly
through the gastrohepatic or gastrocolic omentum. Before opening an
abscess of the pancreas, the peritoneum should be well walled off with
gauze. Pus should be sponged out, and sloughs, which are commonly pres-
ent, should be removed. If the protection of the peritoneum is adequate,
these cases should be expected to do well. As the mortality is still high, when
possible, an operation in two stages should be considered. Abscesses have
been drained through the back at the costovertebral angle, and also by the
transpleural route.
Chronic Pancreatitis. — In old chronic sclerosis of the pancreas due to
alcoholism, syphilis or some infection such as typhoid, which does not give
acute symptoms, surgery has little to offer. In cases in which the common
duct is compressed by connective tissue of the inflamed pancreas, it may
be dilated with a fine probe or freed by traction and lateral motions. In
infections due to duodenal ulcer, the ulcer should be cured by gastroenter-
ostomy or excision. The cases most amenable to surgical treatment are
those due to stone. This is usually located in the common duct or its
ampulla, and so situated as to prevent the free exit of pancreatic secretion.
The catarrhal infection which may be present is transmitted to the pancreatic
duct. Relief is secured by removal of the stone. An infection of the
ducts without stone may be present, or the only stones may be located
in the gall-bladder. In such cases drainage of the gall-bladder by chole-
cystotomy should be secured and continued until the bile becomes sterile.
Drainage of the bile and pancreatic tract by this means has a decided curative
effect upon pancreatitis. It is in these chronic infective cases that chole-
cystenterostomy may be of service in giving permanent free drainage of
the gall-bladder, and relieving pressure at the mouth of the pancreatic duct.
It is to be conceived that in cases in which the pancreatic duct empties into
the common bile duct, and the mouth of the latter is narrowed by the cicatri-
cial contractures following ulcer of the duodenum, the operation of chole-
cystenterostomy would create a new channel, and pancreatic and hepatic
secretions would both reach the bowel by way of the gall-bladder.
Whether to do a cholecystostomy or a cholecystenterostomy may be
difficult to decide. In cases in which the patient is very sick, with glycosuria
or jaundice, the quicker operation is indicated. That is simple cholecys-
totomy, leaving a gall-bladder fistula. If the condition of the patient is
good and there are no gall-stones or discoverable cholecystitis, permanent
drainage into the bowel is the operation of choice. For in many of these
Cases no recognizable inflammation or infection of the gall-tract may be
present; and if there is no other discoverable cause for the pancreatitis there
remains nothing to do but drain the gall-bladder.
Gall-bladder drainage undoubtedly has a curative effect, and this is
SURGICAL TREATMENT
probably due to the relief of pressure upon the pancreas. It permits freer
discharge of pancreatic secretions.
Necrosis of the pancreas requires drainage by gauze or wick packing so
that the peculiar secretions shall find external vent.
•d £
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Tumors of the Pancreas. — Adenoma, carcinoma and sarcoma are all
amenable to treatment by operation, and each has been successfully removed.
How much of the gland is necessary for health is not known; but a number of
cases of complete pancreatectomy with recovery have been reported. If
possible some pancreatic tissue should be left, because, while it is possible
THE ABDOMEN 783
to supply the external secretion of the pancreas, supplying the internal
secretion is difficult.
Cysts of the pancreas are more common and much more hopefully
treated. The cyst is approached at one or the other sides of the median
line, preferably making the approach directly in front of the tumor.
Whether the cyst is to be attacked between the stomach and transverse
colon, above the stomach, or below the transverse colon (Fig. 1459) must
depend upon its place of greatest prominence. It will be found to present at
one of these places.
The lowest mortality has followed operation, which is done in two stages.
By this method, the cyst, bulging under the peritoneum, is made accessible
by holding back the viscera by means of abundant gauze packing surrounded
by rubber protective. After two days or more, when adhesions have devel-
oped, the innermost part of the gauze is removed and the cyst evacuated by
aspiration. After the fluid has been removed, the cyst is freely opened,
packed and drained. In some cases, as the first step of the operation, the
cyst wall may be sutured to the edge of peritoneum of the abdominal wound.
In rare cases the cyst will be found so small, superficial, or isolated that
its extirpation can be accomplished. If the cyst seems to be a part of malig-
nant disease then an effort should be made to remove the whole growth. The
interior should be explored. If it presents cauliflower excrescences, its malig-
nancy may be assumed. A retention cyst is apt to contain crystalline de-
posits or stone.
The sinus following evacuation and drainage may be very slow in healing.
It may close superficially and a reaccumulation of fluid take place (see
Treatment of Sinuses, Vol. I, page 305).
Pancreatic Calculi. — -Whether in the duodenal ampulla or in the pan-
creatic duct in the substance of the gland, stones of the pancreas are amenable
to treatment. Operation after a correct diagnosis is most happy; but in
a large proportion of cases pancreatic calculus has not been the condition
operated for. In operations for gall-stones, when no disease of the gall-
bladder excepting distention is found, examination should be made to deter-
mine whether a pancreatic stone has not caused the symptoms.
The best approach to the body of the pancreas is by a median abdominal
incision, and thence through the gastrohepatic omentum. The stomach is
pulled downward and to the left. By placing a sand-bag behind the patient's
back the pancreas is pressed forward and easily brought into view. If a
stone can be palpated the peritoneum overlying the gland should be incised
at that point. After removal of the stone the wound should be closed.
Drainage should always be provided.
In operating upon the pancreas the rest of the peritoneum should be
walled off by gauze pads in order to prevent soiling with pancreatic fluid.
A stone located in the duodenal ampulla of the pancreatic duct may be
reached by incising the duodenum as for duodenocholedochotomy. The
interior of the duodenum being exposed, the stone is felt under the ampulla at
the cholopancreatic opening, cut down upon, and removed. The wound
in the front of the duodenum is closed in the usual manner.
If a chronic pancreatitis is found and no stone discovered as a causative
factor, drainage of the gall-bladder can be applied. After symptoms of
stone colic, when it is found that the gall-bladder is well filled but free
from thickening and adhesions, and the cystic, hepatic and common ducts
are free from stone; when the head of the pancreas is enlarged and hard
and evidently the seat of chronic inflammation, it is most probable that stone
will be found in the pancreatic duct near the duodenum.
784 SURGICAL TREATMENT
THE SPLEEN
Anatomy. — The spleen lies in the left hypochondrium behind the ribs. It is almost
entirely covered by peritoneum. It lies in close relation to the fundus of the stomach. Its
long axis measures about 13 cm. (5^ inches). The hilum is directed inward and forward
and is the place of entrance of the blood-vessels. Reflections of peritoneum, called liga-
ments, connect the spleen to the left kidney, to the stomach, and to the splenic flexure of
the colon. The spleen is on a level included between two horizontal lines passing through
the spinous processes of the ninth dorsal and first lumbar vertebrae. Its average weight is
150 Gm. (5 ounces). It receives its blood supply through the splenic artery from the
celiac axis. The artery may be tied at the celiac axis or where it is joined bythe gastroepi-
ploica sinistra.
Physiology. — The effects of removal of the spleen seem not to be serious. The organ
seems not to be essential for life or health. After its removal there are an increase in the
number of leukocytes, a decrease in the number of red blood-corpuscles, and a diminu-
tion in the amount of hemoglobin. These changes reach their maximum in about a month,
after which the condition of the blood gradually returns to normal. Other changes such as
lymphocytosis, slight eosinophilia, increase of mast cells, general enlargement of the lym-
phatic glands, or pain in the long bones may appear. Many other exceptional symptoms
have been seen. There seem to be no ill, remote, after-results. Persons without the
spleen go on in the enjoyment of health.
Injuries of the Spleen. — Prolapse of the spleen through a wound in the
abdominal wall requires the treatment of two conditions: the prolapse and
the injury to the spleen. If the organ is not wounded or its blood supply
damaged, it should be returned to the abdomen and the wound closed. An
unduly elongated pedicle should receive the treatment described for wander-
ing spleen. If there is serious injury of the spleen itself, it should be treated
as for wounds of the spleen.
Wounds of the spleen are so commonly associated with injury of the dia-
phragm, pleura, stomach, liver or other viscera that treatment must usually
embrace also the consideration of other structures. Gunshot and stab wounds
are almost invariably fatal from hemorrhage unless prompt operation is done.
Lacerated wounds and rupture of the spleen are even more rapidly fatal unless
immediate operation controls the bleeding. As a preliminary step the pedi-
cle of the spleen should be compressed by soft clamps to close temporarily the
splenic arteries. This is the first thing to be done as soon as the spleen is
exposed. In simple wounds the application of mattress sutures is to be re-
commended. Good-sized catgut should be used and tied with sufficient
force to control bleeding but not so tightly as to cut into the tissue.
The sutures should be inserted deeply so as to control the whole length
of the wound. The operation is not complete unless an inspection of the
whole surface of the organ is made to search for other wounds. If the deep
parts of a wound or a wound of exit are not compressed by sutures, hemorrhage
may continue. Gauze packing, the cautery, and forcipressure crushing
are not so dependable as suture.
Splenectomy is indicated when the wounds are multiple or when extensive
crushing or laceration does not lend itself easily to treatment by suture. This
is the surest way of controlling bleeding; the operation is usually not difficult;
the chief objection to it is that there is apt to be a temporary unbalancing
of the system which does not give the patient as good a chance for recovery
as when the organ is left.
Abscess of the Spleen. — As soon as a diagnosis is made the abscess should
be evacuated. Adhesions to the abdominal wall will often determine the
best approach. Usually it will be below the free border of the ribs, but in
some cases the presence of cellulitis and occlusive pleuritis will indicate
resection of ribs and the transpleural route. Often a wide opening must
be left for the removal of sloughs.
THE ABDOMEN 785
Tuberculosis of the Spleen. — When the disease is a part of a general
tuberculous infection the treatment should be hygienic. When the disease
is localized and confined to the spleen splenectomy should be done. In
cases of tuberculous enlargement of the spleen, with distressing local symp-
toms, even though other tuberculous foci may be present, splenectomy is
indicated. The results of this operation have been satisfactory.
Tumors of the Spleen. — Cysts have been treated by simple drainage,
injection with antiseptic irritants, marsupialization, extirpation of the cyst
and splenectomy. The latter operation has given the best results. Powers
collected, reports of ten splenectomies for cystoma all followed by recovery.
Small cysts may be excised without splenectomy. Hydalid cysts, if large,
should be treated by splenectomy; if not involving all of the spleen, evacua-
tion and drainage should suffice.
In considering splenectomy in any case the mobility of the organ should
be considered. If its removal would be difficult because of the shortness of
the pedicle or the presence of adhesions then incision and free drainage,
together with the application of an irritating chemical or gauze packing
to the interior of the cyst, should be considered. Primary solid tumors of
the spleen are so extremely rare that but few data concerning their treatment
are at hand. The same treatment is indicated as is applied to tumors in other
regions. Secondary neoplastic deposits are scarcely amenable to surgical
treatment.
Hypertrophy of the Spleen. — In simple hypertrophy, the origin of which is
unknown, splenectomy is indicated only when the disease causes distress
because of the weight or pressure of the spleen or because of mobility or
rotation of its pedicle. The same is true in malarial hypertrophy.
Splenic anemia (Band's disease) is a disease in which there seems to be
reasons to believe that the later cirrhosis of the liver is due, at least in part,
to toxic substances formed in the spleen, and early splenectomy is capable
of checking the progress of the disease. But even in the later stages of the
disease some successful cases have been reported. When cirrhosis and
ascites already exist, splenectomy and operation for ascites should prove of
service. The hazards of operation are not great, and without operation the
result is fatal. As time has gone on, more and more favorable results have
been reported until now this operation is a well-established therapeutic
measure. Extraordinary care should be taken to avoid infection, as infected
wounds after splenectomy seem to do very badly.
Hemolytic jaundice, pernicious anemia, biliary cirrhosis, and other dis-
eases in which there is destruction of red blood cells seem to be benefited
by splenectomy.
Many of these cases of hemolytic disease are so mild as not to call for
splenectomy. If the case is progressive, no matter how mild, splenectomy
should be done to forestall the inevitable crisis. The surgeon should not
wait for the development of the splenic tumor in these cases, especially in
the young. In older patients, without actual disability, operation is not
imperative. Transfusion of healthy blood may be depended upon usually
to give temporary improvement.
The mortality of operation is not high if done between crises. Elliott
and Kanavel (Surg., Gyn., and Obst., xxi, 1915) reported forty-eight cases
operated upon, with two deaths. The improvement in the blood picture
after operation is often striking. E. B. Krumbhaar (Jour. Am. Med.
Assoc., Sept. 2, 1916) collected information concerning 153 patients
whose spleens were removed for pernicious anemia: 19.6 per cent, died
within six weeks; 64.7 per cent, were improved; 15.7 per cent, were
VOL. 11—50
786
SURGICAL TREATMENT
not improved, none were restored to perfect health. The best results are
secured if the operation is preceded by one or more blood transfusions.
The patients who do badly after operation may be helped by transfusion.
The far advanced cases are not improved by splenectomy.
Leukemia is no longer treated by splenectomy, as the operation is found
not to give relief. In chronic myeloid leukemia, if treated early, the size of
the spleen may be reduced and the blood picture changed to normal by the
internal administration of benzol (benzene). The drug is given in milk or
in gelatin capsules with an equal amount of olive oil. The beginning dose
~
FIG. 14590. — SPLENECTOMY.
The splenic artery has been tied; the vein has been doubly ligated and cut; accessory
vessels have been tied; and the ligature carrier is passing a ligature through the pedicle.
is 2.5 c.c. (40 minims) daily. The maximum daily amount is 6 c.c. (100
minims), given for 12 days each month. The #-ray applied to the spleen
is effective. The blood and urine should be watched. Benzol and the
#-ray combined are capable of giving pronounced results.
Wandering Spleen. — In simple cases of elongated pedicle the ligaments
of the spleen may be shortened by folding and suture (splenopexy). Twisted
pedicle may be treated in the same way; and even though some infarcts
be present, the pedicle may be untwisted and the organ fixed in its normal
position by sutures. Cases in which the spleen is decidely enlarged are best
treated by splenectomy, as sutures are apt to tear out and adhesions give
way if the organ is abnormally heavy. When rotation of the pedicle has
resulted in complete occlusion of the main vessels splenectomy should be
done.
THE ABDOMEN 787
OPERATIONS ON THE SPLEEN
Splenectomy is easy if there is a free pedicle, and difficult if the spleen is
bound down by adhesions, has a short pedicle, and short ligaments, and the
patient is fat. The abdomen may be opened behind or to the outer side of
the left rectus muscle by a vertical incision beginning just below the free
border of the ribs. The incision should be placed in front of the outer part
of the rectus, the muscle retracted inward, and the abdomen entered through
the posterior sheath of the muscle. This gives the least liability to hernia.
Somewhat better access to the spleen is secured by an incision just external
to the left rectus muscle. If necessary the incision may be continued
upward along the rib margin. A sand-bag behind the back throws the pos-
terior abdominal wall forward. The intestines are packed off with abdominal
pads, and the spleen exposed. Adhesions are divided. The reflections of
the peritoneum which confine the spleen are ligated and cut and the organ
brought forward. Tension should not be made on the splenic vessels as
they are very delicate and easily ruptured. As the spleen is dislocated
forward and brought out of the abdomen the cavity which it occupied
should be packed with warm wet gauze.
The vessels lie behind and internal to the spleen in the folds of peritoneum,
connecting the spleen and left kidney. The vessels should be exposed by
incising the peritoneum and bluntly dissecting them into view. If large,
they should be ligated separately. Good-sized catgut should be used. The
peritoneum or even the tail of the pancreas may be included in the ligature
if necessary to prevent cutting the friable vessels. The accessory vessels
passing to the stomach should not be overlooked. Care should be taken not
to wound the stomach. It is best not to wound the pancreas (Fig. 14590).
After ligation of the vessels the organ is easily detached and the perito-
neum replaced over the bed from which it was removed.
Resection of spleen may be done for tumor, injury or infective disease.
The part removed should be of such a shape that the wound is easily closed.
The shape of a wedge lends itself best to the operation. Hemorrhage may
be prevented by temporarily clamping the pedicle with rubber-covered
clamps. After the wound has been closed with deep mattress sutures the
clamp may be removed and bleeding not expected. It is said that the splenic
artery may be permanently ligated and necrosis will not occur if the vein is
patent.
Splenopexy, for fixing wandering spleen, may be accomplished by
shortening all of the ligaments with folds held by catgut sutures. It is not
advisable to attempt fixation by passing sutures through the substance of the
organ. It is friable; the sutures are apt to pull out; and serious hemorrhage
is apt to occur.
Rydygier devised a method whereby, after exposing the spleen by a
median incision or incision to the outer side of the left rectus muscle, the
spleen is slipped into a pocket behind the peritoneum. A transverse incision
through the peritoneum is made between the ninth and tenth ribs, and the
peritoneum freed from its underlying connective tissue. After'placing the
spleen in this pocket, it is held by a few sutures which close the opening.
Bardenhauer placed the spleen in such a pocket made by a longitudinal
incision in the lateral abdominal wall.
INDEX OF NAMES
ABADIE, 161
Abbe, 1 08, 344/438
Abbott, 354
Ach, 758
Achard, 402
Adams, 145
Adolph, 565
Albee, 350
Allport, 153
Andrews, 676
Audry, 693
BABLER, 558
Balfour, 595, 724
Ballance, 68
Band, 785
Barraquer, 174
Beck, 413
Beebe, 390, 394
Beer, 126, 341, 562
Bellocq, 185
Bennet, 344, 711, 712
Bickham, 656
Billroth, 750
Bircher and Weir, 714
Blad, 558, 560
Bode, 528
Bogojawlensky, 88
Bonninghaus, 197
Bradford, 328
Brauer, 418, 424, 451
Brewer, 415
Brinsmade, 521, 694
Brophy, 265
Brown, 574
Bryant, 462
Butlin, 296
CALOT, 332
Cargile, 522
Carr, 19
Carrel, 562
Carter, 180
Charpy, 431
Chiari, 90
Chipault, 33, 48
Christiani, 394
Clark, 533, 547
Clubbe, 607
Coffey, 541, 675, 685, 712
Colton, 408
Connell, 636, 637, 651, 654, 769
Crile, 52, 231, 235, 391, 392, 393, 547
Crisler, 550
Cryer, 29
Gushing, 19, 25, 37, 38, 77, 82, 88, 92
106, 108, no, 631, 634, 635, 6.36, 649,
655, 656, 660, 662, 674
Czerny, 634, 635
654
DACOSTA, 103
Dahlgren, 29
Davis, 146
Deaver, 578, 579, 727
deForest, 247
Deguise, 377
Dgjerine, 323
Delatour, 695
Bench, 321
deSchweinitz, 130, 159
Desmarest, 348
Desmarres, 150
Deutschmann, 135
DeWecker, 152
Dickinson, 515
Dieffenbach, 146
Dobson, 589
Dollinger, no
Dowd, 574
Doyen, 27, 29. 30, 32
ECK, 561
Elliot, 162
Elliott and Kanavel, 785
Elsberg, 87, 341, 342, 343, 448
Emrich, 570
Estlander, 410
Ewald, 369
FENGER, 267
Fergus, 142
Ferguson, 269
Fetterolf, 189
Finney, 578, 725, 740, 741, 742, 743, 744,
745, 759
Finochietto, 673
Fisher, 529
Flexner, 67
Florio, 556
Foerster, 344
Foote and Weir, 706, 710
Fowler, 410, 528
Franck, 734
Franke, 347, 560
Frazer, 51, 348
Frazier, 37, 77, 87, 106, 107. 109, in
Freeman, 388
French, 209
Freund, 419
Friedliinder, 188, 418, 419, 445, 453, 459,
460
Friedman, 20, 22
Froehlich, 153
GAENSLEN, 344
Gallet, 671
Gant, 693
Gersuny, 692
Gibson, 147, 573, 665
789
790
INDEX OF NAMES
Gigli, 29, 32
Gilbert, 402
Gluck, 224, 231, 233, 234, 236
Gottstein, 187, 211, 437
Gould, 389, 633, 634, 654, 666, 668, 669, 678,
7i4, 736, 7Si
Gray, 117, 397, 431
Green, 243
Guthrie, 562
HAECKER, 429
Hahn, 738
Halsted, 633, 634, 649
Hancock, 161
Harris, 721
Hartley, 106, 108, 671, 674
Haynes, 70, 98
Heine, 157
Heineke and Mikulicz, 740
Heitler, 426
Henle, 436
Herbert, 161
Herschell, 576
Hess, 142
Hirschsprung, 610
Holden, 232
Holt, 719
Hor ley, 7, 108, no
Hort, 576
Hudson, 28, 29
JABOULAY, 392
Jackson, 225, 239, 240, 242, 244, 422, 490,
602
Jamieson, 589
Jane way, 731
Jennings, 480
Jessett, 607
Jianu, 465
Jonnesco, 101
Junker, 188
KADER, 733, 734
Kanavel, 90, 702
Kanavel and Elliott, 785
Keen, 96, 437, 452, 541
Keetley, 572
Kellogg, 610, 611, 614
Kenyon, 38
Killian, 202, 225, 239, 240
Kirstein, 242
Klebs, 207
Knapp, 150, 152, 171, 174
Koch, 429
Kocher, 101, 106, 108, 109, 297, 393, 394,
424, 552, 562, 747
Korner, 314, 3 15
Kraft, 728
Krause, 78, 87, 88, 106, 108
Kronlein, 50, 752, 779
Krumbhaar, 785
Kuettner, 344
Kuhnt, 145
Kummell, 757
Kuyk, 369
LAGRANGE, 157
Lamboth, 559
Landolt, 176
Lane, 261, 444, 602, 613, 614
Lang, 156
Larralde, 417
Lembert, 631, 632, 633, 635, 649
Lenhartz, 721
Lewisohn, 243
Lexer, 108, no
Lilienthal, 420, 421, 662
Loffler, 207, 212
Lorenz, 327
Loreta, 737
Lotheissen, 439
Lothrop, 199
Ludwig, 362
McARDLE, 599
McArthur, 88
McBurney, 510, 572
McGraw, 588, 675, 676
McLean, 675, 676
Martinache, 126
Maunsell, 607, 654, 655, 658, 661, 663
Mayer, 326, 698
Mayo, 384, 385, 386, 579, 642, 644, 685
705, 724, 74i, 750, 7Si, 752, 753, 754, 755
756, 764, 767, 769
Meltzer, 446, 447
Meniere, 319
Metchnikoff, 613
Meyer, 420, 451, 452, 463, 467, 508, 509
7i6, 757, 759
Mikulicz, 375, 526
Mikulicz and Heineke, 740
Mixter, 693
Monks, 621
Montenovesi, 29
Moschcowitz and Wilensky, 767
Motais, 142
Moynihan, 595, 663, 741, 747
Mules, 159
Munro, 344, 532
Murphy, 418, 552, 635, 667, 669, 671, 771
769
NlCOLL, 719
OCHSNER, 436, 551, 548, 554, 616
O'Dwyer, 219, 237
Orth, 479
PAGENSTECHER, 769
Paget, 473
Panas, 152
Panse, 315
Peet, 561, 562
Percy, 492, 494
Perez, 188
Perier, 234
Peterson, 559
Pilcher, 228, 602, 701
Pleth, 662, 677
Plummer, 716
Poirier, 431
Politzer, 301, 306, 307
Polya, 756
Pope, 522
Porter, 390
Pott, 41
INDEX OF NAMES
791
QUINCKE, 68
REID, 49
Richardson, 519, 543
Richter, 433
Riggs, 277
Robinson, 407, 410, 411, 412, 421, 449, 450,
Robson, 675, 696, 697
Rogers, 219, 220
Rosenow, 577
Rosenstein, 561
Rosenthal, 615
Routte, 560
Roux, 464, 465, 771
Rovsing, 712, 713, 715, 728
Ruth, 489
Ryall, 685
SALOMONI, 429
Sampson, 531
Sangman, 417
Sansum, 132
Sauerbruch, 451, 463, 464
Schede, 411, 461, 463
Schoene, 430
Schultz, 209
Scudder, 720
Sebileau, 235
Seiffer, 322
Senn, 675, 731, 732
Sharpe, 99
Sicard, 348
Sippy, 576
Sluder, 214
Smith, 168, 170, 171, 269
Smithies, 720
Spiller, 107, 109
Stewart, 552, 768
Stillman, 719
Stoffel, 347
Stone, 721
Straus, 682, 719
Strauss, 773, 775, 776, 777
Strempel, 533
Summers, 646
Szymanowski, 145
TALMA, 558
Teale, 150
Teschner, 353
Tewksbury, 414
Thomas, 323, 335
Thorner, 237
Torek, 418, 402
Trendelenburg, 430, 499
Tiirck, 636, 638, 639
ULLMANN, 658
VERHOEFF, 127, 152
Verning, 391
Vidal, 561
Vogel, 522
von Bergmann, 108, 439
von Bramann, 96
von Hacker, 436
von Leube, 721
von Mikulicz, 243
von Mutschenbacher, 370
WALKER, 660
Wallstein, 464
Warbasse, 546
Watson, 390
Weir, 572, 573, 671, 693
Weir and Bircher, 714
Weir and Foote, 706, 710
Westbrook, 702
Wiener, 153
Wilder, 132
Wilensky and Moschcowitz, 767
Witzel, 697, 736, 758
Wolff, 405
Woodyatt, 132
ZAAIJER, 758
Zanfel, 71
Zesas, 429
Ziegler, 156
INDEX OF SUBJECTS
ABADIE'S operation in glaucoma, 161
Abbe's method of dilating esophageal stric-
ture, 438
Abbott's treatment of scoliosis, 354
Abdomen, 498
concussion of, 535
contusions of, 535
landmarks, 503
opening of, 504
incisions for. 504
combined, 510
flap, 510
lateral muscle-splitting, 507
vertical, 507
median, 507
intramuscular, 506
postmuscular, 504
transverse, 507
postmuscular, 510
operations on, 498
regions of, 499
relaxed, 540
Abdominal carcinoma, inoperable, 706
muscles, rupture of, 535
operations, 498
adhesions in, blunt dissection of, 522
extensive, 523
interintestinal, 522
omental, 522
to anterior abdominal wall, 522
treatment, 522
binder for dressings, 520
bowel movements after, 531
closure of peritoneum in, 516
of wound in, 516
complications after, 531, 534
control of bleeding in, 515
drainage in, 524
aspiration in, 526
by counteropening, 528
dangers. 527
depth necessary for, 528
gauze for, 525
non-adhering, 529
indications for, 525
methods, 526
objections to, 525
oiled gauze, 529
rectal, 528
withdrawal of, 527
dressing wound in, 519
elevated-head position after, 529
emergency feeding after, 535
feeding after, 534
figure-of-eight suture in, 519
hemorrhage in, 523
increasing abdominal pressure after,
infection of wound in, 537
Abdominal operations, instruments for, 504
meteorism after, 532
methods of dealing with, 520
morphin after, 531
nausea after, 531
oxygen after, 531
pain after, 532
peritoneum in, 498
pneumonia after, 534
position of patient, 499
preparation of patient, 499
preventing leaving instruments in ab-
domen in, 516
prevention of adhesions in, 521
proctoclysis after, 533
rectal tube after, 531
retention of urine after, 533
retraction of wound, 515
shock after, 532
sponging in, 515
thirst after, 533
time for getting up after, 534
toilet of peritoneum in, 515
treatment after, 529
vomiting after, 531
section, 504
ilio-inguinal, 510
low median, by superficial transverse
incision, 513
median, 510
oblique postmuscular. 511
subcostal oblique, 513
vertical postmuscular, 512
wall, 535
actinomycosis of, 538
blood-supply, 501
cancer of, 538
echinococcus cysts of, 538
excessively fat, 538
fibroma molluscum of; 538
fibrosarcoma of, 538
infections of, 536
landmarks. 503
lipoma of, 538
nerve supply, 501
nevus of, 538
pendulous, 540
relaxed, 540
sarcoma of, 538
stitch-hole abscesses in, 537
structures of, 500
tumors of, 538
wounds of, 535
Abducens nerve, injuries of. 63
Abscess, alveolar, 277
cerebellar, usual site, 50
chronic peritoneal, 554
extradural, 319
extramammary, 474
793
794
INDEX OF SUBJECTS
Abscess in Pott's disease, 335
femoral, 337
from mixed infection, 337
inguinal, 337
lumbar, 337
of lower spinal region, 336
of middle cervical region, 336
of upper dorsal region, 336
psoas, 337
retropharyngeal, 335
intracranial, of otic origin, 319
localized, in peritonitis, 553
of anterior chamber of eye, 1 28
of brain, 73
indications for operation, 73
technic of operation, 74
of chest wall, 398
of esophagus, 432
of eyelids, 119
of lung, acute, 414
chronic, 415
rupturing into bronchus, 415
of mediastinum, 444
of neck, 361
of orbit, 137
of palate, 255
of pancreas, 781
of parotid gland, 379
of scalp, 24
of spine, non- tuberculous, 327
of spleen, 784
of tongue, tuberculous, 290
otic, usual site, 50
perigastric, from perforation of stomach,
727
peritonsillar, 212
retroperitoneal, 563
retropharyngeal, 205
secondary, in peritonitis, 553
stitch-hole, in abdomen, 537
subdiaphragmatic, 470
subphrenic, in peritonitis, 553
Absorbable mechanical devices for intesti-
nal anastomosis, 675
Accessory sinuses of nose, 179
foreign bodies in, 1 88
thyroid glands, 380
Accidental wounds of scalp, 18
Accidents in cataract extraction, 167
Ach's method of resection of cardiac end of
stomach, 758
Acoustic vertigo, operation on seventh nerve
in, 112
Acquired stenosis of larynx, 218
of trachea, 218
Actinomycosis of abdominal wall, 538
of intestines, 575
of nasopharynx, 208
of tongue, 290
Adenitis, tuberculous, 368
non-surgical treatment, 369
operation in, 370
Adenofibroma of breast, 475
Adenoids, 208
climate in etiology, 208
evil results from, 208
fresh air in prophylaxis, 208
operation on, 211
Adenoids, operations on, anesthesia in, 209
chair for, 209
instruments for, 209
position of patient, 209
sitting position in, 209
without anesthetic, 208
soft, 208
treatment of, during first year, 211
Adenoma, cystic, of breast, 475
of intestines, polypoid, 582
of stomach, 703
Adenotome, Schultz's, 209
Adherent tonsils, 216
Adhesions in peritonitis, 546
methods of dealing with, in abdominal
operations, 520
of intestines, chronic obstruction from,
610
perigastric, 702
Aditus ad antrum, 316
Adrenalin chlorid in nasal operations, 183
in hemorrhage of stomach, 727
Advancement of capsule of Tenon, 177
of rectus muscle, 176
Aerocele, 218
After-cataract, operations for, 1 74
Air embolism, 430
fresh, to prevent adenoids, 208
insufflation of, in hydrothorax, 402
Alae nasi, collapse of, 195
Alcohol injections in coccygodynia, 358
Alimentary canal, operations on, prepara-
tion of patient for, 564
Allport's method of tattooing cornea, 153
Alternating strabismus, 175
Alum enema, 620
Alveolar abscess, 277
Ambulatory treatment of empyema, 407
Amebic colitis, 570
Anastomosis, intestinal, 646. See also In-
testinal anastomosis.
of anterior nerve roots in spinal canal,
348
Andrews' clamp method of intestinal anasto-
mosis, 676
Anemia, pernicious, 785
splenic, 785
Anesthesia, cocain, in eye operations, 118
for operations on pituitary body, 83
for tooth extraction, 278
holocain, in eye operations, 118
in adenoid operations, 209
in eye operations, 138
in nasal operations, 181
in operations on mouth, 245
in tonsillectomy, 213
Aneurism, arteriovenous, of cavernous sinus,
73
of scalp, 25
arteriovenous, 25
cirsoid, 25
Angina, Ludwig's, 362
Angioma of brain, 75
of breast, 475
of gums, 280
of lips, 254
of scalp, 25
Angular clamp for pyloroplasty, 747
INDEX OF SUBJECTS
795
Angulation of intestines, chronic obstruc-
tion from, 610
Ankyloblepharon, 119, 120
Anterior sclerotomy, 156
Antiseptics for eye use, 1 1 8
in bronchiectasis, 419
Antrum, mastoid, 299
maxillary. See Maxillary antrum.
of Highmore. See Maxillary antrum.
Anus, artificial, 687
closure of, 616
operation for securing muscular con-
trol of, 694
fissure of, chronic intestinal obstruction
from, 6 10
ulcer of, chronic intestinal obstruction
from, 610
Aphthous ulcers of tongue, 290
Apituitarism, 83
Apoplexy, spontaneous cerebral, 58
temporal craniotomy in, 58
Appendicostomy, 571
Appendix, anatomy, 624
exposure of, incision for, 510
Arachnoid space, tapping of, 348
Arch, supra-orbital, 46
Arteries, carotid, wounds of, 360
intercostal, wounds of, 398
internal mammary, wounds of, 398
middle meningeal, 47
Arterio venous aneurism of scalp, 25
Arthritis deformans, Streptococcus viridans
theory of, 613
of sternoclavicular joint, 398
Artificial anus, 687
closure of, 616
operation for securing muscular con-
trol of, 694
larynx, Gluck's, 236
pneumothorax in tuberculosis, 416
Ascites, 557 _
anastomosis of saphenous vein with
peritoneum in, 560
of vena cava with portal vein in, 561
with superior mesenteric vein in,
563
aspiration in, 557
drainage into bladder in, 561
Eck's fistula in, 561
intra-abdominal adhesions in, artificial
formation of, 558
nutmeg liver in, 558
subcutaneous drainage in, 559
tapping in, 557
Aspiration in ascites, 557
in drainage in abdominal operations,
526
in hydrothorax, 401
Asthma, thymic, 394
Atomizer, 181
Atonic dilatation of stomach, chronic, 713
Atresia of esophagus, 433
of lacrimal canals, 136
of puncta lacrimalia, 136
Atrophic rhinitis, 187
Atrophy of bones of skull, 41
of optic nerve, 135
Atropin as mydriatic, 117
Auditory canal, external, 299, 304
acute circumscribed inflammation of,
304
animate bodies in, 305
cellulitis of, 304
cholesteatoma of, 306
diffuse inflammation of, 304
eczema of, 304
epithelial plug in, 306
examination of, 302
exostoses of, 304
foreign bodies in, 305
impacted cerumen in, 305
inanimate bodies in, 305
keratosis obturans in, 306
mycosis of, 304
wounds of, 304
nerve, injuries of, 63
sensory center of brain, 45
Aural specula, 302
Auricle, 303
boils of, 304
cellulitis of, 303
congenital defects, 303
excessive development of, 303
frost-bite of, 304
furuncles of, 304
hematoma of, 303
lobule of, cleft, 303
malformations of, 303
perichondritis of, 303
right, paracentesis of, 425
skin diseases of, 304
supernumerary, 303
wounds of, 303
Auricular point, 45
Auriculotemporal craniotomy for exposure
of Gasserian ganglion, 106
Autoserotherapy in hydrothorax, 402
Avulsion of scalp, 23
complete, 23
Axilla, cancer of, extensive recurrent, 494
lymphatics of, 472
BABIES, mastoid operation on, 318
Back, painful, 350
Banti's disease, 785
Barraquer's method of cataract extraction,
174
Beer and Elsberg's method of laminectomy
in medullary tumors of spinal cord, 341
Bellocq's canula in nasal hemorrhage, 185
Benign tumors of breast, 475
incisions for removal, 477
of stomach, 703
Bifid tongue, 286
uvula, 255
Bilateral torticollis, 375
Biliary calculus, 780
cirrhosis, 785
Binder for abdominal operations, 520
Bismuth paste in empyema, 412, 413
in chronic suppurative otitis media,
310
Bites of insects on mouth, 247
Bladder, drainage into, in ascites, 561
Blad's method of drainage in ascites, 560
Blastomycosis of eyelids, 120
796
INDEX OF SUBJECTS
Blepharitis, 119
squamous, 119
Blepharophimosis, 119, 120
Blepharoplasty, 142
for resection of eyelids, 147
Blepharospasm, 120
Blepharotomy, 143
Blindness with brain tumors, 178
Blood-cysts, mesenteric, 564
Blood-vessels, wound of, cut-throat with, 360
Blowing nose in nasal infections, 186
Bode's position for drainage, 528
Body, ciliary. See Ciliary body.
Bogojawlensky's osteoplastic flap operation
on pituitary body, 88
Boils of auricle, 304
Boldt's binder for abdominal dressings after
operation, 520
Bone drill, brace for, 29
temporal, infections of, intracranial com-
plications, 318
Bone-cutting forceps, linear, Hudson's, 29
Bones of ear, 299
of skull. See Skull, bones of.
turbinated, 179
Bone-saw, Gigli's wire, 29
Bonninghaus' method of obliterating max-
illary antrum, 197
Bougies, esophageal, 434
olive, 434
Braces, metallic, in Pott's disease, 333
Bradford's frame in Pott's disease, 328
Brain, abscess of, 73, 319
indications for operation, 73
technic of operation, 74
anatomy, 43
angioma of, 75
auditory sensory center of, 45
bulging of, in operation, prevention, 51
carcinoma of, 75
compression of, 53
venesection for, 54
concussion of, 52
cortex, motor area of, anatomy, 44
sensory area of, 45
cortical function topography, 45
contusions of, 52 j
cystoma of, 75
decompression of, 54
electric reaction of motor areas, testing
for, 51
endothelioma of, 75
fibroma of, 75
foreign bodies in, 63
glioma of, 75
gliosarcoma of, 75
hernia of, 64
hypophysis of. See Pituitary body.
inflammations of, 73
injuries of, 63
lateral ventricle of, 48
lipoma of, 75
myxoma of, 75
olfactory sensory center of, 45
operations on, advantages of outward
dislocation in, 51
hexamethylenamin to prevent menin-
gitis after, 52
Brain, operations on, lumbar puncture in, 5 1
preventing bulging in, 51
psammoma of, 75
reading center of, 44
sinuses of, 44
lateral, 47
skull and, relations, 46
special sensation areas of, 45
speech center of, 44
substance, hemorrhage into, 57
superior longitudinal sinus of, 47
surface topography, 44
syphilis of, 75
teratoma of, 75
topography of, 48
tuberculosis of, 75
tumors of, 75. See also Tumors of brain.
visual sensory center of, 45
wounds of, 6 1
bullet, 62
stab, 62
writing center of, 44
Blood-letting. See Venesection.
Branchial cysts of neck, 372
fistulae of neck, 372
Breast, 471
adenofibroma of, 475
adenoma of, cystic, 475
angioma of, 475
benign tumors of, 475
caked, 473
cancer of, 477
contraindications to operation, 477
cure, 477
doubtful, operations in, 478
early and complete extirpation of, 477
extensive recurrent, 494
inoperable, 494
lines of incision in, 480
lymph glands in, 479
operation in, 477, 489
after-treatment, 488
closure of wound, 486, 492
drainage, 488
dressing, 488
radical cautery, 492
saving of blood, 486
shock in, 486
steps, 480
prevention, 477
prognosis, 478
recurrence, operations for, 478
tissues to be removed in, 479
congenital anomalies, 472
contusions of, 472
cystadenoma of, 475
cysts of, 476
dermoid cysts of, 477
female, anatomy 471
fistula of, chronic, 474
foreign bodies in, 472
hydatid cysts of, 477
hypertrophy of, 472
senile parenchymatous, 475
lipoma of, 475
lymphatics of, 472
male, cancer of, 497
chronic mastitis in, 497
INDEX OF SUBJECTS
797
Breast, male, tumors of, 497
myxoma of, intracanalicular, 475
neuralgia of, 473
nerves of, 475
papillomatous cysts of, 477
simple cysts of, 477
tuberculosis of, 475
tumors of, benign, incisions for removal,
477
mixed, 475
wounds of, 472
Bregma, 45
Brinsmade's operation for securing muscu-
lar control of artificial anus, 694
Bronchi, distention of, 419. See also Bron-
chiectasis.
foreign bodies in, 224
removal, 244
pneumotomy for, 456
strictures of, 422
Bronchiectasis, 419
advanced, 419
antiseptics in, 419
colloidal silver in, 419
ligation of pulmonary artery in, 420
mild, 419
phrenic neurectomy in, 420
pneumectomy in, 420
pneumolysis in, 420
pneumotomy in, 419
superheated air inhalations in, 419
thirst cure, 419
thoracoplasty in, 420
Bronchoscopy, 225, 239
lower, 243
position of patient for, 240
superior, 242
Brophy's method of operation in cleft-
palate, 265
Bryant's method of posterior osteoplastic
thoracotomy, 462
Bulbus oculi, 115, 116
Bullet wounds of abdominal wall, 535
compression treatment, 536
of brain, 62
of intestines, perforating, 567
of spine, 325
Burns of conjunctiva, 124
of cornea, 128
of larynx, 219
of neck, 373
of tongue, 288
of trachea, 219
Burrs, Doyen's, 27, 29
Hudson's, 28, 29
Bursal cysts of neck, 372
Button method of intestinal anastomosis,
667
lateral, 671
CACHEXIA hypophyseopriva, 83
Caked breast, 473
Calcium hypochlorite in peritonitis, 551
Calculi, biliary, 780
of salivary ducts, 291, 379
pancreatic, 783
Calot's high jacket in Pott's disease, 332
Camphorated oil in peritonitis, 551
Canal, external auditory, 299, 304. See
also Auditory canal, external.
Fallopian, 299
Canals, lacrimal, atresia of, 136
enlargement of, 177
Cancer, abdominal, inoperable, 706
infection, 706
of abdominal wall, 538
of axilla, extensive recurrent, 494
of brain, 75
of breast, 477. See also Breast, cancer of.
of cardia, resection for, 756
of cecum, 589
of colon, 584
of descending colon, 590
of hepatic flexure of colon, 590
of intestines, 583, 588
of larynx, 223
of lower part of sigmoid, 591
of lymphatics of neck, 363
of male breast, 497
of middle and upper sigmoid, 592
of transverse colon, 590
of neck, extensive recurrent, 494
secondary, 372
of nipples, 473
of nose, 1 88
of pyloric end of stomach, radical opera-
tion for, 756
of pylorus, 720
of sigmoid, 589
of skull, 42
of splenic flexure of colon, 590
of stomach, 703
choice of operation in, 704
doubtful, exploratory operation in, 703
gastrectomy in, 704
gastro-enterostomy in, 704
gastrojejunostomy in, 705
gastrostomy in, 705
inoperable, 704
involvement of transverse mesocolon in,
705
operative mortality, 704
palliative operations in, 704
pyloric, operation for, 756
recurrence, 704
symptoms, 703
of thorax, extensive recurrent, 494
of thyroid gland, 381
of tongue, 292
excision in, 293. See also_Excision of
tongue.
operation in, 364
of upper part of rectum, 591
Cancrum oris. 247
Canthoplasty, 143
for enlarging palpebral fissure, 142
Canula, Bellocq's, in nasal hemorrhage,
185
Capsule, Tenon's, advancement of, 177
Capsulotomy, preliminary, fort immature
cataract, 168
Cardia, cancer of, resection for, 756
Cardiac orifice of stomach, 698
stenosis of, 715
798
INDEX OF SUBJECTS
Cardiolysis for pericardial adhesions, 424
Cardiorrhaphy, 427
Cardiospasm, 716
Cargile's membrane to prevent adhesions in
abdominal operations, 522
Caries of ribs, 398
of teeth, 275
Carotid artery, wounds of, 360
gland, 395
Carr's clamp for scalp operations, 21
Carter's nasal splint, 180
Cartilages, costal, necrosis of, 398
resection of, in rigidity of chest, 421
laryngeal, dislocations of, 220
nasal, transplanting of, 192
Caseous tonsillitis, 212
Cataract, 132
after-, operations for, 174
artificial ripening in, 133
best time for operation, 133
congenital, 133
couching, 172
depressing, 172
discissipn of, 169
extraction, accidents in, 167
after-treatment, 166
combined, 166
linear, 170
of crystalline lens without incision of
capsule in, 170
simple, 165
suction in, 173
suturing corneal wound after, 172
two-stage, 171
vacuum, 174
with capsule after subluxation, 171
without iridectomy, 165, 166
immature, intracapsular extraction, 171
preliminary capsulotomy for, 168
monocular, 133
needle operation for, 169
operations for, 165
partial, 133
ripe, 133
secondary, operations for, 174
traumatic, 133
immediate removal, 173
zonular, 133
Catarrhal acute laryngitis, 220
tonsillitis, 212
epidemic conjunctivitis, 122
esophagitis, acute, 432
inflammation, acute, of frontal sinuses,
199
of maxillary antrum, 195
chronic, of frontal sinuses, 199
of maxillary antrum, 195
Catheterization of Eustachian tube, 302
Cauliflower ear, 303
Caustics, gastritis due to, 702
Cautery, actual, in ulcer of stomach, 724
radical, in cancer of breast, 492
Cavernous sinus, arteriovenous aneurism
in, 73
thrombosis of, 72
Cecostomy, 572
Cecum, anatomy, 624
Cecum, cancer of, 589
exposure of, incision for, 510
resection of, indications for. 642
tuberculosis of, 575
Cells, mastoid, 299
Cellulitis of auricle, 303
of external auditory canal, 304
of lips, 246
of neck, 361
superficial, 362
of parotid gland, 379
of scalp, 23
Cenencephalocele, 93
Cerebellar abscess, usual site, 50
Cerebellopontine angle, osteoplastic crani-
otomy for exposure of, 41
Cerebral abscess, usual site, 50
apoplexy, spontaneous, 58
temporal craniotomy in, 58
localization, 48
ventricles, lateral, puncture of, in hydro*
cephalus, 96
puncture of, in hydrocephalus, 95, 96
Cerebrospinal meningitis, epidemic, 67
carriers in, 67
Flexner's treatment, 67
lumbar puncture in, 67
rhinorrhea, 73
sinuses, 73
Cerumen, impacted, in external auditory
canal, 305
Cervical esophagectomy, partial, 443
esophagotomy, external, 442
mediastinotomy in esophageal abscess,
433
pleura, 399
ribs, 373
Chair, French's, for adenoid operations,
209
Chalazion, 120
Chapped lips, 246
Chenopodium oil in amebic colitis, 570
Chest, rigidity of, 421
wall, abscess of, 398
inflammations of, 398
penetration of, wounds of lung with, 413
tumors of, 444
wounds of, non-penetrating, 397
penetrating, 397
Chiari's incision for nasal approach to
pituitary body, 90
Children, acute simple rhinitis in, 186
Chipault's method of craniocerebral locali-
zation, 48, 49
primary lines, 48
secondary lines, 49
Chlorinated oil in peritonitis, 551
Choked disk, 135
Cholecystitis, 780
Cholesteatoma of external auditory canal,
306
Chondritis, 223
costal, 398
Chorda tympani, 299
Choroid, diseases of, 130
foreign bodies in, 130
injuries of 130
INDEX OF SUBJECTS
799
Choroid, rupture of, 131
tuberculosis of, 130
tumors of, 130
wounds of, 130
Choroiditis, 130
suppurative, 130
Cicatricial contractures of eyeball, old,
operations for, 159
stenosis of esophagus, 433
of pylorus, 720
Ciliary body, diseases of, 130
inflammation of, 130
wounds of, 130
Circular occlusion method of intestinal
anastomosis, 658
Circumscribed acute inflammation of ex-
ternal auditory canal, 304
Cirrhosis, biliary, 785
of stomach, 702
Cirsoid aneurysm of scalp, 25
Cisterna magna, drainage of, into cranial
sinuses, in hydrocephalus, 98
Clamp method of intestinal anastomosis,
676
Cleansing mouth, 244
Cleft eyelids, 119
lobule of auricle, 303
Cleft-palate, 257
early pressure treatment, 258
etiology, 257
operation in, 258
after-treatment, 265
best time for, 258
disturbed phonation after, 266
failure of union, 265
for closing narrow cleft, 259
wide cleft, 262
incisions for, 261
instruments for, 258
jaw-compressing, 265
later, 258
position of patient, 258
suture of intermaxillary segment, 258
voice-training after, 266
with sliding flap, 261
Climate in etiology of adenoids, 208
Cocain anesthesia in eye operations, 118
hydrochlorid as mydriatic, 118
Coccobacillus fcetidus ozcenae vaccines in
ozena, 188
Coccygeal neuralgia, 357
Coccygodynia, 357
alcohol injections in, 358
massage in, 358
removal of coccyx for, 359
Coffey's operation for relaxed abdominal
wall, 541
Colitis, 570
amebic, 570
colon irrigation in, 570
continuous irrigation in, 571
mucous, chronic intestinal obstruction
from, 610
Collapse of alae nasi, 195
peritoneal, 549
Colloidal silver in bronchiectasis, 419
Colon, acquired dilatation of, 614
Colon, acute flexures of, chronic intestinal
obstruction from, 610
obstruction of, 598
angulations of, chronic intestinal ob-
struction from, 610
ascending, anatomy, 625
resection of, indications for, 642
cancer of, 584
congenital dilatation of, 614
descending, anatomy, 625
cancer of, 590
dilatation of, chronic intestinal obstruc-
tion from, 610
hepatic flexure, cancer of, 590
ptosis of, 616
perforation of, 582
resection of, preventing obstruction to
passage of gas in, 644
splenic flexure, cancer of, 590
ptosis of, 616
transverse, anatomy, 625
cancer of middle of, 590
ptosis of, 616
resection of, with preservation of
omentum, 646
sagging of, with elongation of gastro-
colic ligament, in gastroptosis, 713
Colostomy, 573, 685
apparatus to collect feces after, 695
inguinal, left, 686
lumbar, 695
Colton's drainage tube in empyema, 408
Combined iridectomy and sclerotomy, 157
Compression of brain, 53
venesection for, 54
Concussion of abdomen, 535
of brain, 52
of spinal cord, 324
of thorax, 397
Condyloid point of inferior maxilla, 45
Congenital anomalies of breast, 472
cataract, 133
cysts of neck, 372
defects of external ear, 303
idiocy, 103
imbecility, 103
insanity, 103
stenosis of esophagus, 433
of larynx, 218
of trachea, 218
Conical cornea, operations for, 153
Conjunctiva, burns of, 124
diseases of, 121
eczema of, 123
foreign bodies in, 124, 127
hyperemia of, 121
inflammation of, 121. See alsoj Con-
junctivitis.
injections under, 151
operations on, 149
skin diseases involving, 1 24
tumors of, 124
wounds of, 121, 124
Conjunctivitis, acute contagious, 122
diphtheric, 123
diplobacillus, 122
epidemic catarrhal, 122
800
INDEX OF SUBJECTS
Conjunctivitis, follicular, 123
gonorrheal, 123
granular, 123
neonatorum, 122
non-gonorrheal, 122
phlyctenular, 123
pseudomembranous, 123
purulent non-specific, 121
simple, 121
sympathetic, 130
vernal, 123
Connell's end-to-end anastomosis with
mattress sutures, 651
Constipation, chronic, in chronic intestinal
stasis, 613
Contagious conjunctivitis, acute, 122
Continuous gastric lavage, 701
intestinal suture, 620
Contractures of eyeball, old cicatricial,
operations for, 159
Contusions of abdomen, 535
of brain, 52
of breast, 472
of face, 115
of intestines, 565
of larynx, 219
of scalp, 17
of spinal cord, 324
of thorax, 396
of trachea, 219
Coprostasis, chronic intestinal obstruction
from, 6 10
Cord, spinal. See Spinal cord.
Cornea, adhesions of, to iris, 156
burns of, 128
conical, operations for, 153
diseases of, 124
eczema of, 125
foreign bodies in, 127
inflammation of. See Keratitis.
method of inspection, 116
opacity of, 126
operations on, 152
paracentesis of, 152
tattooing of, 152
transplantation of, 153
tumors of, 128
ulcers of, 125
simple, 125
wounds of, 121, 128
Corneal opacity, 126
Coronal suture, 45
Corrosive esophagitis, 432
Corset, decompression, in scoliosis, 354
in Pott's disease, 334
in scoliosis, 353
Costal cartilages, excision of, for exposure of
heart and pericardium, 424
necrosis of, 398
resection of, in empyema, 419
in rigidity of chest, 421
chondritis, 398
joints, arthritis of, 398
pleura, anatomy, 399
Couching cataract, 172
Cracks of tongue, 289
Craniocerebral localization, 48
Craniocerebral localization, Chipault's
method, 48, 49
Reid's method, 49
topography, 45
Craniotabes, 41
Craniotomy for exposure of Gasserian
ganglion, 106
auriculotemporal, 106
control of hemorrhage in. 109
dividing sensory root, 107
high temporal, 106
intracranial method, 107
low temporal, 106
mortality, 109
operation of choice, 109
position of patient for, 108
removing ganglion in, 107
part of ganglion in, 108
results, no
special modifications, 108
subtemporal, 106
two-stage operation, 108
in intracranial hemorrhage in newborn,
61
osteoplastic, 30, 34
administration of anesthetic, 31
cutting bone flap in, 32, 33
flap method, 38
in occipital region, 31
incisions for, 31
intermuscular temporal, 36
method of applying drainage in, 35
occipital, bilateral, 38, 40, 41
unilateral, 37, 39
position on table for, 31
preparation of patient, 30
suboccipital, 36
temporal, 34, 36
two-stage operation, 32
subtemporal, 106
temporal, in spontaneous cerebral apo-
plexy, 58
Crile's method of laryngectomy, 235
of ligation of thyroid gland, 393
of thyroidectomy, 392
Crises, gastric, of tabes, excision of spinal
ganglia in, 348
rhizotomy for, 347
Cryer's spiral osteotome, 28
Cryptophthalmos, 119
Crystalline lens, diseases of, 132
dislocation of, 134
extraction of, without incision of
capsule, in cataract, 170
foreign bodies in, 133
Curvature of spine, lateral, 352. See also
Scoliosis.
urved needle for intestinal suture, 627
ushing's approach in operations on pit-
uitary body, 88
method for suboccipital unilateral crani-
otomy, 38
parallel continuous stitch in intestinal
suture, 631
rubber tourniquet for scalp operations,
20, 21
Cut-throat with wound of air-passages, 360
INDEX OF SUBJECTS
801
Cut-throat with wound of blood-vessels, 360
Cyclitis, 130
Cyclodialysis, 157
in glaucoma, 161
Cyst, Meibomian, 120
mesenteric, 564
of breast, 476
of eyelids, 138
of intestinal wall, 582
of intestines, gaseous, perforation of,
S.8i
of jaws, 286
of lung, echinococcus, 445
of maxillary antrum, 197
of neck, 372
of omentum, 620
of pancreas, 783
of spleen, hydatid, 785
of stomach, 703
of teeth, 280
of tongue, 292
of umbilicus, 537
of urachus, 538
retroperitoneal, 564
sebaceous, of face, 115
of scalp, 24
Cystadenoma of breast, 475
Cystic mastitis, chronic, 474
Cystoma of brain, 75
of lips, 254
Czerny's mucosa suture of intestine,
635
DACRYOCYSTITIS, 136
Davis' operation for ectropion, 146
Deafness, advanced tympanic, 319
Decompression corset in scoliosis, 354
in brain tumors, 78
in epilepsy, 101
of brain, 54
Decortication of lung in chronic non-
tuberculous empyema, 410
Defects, congenital, of auricle, 303
Deflections of nasal septum, 188
Deformities of jaws, 280
of lower jaw, with defective occlusion,
283
of skull, 42
Deguise's method of closing parotid sali-
vary fistula, 377
Delatour's apparatus for collecting feces
after colostomy, 695
Dench's operation in middle-ear disease
with labyrinthine involvement, 321
Depressing cataract, 172
Dermoid cysts of breast, 477
tumors of scalp, 24
DeSchweinitz's rules for enucleation of the
eye, 130
Desmarres' operation for pterygium, 150
Detachment of retina, 134
DeWecker's operation for staphyloma, 152
Diabetes, soft eyeball in, 132
Diabetic iritis, 1 29
retinitis, 134
Diaphragm, hernia of, treatment, 470
thoracic exposure of, 467
VOL. II— 51
Diaphragm, tumors of, treatment, 470
wounds of, 398, 536
Diaphragmatic pleura, 399
Diaphragmotomy, subpleural, for sub
phrenic abscess, 554, 555
Dichloramin in peritonitis, 551
Dickinson's rubber retractor, 515
Dieffenbach's operation for ectropion, 146
Diffuse inflammation of external auditory
canal, 304
Dilatation of colon, acquired, 614
chronic intestinal obstruction from,
610
congenital, 614
of esophagus, 438
of stomach, 713
acute, 615, 714
chronic, atonic, 713
gastroplication in, 714
postoperative, 615
Dionin in diseases of cornea, 1 24
in eye diseases, 118
Diphtheria, 207
Diphtheric conjunctivitis, 123
Diplobacillus conjunctivitis, 122
Direct laryngoscopy, 240
Disk, choked, 135
Dislocations of crystalline lens, 134
Diverticula, intestinal, 603
of esophagus, 438
extirpation of, 439
Doyen's burr, 27, 29
hand saw for linear bone incisions, 30
Drainage in abdominal operations, 524
of maxillary antrum, 195
of pancreas, 780
in peritonitis, 547, 549
subcutaneous, in ascites, 559
Drill, bone, brace for, 29
Drum, ear, 299. See Tympanic membrane.
Dry laryngitis, 222
Duboisin sulphate as mydriatic, 118
Duct, thoracic. See Thoracic duct.
Duodenal fistula, 582
lavage, 701
ulcer, 576
gastrojejunostomy in, 578
indications for operation in, 577
intermittency in, 577
jejunostomy in, 578
operative treatment, 577
perforating, 579
permanent occlusion of pylorus for,
578
pyloroplasty in, 578, 740
reconstruction operation after, 775 _
Duodenostomy in corrosive esophagitis
432
Duodenum, anatomy, 621
exposure of, route for, 780
occlusion of, 615
ulcer of, reconstruction operation after,
775
Dura mater, anatomy, 43
venous sinuses of, thrombosis of, 70
infective, 71
wounds of, 61
802
INDEX OF SUBJECTS
Dysentery, tropical, 570
Dyspeptic ulcers of tongue, 289
Dyspnea after operation in harelip, 274
thymic, 395
EAR, 299
anatomy of, 299
bones of, 299
cauliflower, 303
drum, 299. See Tympanic membrane.
external. See Auricle.
middle. See also Middle ear.
ossicles of, 299
postmeatal triangle of, 300
running, 310
Ecchymosis of eyelids, 121
Echinococcus cysts of abdominal wall,
538
of lung, 445
of neck, 372
Eck's fistula in ascites, 561
Ectropion, 119, 120
operations for, 144
Eczema of conjunctiva, 1 23
of cornea, 125
of external auditory canal, 304
of nipples, 473
Edema of glottis, 22
of optic nerve, intra-ocular, 135
papilla, engorgement, 135
Effusion, non-infective meningeal, 68
Electric reaction of motor areas of brain,
testing for, 51
Electrocautery in stricture of esophagus,
438
Electrode for testing electric reaction of
motor areas and nerves, 51
Electrolysis for dilatation of esophageal
stricture, 438
Elephantiasis nervosum of scalp, 24
Elevated-head position after abdominal
operations, 529
Elevator for tooth extraction, 279
Elliot's method of trephining sclera in
glaucoma, 162
Elongated mesocolon, 616
Elongation of uvula, 255
Elsberg and Beer's method of laminectomy
in medullary tumors of spinal cord, 341
apparatus for insufflation of lungs, 448
extrusion treatment of medullary tumors
of spinal cord, 342
incision for frontal approach to pituitary
body, 87
Embolism, air, 430
gas, from artificial pneumothorax, 417
Emetin in amebic colitis, 570
Eminence, frontal, 46
Emphysema, 400
of neck, 361
pulmonary, rib resection in, 419
subcutaneous, in artificial pneumothorax,
417
Empyema, 402
after-treatment, 404
ambulatory treatment, 407
bismuth paste in, 412, 413
Empyema. chronic non-tuberculous, 409
decortication of lung in, 410
removing plastic deposits from lung
in, 410
combined operations in, 411
delayed healing in, 404
Estlander's rib resection in, 410
internal thoracotomy for, 403
muscle implantation in, 411
of frontal sinuses, 199
of maxillary antrum, 195
of pericardium, 423
operation for, 403
without rib-resection, 408
promoting expansion of collapsed lung
after operation, 405
rib trephining for, 407
Schede's operation in, 411
securing increase of intrapulmonary
pressure after operation, 405
simple intercostal thoracotomy in, 403
suction in, after operation, 406
thoracoplasty in, 410
tuberculous, 413
valve device in, 406
Encephalitis, acute, 73
Encephalocele, 92
operation on, 93
Encephalocystocele, 93
Enchondroma of jaws, 286
Endameba buccalis, 277
Endonasal operations on lacrimal sac, 178
Endothelioma of brain, 75
Endolaryngeal operations, local anesthesia
in, 218
End-to-end intestinal anastomosis by in-
vagination method, 654
of segments of unequal size, 656
simple, 647
with mattress sutures, 651
End-to-side intestinal anastomosis, 665
Enemata, 620
Engorgement edema of optic papilla, 135
Enlarged thymus, 395
Enterectomy, partial, 636
Enteric feeding, 701
Entero-enterostomy, 646. See also Intes-
tinal anastomosis.
Enteroptosis, 616
Enterorrhaphy, 628. See also Intestinal
suture.
Enterostomy, 573, 683
for acute intestinal obstruction, 685
Entropion, 119, 120
operations for, 143
Enucleation of eyeball, 121, 157
grafting eyeball after, 160
remote, insertion of artificial globe
after, 159
rules for, 130
transplantation of fat into orbit after,
1 60
of growths in thyroid gland, 385
of tonsils, 213, 214
Ependyma, diseases of, 65
Epicanthus, 119
Epidemic catarrhal conjunctivitis. 122
INDEX OF SUBJECTS
803
Epidemic cerebrospinal meningitis, 67
carriers in, 67
Flexner's treatment, 67
lumbar puncture in, 67
Epigastrium, lipoma of, 538
Epilepsy, 99
curative effects of operations, 101
decompression in, 101
focal, 101
from tumors, 101
internal treatment, 102
of spontaneous origin, 101
prophylaxis, 99
removal of sympathetic ganglia of neck
in, 101
thymic, 385
traumatic causes, removal of, 100
with enlarged thymus, 101
Epileptic habit, 99
Epiphoria, 136
Episcleritis, 128
Epis taxis, 184
Epithelial plug in external auditory canal,
306
Epithelioma of face, 115
of gums, 280
of lower lip, 247
excision of lip for, 252
incomplete operation for, 250
operations for, 247-254
resection of lip for, 251
Epulis, 280
Erysipelas of scalp, 24
Eserin as miotic, 1 1 8
in acute intestinal stasis, 614
Esophageal bougies, 434
forceps, 440
Esophagectomy, partial cervical, 443
Esophagismus, 442
Esophagitis, acute catarrhal, 432
chronic, 433
corrosive, 432
gangrenous, 433
Esophagogastrojejunostomy, Roux's
method, 464
Esophagoplasty, 464
Esophagoscopes, 243
Esophagoscopy, 243
Esophagotomy, external cervical, 442
internal, in stricture of esophagus, 438
Esophagus, abscess of, 432
anatomy, 430
atresia of, 433
congenital stenosis of, 433
diverticula of, 438
extirpation of, 439
fissures of, 433
fistula of, 439
foreign bodies in, 440
removal, 244
operation for, 441
hemorrhage from, 432
inflammations of, 432
resection of, of lower segment, 470
rupture of, 432
spasm of, 442
stenosis of, cicatricial, 433
Esophagus, stricture of, 433. See also
Stricture of esophagus.
thoracic, resection of, 463
tumors of, 445
ulceration of, 432
ulcers of, 433
wounds of, 360, 431
Estlander's rib resection in empyema, 410
Ether, sulphuric, in peritonitis, 551
Ethmoid sinuses, 180
suppuration of, 197
operation in, by orbital route, 198
Ethyl morphin hydrochlorid, in eye dis-
eases, 118
Eustachian tube, 299
catheterization of, 302
patency of, 301
Eventration in intestinal gangrene, 609
in intussusception, 607
Eversion of eyelid, method, 116
operation for, 144
Evisceration of eyeball, 159
Excision of costal cartilage for exposure of
heart and pericardium, 424
of lacrimal sac, 178
of lower lip for epithelioma, 252
of non-toxic goiter, 385
control of hemorrhage, 388
results, 389
tracheotomy with, 389
of spinal ganglia in gastric crises ofi tabes,
348
of sternomastoid muscle in torticollis 375
of tongue for carcinoma, 293
after division of lower jaw, 297
after-treatment, 299
complete, 294
instruments for, 293
position of patient, 293
preparations, 293
through submaxillary incision, 297
without preliminary ligation of the
vessels, 296
operation in trachoma, 151
Exclusion, intestinal, 677
of pylorus, 771
Exfoliative glossitis, 289
Exophthalmic goiter, 390
Exophthalmos, extreme, in hyperthyroid-
ism, 391
pulsating, 137
in arteriovenous aneurism of cavernous
sinus, 73
Exostoses of external auditory canal
3°4
Exposure of nasopharynx, 216
External angular process of supra-orbital
arch, 46
auditory canal, 304. See Canal, external
auditory.
ear. See Auricle.
Extirpation of diverticula of esophagus,
439
Extraction of cataract. See Cataract ex-
traction.
of teeth, 278
anesthesia for, 278
804
INDEX OF SUBJECTS
Extraction of teeth, bleeding after, 279
technic, 278
with elevator, 279
Extradural abscess, 319
hemorrhage, 55
ligation of middle meningeal artery
in, 56
infections, 65
of otic origin, 65
Extramammary abscess, 474
Extrapial hemorrhage compressing spinal
cord, 325
Extrusion of iris, 121
of medullary tumors of spinal cord, 342
Eye, 115
anatomy, 115
anterior chamber of, abscess of, 128
drainage of, 152
antiseptics for, 118
diseases of, subconjunctival injections
in, 179
muscles of, 116
disorders of, 135
operations on, 1 74
paralysis of, 135
operations on, 138
cocain anesthesia in, 118
dressings for, 138
holocain anesthesia in, 118
instruments for, 138, 139
materials for, 119, 138
position of patient, 118
of surgeon, 119
preparation of patient, 118
of region for, 138
shield for, 138, 140
Eyeball, adhesion of eyelids to, operations
for, 150
enucleation of, 121, 157
grafting eyeball after, 160
remote, insertion of artificial globe
after, 159
rules for, 130
transplantation of fat into orbit after,
1 60
evisceration of, 159
implantation of artificial globe after,
iS9
iron foreign bodies in interior, removal
of, 1 60
old cicatricial contractures of, operations
for, 159
operations on, 157
soft, in diabetes, 132
turning forward of lid margin away from,
1 20
of lid border toward, 120
wounds of, 121
Eyelids, absence of, 119
adhesion of, to eyeball, operations for,
150
blastomycosis of, 120
cellulitis of, 119
cleft, 119
cohesion at outer angle, 119
with ball, 119
congenital anomalies, 119
Eyelids, cysts of, 138
diseases of, 119
ecchymosis of, 121
eversion of, method, 116
operation for, 144
granular, 123
herpes zoster of, 119 "
inability to close, 120
inflammation of margins, 119
injuries of, 120
inversion of, operations for, 143
operations on, 138
ptosis of, 119
operations for, 138
resection of, blepharoplasty for, 147
seborrhea of, 1 19
tumors of, 120
turning forward of margin away from
ball, 1 20
of border toward ball, 1 20
union between margins of, 119
upper, operation for restoration, 142
ptosis of, 1 20
wounds of, 121
FACE, contusions of, 115
epithelioma of, 115
inflammations of, 115
injuries and diseases of, 115
moles of, 115
nevi of, 115
sebaceous cysts of, 115
tumors of, 115
wounds of, 115
Facial nerve, injuries of, 63
Fallopian canal, 299
Faradism in hyperthyroidism, 390
Fat, transplantation of, into orbit, after
enucleation, 160
Fauces, operations on, 205
Fecal fistula, closure of, 616, 617
temporary, 619
permanent, 687
temporary, 686
with obstruction, closure of, 618
with spur, closure of, 618
Feces, impacted, chronic intestinal obstruc-
tion from, 610
Feeding after abdominal operations, 534
after intestinal operations, 778
after stomach operations, 778
enteric, 701
Femoral abscess in Pott's disease, 337
Fenger's operation in harelip, 267
Fergus' operation for ptosis of eyelids, 142
Ferguson's bandage for harelip, 269
Fetterolf's file for deviations of septum, 189
Fibro-adenoma of breast, 475
Fibroma molluscum of abdominal wall, 538
of brain, 75
of jaws, 286
of nasopharynx, 208
of peritoneum, 563
of scalp, 24
Fibroneuroma of scalp, 24
Fibrosarcoma, 280
of abdominal wall, 538
INDEX OF SUBJECTS
805
Fifth nerve, anatomy, 105
injuries of, 63
intracranial operations on, 105
for neuralgia, 115
Figure-of-eight suture, double, for closing
abdominal wound, 519
for closing abdominal wound, 519
Finney's method of pyloroplasty with
gastroduodenostomy, 741
Finochietto's method of introducing button
for lateral intestinal anastomosis, 673
Fissure, anal, chronic intestinal obstruction
from, 6 10
of esophagus, 433, 439
of lips, 246
of nipple, 473
of Sylvius, 46
Rolandic, 46
lower end, 46
Fistula, duodenal, 582
Eck's in ascites, 561
fecal, closure of, 618
temporary, 619
permanent, 687
temporary, 686
with obstruction, closure of, 618
with spur, closure of, 618
intestinal, closure of, 616
permanent, in lower small intestinej
685
temporary, 683
milk, 474
of breast, chronic, 474
of lacrimal gland, 136
of neck, branchial, 372
of umbilicus, 537
of urachus, 538
parotid salivary, 377
Fixation in torticollis, 373
Flexner's treatment of epidemic cerebro-
spinal meningitis, 67
Fluidity of vitreous, 134
Focal epilepsy, 101
Follicular conjunctivitis, 123
tonsillitis, 212
Forceps, esophageal, 440
Foreign bodies in accessory sinuses, 188
in brain, 63
in breast, 472
in bronchi, 224
pneumotomy for, 456
in choroid, 130
in conjunctiva, 127
in cornea, 127
in crystalline lens, 133
in esophagus, 440
operation for, 441
removal, 244
in external auditory canal, 305
in heart, 429
in larynx, 224
removal, 244
in maxillary antrum, 197
in nose, 188
in peritoneal sac, 544
in pharynx, 216
in sclera, 129
Foreign bodies in stomach, 714
removal, 244
in tongue, 287
in tonsils, 216
in trachea, 224
removal, 244
in vitreous, 134
intestinal obstruction from, 608
iron, in interior of eyeball, removal of,
1 60
Fowler's method of decortication of lung,
410
position for drainage, 528
Fractures of larynx, 219
of trachea, 219
Franck's method of gastrostomy through
external cone, modified, 734
Franke's method of avulsion of intercostal
nerves, 347 _
method of drainage in ascites, 560
Frazier's attachment for holding patient in
craniotomy, 37
method of frontal approach to pituitary
body, 87
French's chair for adenoid operations, 209
Friedman's safety p..j hemostat in scalp
operations, 20, 21
Froehlich's method of tattooing cornea,
153
Frontal eminence, 46
sinuses, 179
catarrhal inflammation of, acute, 199
chronic, 199
empyema of, 199
free opening of, 199
obliteration of, 202, 205
wide opening of, 200
Frost-bite of auricle, 304
Functional scoliosis, 353
Fundus of stomach, 698
Fungus cerebri, 65
Furrows of tongue, 289
Furuncles of auricle, 304
GAENSLEN'S method of osteoplastic lami-
nectomy, 344
Gag, mouth, 245
Galactocele, 477
Gall-bladder, exposure of, incision for,
Si3
Gall-stone disease, 780
Gall-stones, intestinal obstruction from,
608
Galvanism in hyperthyroidism, 390
Ganglia, sympathetic, of neck, removal, in
epilepsy, 101
Gangrene of intestines, 609
eventration for, 609
of lung, 415
Gangrenous esophagitis, 433
stomatitis, 247
Gas embolism from artificial pneumothorax,
417
Gaseous cysts of intestinal wall, 582
Gasserian ganglion, exposure of, craniotomy
for, 106
806
INDEX OF SUBJECTS
Gastrectomy in cancer of stomach, 704
partial, 751, 759
gastrojejunostomy after, 755
shock in, 776
total, 761
Gastric cancer, 703. See also Cancer of
stomach.
crises of tabes, excision of spinal ganglia
in, 348
rhizotomy for, 347
lavage, 700
continuous, 701
contraindications, 701
in peritonitis, 547, 550
indications for, 701
method, 700
ulcer, 720. See also Ulcer of stomach.
Gastritis due to caustics, 702
phlegmonous, 70 z
Gastrocolic ligament, elongation of, with
sagging of transverse colon, in gastro-
ptosis, 713
route of approach to pancreas, 779
Gastroduodenostomy, 747
pyloroplasty with, 741
Gastro-enterostomy, 762
feeding after, 778
in gastric cancer, 704
in gastroptosis, 713
in ulcer of stomach, 722
posterior, in pyloric stenosis, 719
shock in, 776
Gastro-esophagoplasty, Jianu's method,
465
Gastrohepatic route of approach to pan-
creas, 779
Gastro-intestinal tract, reconstruction of
wall, by tissue transplantation, 773
Gastrojejunal ulcer, 580
Gastrojejunostomy after resection of pyloric
end of stomach, 755
anterior, 769
in cancer of stomach, 705
in duodenal ulcer, 578
posterior, 762
Gastropexy in gastroptosis, 711
Gastroplasty by transverse incision in hour-
glass stomach. 709
for hour-glass stomach, 709
shock in, 776
Gastroplication in dilatation of stomach,
714
Gastroptosis, 710
elongation of gastrocolic ligament with
sagging of transverse colon in, 713
gastroenterostomy in, 713
gastropexy in, 711
hepatopexy in, 712
pressure pad in, 711
Gastroscopy, 244
Gastrostomy, 730
by canalization of stomach wall, 736
in cancer of stomach, 705
in stricture of esophagus, 436
through external cone, 734
through internal cone, 731
with external flap, 731
Gastrotomy, 730
in corrosive esophagitis, 432
Gauze drainage in abdominal operations,
S2S
Gibson's operation for resection of eyelids,
147
wooden clamp for lateral intestina
anastomosis, 665
Gigli's wire bone saw, 29
Gingivitis, 277
Glabella, 45
Gland, carotid, 395
lacrimal, 136
thymus, 394
thyroid, 380
Glanders of nasopharynx, 208
Glands, internal jugular, 363
occipital, 363
parathyroid, anatomy, 380
parotid, 363
retro-auricular, 363
retropharyngeal, 363
salivary, 377
submaxillary, 363
submental, 363
subparotid, 363
substernomastoid, 363
supraclavicular, 363
thyroid, accessory, 380
Glaucoma, 131
intravenous injections of glucose in,
132
iridectomy in, 131
malignant, 132
mydriasis in, 118
operations for, 161
osmosis treatment, 131
Glioma of brain, 75
of retina, 135
Gliosarcoma of brain, 75
Globe. See Eyeball.
Glossitis, acute parenchymatous, 288
exfoliative, 289
superficial, acute, 288
chronic, 288
Glottis, edema of, 221
spasm of, 221
Gliick's artificial larynx, 236
methods in laryngectomy, 233, 234
Glucose, intravenous injections of, in
glaucoma, 132
Glycerin enema, 620
Goiter, 381
contraindications to operation in, 382
exophthalmic, 390
incision for, 382
indications for operation in, 382
inflammation of, 380
intrathoracic, 446
non-toxic, excision of, 382
control of hemorrhage in, 388
results, 389
operative treatment, 382
vascular, operation on, 388
Gonorrhea! conjunctivitis, 123
iritis, 129
stomatitis, 247
INDEX OF SUBJECTS
807
Gottstein's treatment in atrophic rhinitis,
187
Gould's infolding right-angle mattress
suture of intestines, 634
method of end-to-side intestinal anasto-
mosis, 666
Gouty iritis, 129
Graduated tenotomy in heterophoria, 176
Grafting eyeball after enucleation, 160
of teeth, 279
Grafts, omental, in intestinal suture, 629
peritoneal, 544
Granular conjunctivitis, 123
eyelids, 123
Grattage operation in trachoma, 151
Graves' disease, 389
Green's direct-illumination esophagoscope,
243
Gridiron incision, intramuscular, in abdomi-
nal section, 510
Guillotine, 213
removal of tonsils with, 216
Gums, 274
angioma of, 280
epithelioma of, 280
inflammation of, 277
sarcoma of, 280
myeloid, 280
tumors of, 280
Gunshot wounds of tongue, 288
of spleen, 784
HABIT, epileptic, 99
Habitual torticollis, 377
Hahn's method of pylorodiosis, 737
Halsted's right-angle mattress stitch in
intestinal suture, 633
Hammock for lateral correction in scolio-
sis, 354
suspension, for applying jacket in Pott's
disease, 329
Hancock's operation for glaucoma, 161
Hand saw, Doyen's, for linear bone incisions,
3°
Hard-rubber bridge in saddle-nose, 194
Harelip, 206
deformed nostril with, 273
double, operation for, 271
lateral, operation for, 269
notched lip after, 273
operation for, 267
after-treatment, 273
dyspnea after, 274
failure of union in, 274
split-flap, 267
Harrington's segmented ring for intestinal
anastomosis, 674
Harris' diet in ulcer of stomach, 721
Hartley-Krause method of removing Gas-
serian ganglion, 108
Haynes' operation in meningitis, 70
Head, diseases of, 17
injuries of, 17
support of, in Pott's disease, 353
tower, 42
Heart, 424
anatomy, 424
exposure of, by plastic flap, 426
Heart failure of newborn, 430
foreign bodies in, 429
massage of, for syncope, 430
operative exposure, 424
reanimation of, 430
suture of, 427
wounds of, 428
penetrating, 429
Heineke and Mikulicz's method of pyloro-
plasty, 740
Heine's method of cyclodialysis, 157
Hematemesis, 727
Hematoma of auricle, 303
of scalp, 17
Hematomyelia, 325
Hemolytic jaundice, 785
Hemorrhage after extraction of teeth, 279
after tonsillectomy, 214
control of, in abdominal operations, 515
in goiter excision, 388
extradural, 55
ligation of middle meningeal artery
in, 56
extrapial, compressing spinal cord, 325
from esophagus, 432
from larynx, 223
from nose, 184
in abdominal operations, 523
control of, 515
in scalp wounds, control of, 18
into brain substance, 57
into retina, 135
into spinal cord, 325
into vitreous, 134
intra-abdominal postoperative, 524
intracranial, 54
in newborn, 60
craniotomy in, 61
labyrinthine, 319
of stomach, 727
operation for, 728
subarachnoid, 57
subdural, 56
Hemorrhagic cysts of neck, 372
retinitis, 134
Hemorrhoids, chronic intestinal obstruc-
tion from, 610
Hemostasis in mouth, 245
in nasal operations, 183
Hemostat, Friedman's, for scalp operations,
20, 22
Hemothorax, 400
Hepatopexy in gastroptosis, 712
Herbert's wedge-isolation operation for
glaucoma, 161
Hernia cerebri, 64
of brain, 64
of diaphragm, treatment, 470
Herpes of lips, 246
of nasopharynx, 208
of tongue, 288
zoster of eyelids, 119
Herpetic keratitis, 127
ulcers of tongue, 290
Hess' operation for ptosis of eyelids, 142
Heterophoria, graduated tenotomy in,
176
partial tenotomy in, 176
808
INDEX OF SUBJECTS
Hexamethylenamin to prevent meningitis
after brain operations, 52
High inguinal sigmoidostomy, 689
tracheotomy, 227
Highmore, antrum of, 179. See Maxillary
antrum.
Hirschsprung's disease, chronic intestinal
obstruction from, 610
Holocain anesthesia in eye operations, 118
Homatropin as mydriatic, 118
Hordeolum, 119
Hormonal in acute intestinal stasis, 614
Horny elevations of lips, 254
Hot-air treatment of chronic suppurative
otitis media, 309
Hour-glass stomach, 706
gastroplasty for, 709
by transverse incision, 709
Hudson's burrs, 28, 29
linear bone-cutting forceps, 29
Hydatid cysts of breast, 477
of spleen, 785
Hydrencephalocele, 92
Hydrocephalus, 94, 350
acquired internal, 95
congenital, subtemporal drainage in, 96
ventricular, 95, 97
subperitoneal drainage in, 97
drainage of cisterna magna into cranial
sinuses in, 98
external, 94. 95
puncture of cerebral ventricles in, 95, 96
Hydrothorax, 401
aspiration in, 401
autoserotherapy in, 402
insufflation of air in, 402
tuberculous, 413
Hygiene of mouth, 245
Hyoscin as mydriatic, 118
Hyperchlorhydria in ulcer of stomach,
treatment, 722
Hyperemia of conjunctiva, 121
Hyperplastic nasopharyngitis, 205
rhinitis, 187
Hyperthyroidism, 389
dangers of non-operative treatment, 391
extreme exophthalmos in, 391
faradism in, 390
galvanism in, 390
ligation of thyroid gland in, 393
operative treatment, 391
quinin and urea injections in, 390
radium in, 390
thyreoprivic serum in, 390
thyroidectomy in, 392
x -rays in, 390
Hypertrophic stenosis of pylorus, acquired,
720
subglottic laryngitis, 219
Hypertrophy of breast, 472
senile parenchymatous, 475
of lacrimal gland, 136
of spleen, 785
of thymus gland, 446
of tongue, 290
of tonsils, chronic, 212
of turbinates, i86j
Hypodermoclysis^in peritonitis, 550
Hypophysis of brain. See Pituitary body
Hypopyon, 128
keratitis, 126
operation for. 152
Hypothyroidism, 394
Hysteria, traumatic, 103
Hysterical spine, 355
IDIOCY, congenital. 103
Ileocecal valve, anatomy, 625
incompetent, 614
obstruction, 602
Ileocolostomy for tuberculosis of cecum,
575
in chronic intestinal stasis, 613
Ileum, anatomy, 624
Ileus, paralytic, 552
pituitrin in, 553
Ilio inguinal abdominal section, 510
Imbecility, congenital, 103
Imbedded tonsils, 216
Immature cataract, intracapsular extrac-
tion, 171
preliminary capsulotomy for, 168
Impacted cerumen in external auditory
canal, 305
Implantation, muscle, in empyema, 411
Incompetent ileocecal valve, 614
Incomplete tonsillectomy, 213
Incus, 299
Infancy, pyloric stenosis of, 717
Infections, extradural, 65
of abdominal wall, 536
of intestinal canal, 569
of mediastinum, 444
of scalp, 23
of temporal bone, intracranial complica-
tions of, 318
Infective diseases of cranial bones, 41
processes in neck, 361
thrombosis of venous sinuses of dura
mater, 71
Inflammations of brain, 73
of chest wall, 398
of conjunctiva, 121. See also Conjunc-
tivitis.
of esophagus, 432
of face, 115
of lacrimal gland, 136
of lips, 246
' of mouth, 246
of nipple, 473
of omentum, 620
of stomach, 702. See also Gastritis.
of thyroid gland, 380
Inguinal abscess in Pott's disease, 337
colostomy, left, 686
sigmoidostomy, 685
high, 689
low, 690
Inion, 45
Injuries, general, of neck, 360
of brain, 63
of choroid, 130
of head, treatment, 17
of intracranial nerves, 63
of larynx, 219
of meningeal sinuses, 64
INDEX OF SUBJECTS
809
Injuries of nose, 183
of peritoneum, 542
of spleen, 784
of tongue, 287
of trachea, 219
Inoperable abdominal carcinoma, 706
Insanity, 102
cases demanding operation, 103
congenital, 103
primary traumatic, 102
surgical treatment, 104
Insects, bites of, on mouth, 247
Instruments for operations on eye, '138
on nose, 180
leaving in abdomen in operations, pre-
vention, 516
Insufflation of air in hydrothorax, 402
of lungs, 446
apparatus for, 447
Intercostal artery, wounds of, 398
thoracotomy, simple, in empyema, 403
Interintestinal adhesions in abdominal
operations, 523
Intermuscular temporal craniotomy, 36
Internal angular process of supra-orbital
arch, 46
sclerotomy, 157
Interpleural pneumolysis in tuberculosis,
418
Interrupted intestinal suture, 628
Interstitial keratitis, 127
mastitis, chronic, 474
Intestinal anastomosis, 646
by circular occlusion method, 658
by clamp method, 676
by lateral implantation, 665
by simple invagination, 66 1
end-to-end, by invagination method,
654
of segments of unequal size,
656
simple, 647
with mattress sutures, 651
end-to-side, 665
invagination method, with ring or bob-
bin, 658
knitting needles for, 677
lateral, 661, 663
button method, 671
forming blind end in, 662
technic, 663
rubber ligature method, 675
with absorbable devices, 675
with button, 667
with knitting needles, 677
with mechanical devices, 666
with segmented ring, 674
canal, infections of, 569
exclusion, 677
fistula, closure of, 616
permanent, in lower small intestine, 685
temporary, 683
obstruction, 595, 599
acute, 595
enterostomy for, 685
angulation in, 600
at ileocecal valve, 602
chronic, 610
Intestinal obstruction, desperate' [cases, ,597
from adhesions, 600
from diverticula, 603
from foreign bodies, 608
from gall-stones, 608
from gangrene, 609
from intussusception, 604
from pericolic adhesions, 602
from strangulation by bands, 599
from stricture, 609
from volvulus, 608
in peritonitis, 553
operation in, 595
after-treatment, 598
preparations for, 595
operations, instruments for, 626
feeding after, 778
resection, 636
anastomosis after, 639
indications for, 639
sinus, closure of, 616
stasis, acute, 614
chronic, 610
colostomy for, 574
dietetic treatment, 611
ileocolostomy in, 613
Kellogg's treatment. 610
kinks from, 611
Lane's treatment, 614
vaccines in, 611
operation in, 611
suture, 628
continuous, 628
interrupted, 628
mattress interlocking stitch. 636
methods, 628
mucosa, 635
needles for, 627
omental grafts in, 629
parallel continuous stitch, 636
purse-string, 35
right-angle mattress stitch, 633
seromuscular, 629
mattress stitch, 633
simple right-angle stitch, 631
sterilization of mucous membrane in,
630
toxemia, chronic, 610
wall, cysts of, 582
Intestines, actinomycosis of, 575
adenoma of, polypoid, 582
anatomy, 621
cancer of, 583, 588
contusions of, 565
diverticula of, 603
inflammation of, acute phlegmonous, 574
irrigation of, indications for, 571
large, anatomy, 624
surface topography, 625
lumen of, closure of, 681
by purse-string suture, 681
transverse, 682
operations on, 621
perforation of, 576
malignant, 581
of gaseous cysts, 581
suppurative, 581
prolapse of, 616
810
INDEX OF SUBJECTS
Intestines, rupture of, 566
sarcoma of, 583
strangulation by bands, 599
submuscularis- mucous-membrane occlu-
sion of, 682
suture of, 628. See also Intestinal
suture.
tubercular perforation of, 581
tuberculosis of, 574
tumors of, 582
ulcers of, 576
wounds of, non-perforating, with wounds
of mesentery, 568
perforating, 567
suturing, 635
Intra-abdominal hemorrhage, postoperative,
524
Intracanalicular myxoma of breast, 475
Intracapsular extraction of immature cata-
ract, 171
Intracranial abscess of otic origin, 317
complications of infections of temporal
bone, 318
diseases, 42
hemorrhage, 54
in newborn, 60
craniotomy in, 61
injuries, 42
nerves, injuries of, 63
operations on fifth nerve, 105
for neuralgia, 115
on seventh nerve, no. See also
Seventh nerve.
structures, wounds of, 61
Intranasal treatment of sinus infections,
201
Intra-ocular edema of optic nerve, 135
Intrapulmonary pressure, increased for
operations through mediastina and pleu-
rae, 446
Intraspinal tumors, 338
Intrathoracic goiter, 446
Intravenous injections of glucose in glau-
coma, 132
Intubation of larynx, 237
indications for, 237
instruments for, 237
postoperative care, 239
technic, 238
Intussusception, 604
irreducible, 605
gangrenous, 607
non-gangrenous, 605
reducible, 605
resection in, 607
Invagination method of end-to-end in-
testinal anastomosis, 654
of segments of unequal size,
.656
of intestinal anastomosis, simple, 66 1
with ring or bobbin, 658
Inversion of eyelids, operations for, 143
Inverted nipple, 472
lodin in peritonitis, 550
Ipecac in amebic colitis, 570
Iridectomy, 154
combined with sclerotomy, 157
in glaucoma, 131, 161
Iridectomy with cataract extraction, 166
without cataract extraction, 165
Iridodialysis, 129
Iridotomy, 155
V-shaped, Ziegler's 156
Iris, adhesions of, to cornea, 156
diseases of, 129
extrusion of, 121
operations on, 154
tumors of, 129
wounds of, 1 29
Iritis, 129
diabetic, 129
gonorrheal, 129
gouty, 129
rheumatic, 129
syphilitic, 129
Iritoectomy, 155
Iron foreign bodies in interior of eyeball,
removal of, 160
Ironing for stiff neck, 373
Irrigation in peritonitis, 549
JACKET, plaster-of-Paris, in Pott's disease,
329, 335
Jackson's instruments for tracheoscopy
and bronchoscopy, 239
method of direct laryngoscopy, 240
of superior bronchoscopy, 242
operation in cancer of breast, 490
Janeway's method of gastrostomy with
external flap, 731
Jaundice, hemolytic, 785
Jaws, 280
cysts of, 286
defective occlusion of, 281
deformities of, 280
enchondroma of, 286
fibroma of, 286
lower, deformities of, with defective
occlusion, 283
division of, excision of tongue for carci-
noma after, 297
underdeveloped, 280
malocclusion of, with prognathism, 283
necrosis of, 286
odontoma of, 286
osteoma of, 286
osteomyelitis of, 283
periostitis of, 283
sarcoma of, 286
myeloid, 286
peripheral, 286
tumors of, 286
Jejunal ulcer, 580
Jejunostomy, 695
for duodenal ulcer, 578
indications for, 696
Jejunum, anatomy, 624
Jianu's method of gastro-esophagoplasty,
465
Joints, spinal, sprains of, 324
Jugular glands, internal, 363
vein, internal, wounds of, 360
Jury-mast in Pott's disease, 333
KADER'S method of gastrostomy, 734
Kellogg's treatment of chronic intestinal
stasis, 610
IXDEX OF SUBJECTS
811
Keloids of scalp, 24
Kenyon's method of craniotomy by osteo-
plastic flap method, 38
Keratitis, 124
bullosa, 127
herpetic, 127
hypopyon, 126
interstitial, 127
neuroparalytic, 126
operation for, 152
phlyctenular, 125
vascular, 127
with pus in anterior chamber, 126
xerotic, 127
Keratoconjunctivitis, nodular lymphatic,
125
Keratoconus, operations for, 153
Keratosis obturans in external auditory
canal, 306
of nasopharynx, 208
Killian's instruments for tracheoscopy and
bronchoscopy, 239
operation for obliteration of frontal sinus,
202—205
Klebs-Loffler membranous pharyngitis, 207
Knapp's expression operation in trachoma,
150
method of cataract extraction, 171
operation for pterygium, 150
for staphyloma, 152
in secondary cataract, 1 74
Knitting needles for intestinal anastomosis,
677
Kocher's method of excision of tongue for
carcinoma, 297
of gastroduodenostomy, 747
Korner's method in radical mastoid opera-
tion, 314
Krause's knife for operations on pituitary
body, 87
Kredel's metal bobbins for scalp operations,
21
Kronlein's method of approach to pan-
creas, 779
of cerebral localization, 50
Kuhnt-Szymanowski operation for ectro-
pion, 145
Kyphosis, 351
LABYRINTHINE disease, 319
radical mastoid operation in, 314
hemorrhage, 319
involvement following middle-ear sup-
puration, 320
Lacerated wounds of spleen, 784
Lacrimal apparatus, diseases of, 136
operations on, 177
canals, atresia of, 136
enlargement of, 177
gland, fistula of, 136
hypertrophy of, 136
inflammation of, 136
prolapse of, 136
removal of, 137, 178
of palpebral portion, 178
tumors of, 136
sac, endonasal operations on, 178
excision of, 178
Lacrimal sac, fistula of, 136
removal of, 136
sounds, 177
Lactation mastitis, 473
Lagophthalmos, 120
Lagrange's method of combined iridectomy
and sclerotomy, 157
Lambda, 45
Lambdoid suture, 46
Lambotte's method of drainage in ascites,
559
Laminectomy, 339
for paralysis in Pott's disease, 337
in medullary tumors of spinal cord, 341
indications for, 339
lumbar, in meningitis, 70
osteoplastic, 344
postoperative case, 343
results, 343
Lane's operation for cleft palate, 261
treatment of chronic intestinal stasis, 614
Laryngeal cartilages, dislocations of, 220
nerve, recurrent, anatomy, 380
Laryngectomy, after-treatment, 236
exceptional conditions in, 234
one-stage, 231
partial, 231
phonation after, 236
total, 231
two-stage, 235
Laryngismus stridulus, 221
Laryngitis, acute catarrhal, 220
chronic, 222
dry, 222
hypertrophic subglottic, 219
membranous, 221
stridulous, 221
Laryngoscopy, direct, 240
Laryngotomy, median, 230
transverse, 230
Laryngotracheotomy, 227, 230
Larynx, 217
acquired stenosis of, 218
anatomy, 217
artificial, Gliick's, 236
burns of, 219
cancer of, 223
congenital stenosis of, 218
contusions of, 219
examination, 217
foreign bodies in, 224
fractures of, 219
hemorrhage from, 223
inflammation, of, 220
injuries of, 219
intubation of, 237. See also Intubation
of larynx.
malformations of, 218
operations on, 217, 226
removal of foreign bodies from, 244
spasm of, 221
syphilis of, 223
treatment, 217
tuberculosis of, 222
tumors of, 223
wounds of, 220
Lateral curvature of spine, 352. See also
Scoliosis.
812
INDEX OF SUBJECTS
Lateral implantation method of intestinal
anastomosis, 665
intestinal anastomosis, 66 1, 663
button method, 671
forming blind end in, 662
technic, 663
sinuses of brain, 47
tarsorrhaphy, 143
ventricle of brain, 48
Lavage, duodenal, 701
gastric, 700
continuous, 701
contraindications, 701
in peritonitis, 547, 550
indications for, 701
method, 701
Laxative enema ta, 620
Left inguinal colostomy, 686
Lembert's simple right-angle stitch in
intestinal suture, 631
Lenhartz's treatment of ulcer of stomach,
721
Lens, crystalline, diseases of, 132
dislocation of, 134
extraction of, without incision of cap-
sule, in cataract, 170
foreign bodies in, 133
Leontiasis ossea, 41
Leprosy of tongue, 290
Leptomeningitis, 65
Leukemia, 786
Leukocythemic retinitis, 134
Leukoplakia of tongue, 289
Lewisohn's telescoping esophagoscope,
.243
Ligaments of spine, relaxation of, 357
sprains of, 357
Ligation of middle meningeal artery in
extradural hemorrhage, 56
of ophthalmic artery, 137
of pulmonary artery in bronchiectasis,
420
of thyroid gland, 393
Ligneous induration of neck, 362
Line, naso-inial, 46
nasolambdoidal, 45
Sylvian, 46
Linear extraction of cataract, 170
Lingual tonsil, diseases of, 290
Linitis, plastic, 702
Lip, lower, epithelioma of, excision of lip
for, 252
incomplete operation for, 250
operations for, 247-254
resection of lip for, 251
notched-, operation for, 273
Lipoma of abdominal wall, 538
of brain, 75
of breast, 475
of epigastrium, 538
of peritoneum, 563
of scalp, 24
of stomach, 703
Lips, angioma of, 254
cellulitis of, 246
chapped, 246
cystoma of, 254
fissure of, 246
Lips, herpes of, 246
horny elevations of, 254
inflammations of, 246
permanent enlargement of, 255
tumors of, benign, 254
ulcers of, 246
wounds of, 246
Liver, nutmeg, ascites in, 558
Lobule of auricle, cleft, 303
Local anesthesia in endolaryngeal opera-
tions, 218
in nasal operations, 181
Localization, cerebral, Kronlein's method,
5°
craniocerebral, 48
Chipault's method, 48, 49
Reid's method, 49
Lordosis, 352
Lorenz's reclining plaster-bed in Pott's
disease, 327
Loreta's method of pylorodiosis, 737
Lothrop's operation in empyema of frontal
sinuses, 199
Low inguinal sigmoidostomy, 690
tracheotomy 228
Lower bronchoscopy, 243
jaw, underdeveloped, 280
lip, epithelioma of, excision of lip for,
252
incomplete operation for, 250
operations for, 247-254
resection of lip for, 251
Ludwig's angina, 362
Lumbago, 350
Lumbar abscess in Pott's disease, 337
colostomy, 695
laminectomy in meningitis, 70
puncture, dangers of, in brain tumors,
77
in brain operations, 51
in epidemic cerebrospinal meningitis,
67
in non-infective meningeal effusion, 68
in tuberculous meningitis, 68
Lumbosacral pain, 350
Lungs, 413
abscess of, acute, 414
chronic, 415
rupturing into bronchus, 415
cysts of, echinococcus, 445
decortication of, in chronic non-tubercu-
lous empyema, 410
gangrene of, 415
insufflation of, 446
apparatus for, 447
operations on, 453
operative exposure of, 453
in two stages, 456
of apex, 456
resection of, in tuberculosis, 416
rupture of, 413
tuberculosis of, 416. See also Tuber-
culosis.
tumors of, 445
wounds of, suturing of, 414
with penetration of chest wall, 413
with pleural infection, 414
Lupus of pharynx, 207
INDEX OF SUBJECTS
813
Lymphatic cysts of neck, 372
nodular keratoconjunctivitis, 125
Lymphatics of axilla, 472
of breast, 472
of neck, anatomy of 363
carcinoma of, 363
diseases of, 363
of stomach, 699
Lymph-glands of neck, tuberculous, 368
non-surgical treatment, 369
operation for, 370
Lymphoma of neck, malignant, 372
MACROCHEILIA, 255
Macroglossia, 290
Malarial hypertrophy of spleen, 785
Malformations of auricle, 303
of larynx, 218
of nasal septum, 188
of trachea, 218
Malignant glaucoma, 132
tumors. See Cancer.
Malleus, 299
Malocclusion of jaws with prognathism,
283
of lower jaw, 281
Malposition of puncta lacrimalia, 136
Mammary artery, internal, wounds of,
398
Massage, cardiac, for syncope, 430
in coccygodynia, 358
Mastitis, acute, 473
chronic, 474
cystic, 474
of male breast, 497
interstitial, chronic, 474
lactation, 473
stagnation, 473
Mastoid antrum, 299
cells, 299
operation, 316, 317
first change of dressing, 318
indications for, in acute otitis media,
308
on babies, 318
radical, 312
in labyrinthine disease, 314
indications for, in chronic suppura-
tive otitis media, 311
Korner's method, 314
Panse's method in, 315
technic, 312
Mastoiditis, acute, operation for, 317
chronic, operation for, 316
radical, 312. See also Mastoid
operation, radical.
Mattress sutures, end-to-end intestinal
anastomosis with, 651
Maunsell's invagination method of end-to-
end intestinal anastomosis, 654
Maxilla, inferior, condyloid point of, 45
Maxillary antrum, acute catarrhal inflam-
mation of, 195
chronic catarrhal inflammation of,
iQS
drainage of, 195
empyema of, 195
foreign bodies in, 197
Maxillary antrum, free opening of, 196
mouth and, closure of sinuses between,
197
obliteration of, 196
tumors of, 197
sinus, 179
Mayer's operation in osteomyelitis of spine,
326
Mayo's method of posterior gastro-enter-
ostomy, 767
McBurney's intramuscular gridiron in-
cision for abdominal section, 510
point, 510
McGraw's rubber ligature method of in-
testinal anastomosis, 675
Meatus, inferior, of nose, 179
middle, of nose, 179
superior, of nose, 179
Median abdominal section, 510
low, by superficial transverse in-
cision, 513
fistulae of neck, 372
laryngotomy, 230
tarsorrhaphy, 143
Mediastina, 444
exposure of, anterior, 458
by median division of sternum, 459
posterior, 459
operations on, 458
with increased intrapulmonary pres-
sure, 446
Mediastinotomy, cervical, in esophageal
abscess, 433
Mediastinum, abscess of, 444
anterior, 458
infections of, 444
middle, 458
posterior, 458
superior, 458
tumors of, 446
Medullary tumors of spinal cord, extru-
sion treatment, 342
laminectomy in, 341
Megacolon, 614
Meibomian cyst, 120
Meltzer's method of insufflation of lungs,
447
Membrane, tympanic, 299
operations through, in chronic otitis
media, 311
wounds of, 301
Membranous laryngitis, 221
pericolitis, 602
pharyngitis, Klebs-Loffler, 207
rhinitis, 186
stomatitis, 247
tonsillitis, 212
Meniere's disease, 319
Meningeal artery middle, 47
ligation of, in extradural hemor-
rhage, 56
effusion, non-infective, 68
sinuses, injuries of, 64
Meninges, diseases of, 65
tumors of, 75
wounds of, 6 1
Meningitis after brain operations, hexa-
methylenamin to prevent, 52
814
INDEX OF SUBJECTS
Meningitis, epidemic cerebrospinal, 67
carriers in, 67
Flexner's treatment, 67
lumbar puncture in, 67
lumbar laminectomy in, 70
of otic origin, 66
operative treatment, 69
subdural, 65
pyogenic organisms in, 66
syphilitic, 68
tuberculous, 68
Meningocele, 92, 349
spurious, 25
Mercurial ulcers of tongue, 290
Mercury for dilatation of esophageal stric-
ture, 435
Mesenteric blood-cysts, 564
cysts, 564
triangle, 625
tumors, 563, 564
vein, superior, anastomosis of, with vena
cava, in ascites, 563
vessels, stoppage of, gangrene of in-
testines from, 609
Mesentery, long, chronic intestinal ob-
struction from, 6 10
wounds of, 568
non-perforating wounds of intestine
with, 568
Mesocolon, elongated, 616
transverse, involvement of, in gastric
cancer, 705
Metallic braces in Pott's disease, 333
Meteorism after abdominal operations,
532
Meyer's method of resection of cardiac
end of stomach, 758
operation in cardiospasm, 716
pneumatic cabinet for negative and posi-
tive pressure in thoracic surgery, 451
transverse abdominal incision, 508
Micrococcus catarrhalis vaccines in ozena,
1 88
Middle ear, 306
curettage of, in chronic suppurative
otitis media, 311
inflammation of, acute, 306. See also
Otitis media, acute.
Midsagittal point, 45
Midzygomatic point, 45
Mikulicz's gauze envelop drain in abdomi-
nal operations, 526
method of pyloroplasty, 740
Milk and molasses enema, 620
fistula, 474
Milliner's needle for intestinal suture, 627
Miotics, use of, 118
Mixed enema, 620
Molasses and milk enema, 620
Moles of face, 115
Monocular cataract, 133
Morphin after abdominal operations, 531
Motais' operation for ptosis of eyelids,
142
Motor area of brain cortex, anatomy,
44
electric reaction of, testing for,
Si
Mouth, 244
examination of, 245
hemostasis in, 245
hygiene of, 245
inflammations of, 246
insect bites on, 247
maxillary antrum and, closure of sinuses
between, 197
operations on, anesthesia in, 245
Mouth-gag, 245
Moynihan's angular clamp for pyloro-
plasty, 747
method in intestinal suture, 628
Mucocele of maxillary antrum, 197
Mucosa suture of intestine, 635
Murphy's button method of intestinal
anastomosis, 667
Muscae volitantes, 134
Muscle implantation in empyema, 411
Muscles of eye, 116
disorders of, 135
operations on, 174
paralysis of, 135
Mycosis of external auditory canal, 304
of nasopharynx, 208
of tonsils, 212
Mycotic stomatit s, 246
Mydriatics in glaucoma, 118
use of, 117
Myelocystocele, 349
Myeloid sarcoma of gums, 280
of jaws, 286
Myelomeningocele, 349
Myoma of stomach, 703
Myxoma of brain, 75
of breast, intracanalicular, 475
NASAL cartilage, transplanting of, 192
cavities, infections of, 186
duct, occlusion of, 136
infections, specific, 188
septum, 179
anatomy, 89
deflections of, 188
forceps, 191
malformations of, 188
perforation of, 195
submucous resection of, 190
speculum, 181
splints, 1 80
synechia, 195
Nasion, 45
Naso-inial line, 46
Nasolambdoidal line, 45
Nasopharyngitis, hyperplastic, 205
syphilitic, 205
Nasopharynx, actinomycosis of, 208
adenoids of, 208. See also Adenoids.
exposure of, 216
fibromata of, 208
glanders of, 208
herpes of, 208
keratosis of, 208
mycosis of, 208
operations on, 205
tumors of, 208
Nausen after abdominal operations, 531
Neck, 360
INDEX OF SUBJECTS
815
Neck, abscess of, 361
branchial cysts of, 372
fistulae of, 372
burns of, 373
bursal cysts of, 372
cancer of, extensive recurrent, 494
secondary, 372
cellulitis of, 361
superficial, 362
congenital cysts of, 372
cysts of, 372
echinococcus cysts of, 372
emphysema of, 361
general injuries of, 360
hemorrhagic cysts of, 372
infective processes in, 361
ligneous induration of, 362
lymphatic cysts of, 372
lymphatics of, anatomy of, 363
carcinoma of, 363
diseases of, 363
lymphoma of, malignant, 372
median fistulas of, 372
nerves of, wounds of, 360
stiff, ironing for, 373
tuberculous lymph-glands of, 368
non-surgical treatment, 369
technic of operation for, 370
tumors of, 372
solid, 372
Necrosis of costal cartilages, 398
of jaws, 286
of pancreas, 782
of ribs, 398
Needle operation for cataract, 169
Needles used for intestinal suture, 627
Nephritic retinitis, 134
Nerves, intracranial injuries of, 63
of neck, wounds of, 360
of stomach, 700
optic, diseases of, 135
recurrent laryngeal, anatomy, 380
roots, relation of, to spine, 323
spinal accessory, resection of, in torti-
collis, 376
posterior roots of, division of, 344.
See also Rhizotomy.
operations on, 344
Neumann's operation in middle-ear dis-
ease with labyrinthine involvement, 321
Neuralgia, coccygeal, 357
alcohol injections in, 358
massage in, 358
removal of coccyx for, 358
facial, intracranial operations on fifth
nerve for, 115
of breast, 473
rhizotomy for, 346
Neurasthenia, surgical treatment, 105
traumatic, 103
Neurectomy, phrenic, in bronchiectasis,
420
Neuritis, orbital optic, 135
Neurofibromatosis, multiple, of scalp, 24
Neuroparalytic keratitis, 126
Neuroses, posttraumatic, 102
surgical treatment, 105
Neurotic spine, 355
Nevus of abdominal wall, 538
of breast, 475
of face, 115
of scalp, 25
Newborn, heart failure of, 430
intracranial hemorrhage in, 60
craniotomy in, 61
Nicoladoni's method in salivary fistula,
378
Nipples, diseases of, 473
eczema of, 473
fissures of, 473
inflammations of, 473
inverted, 472
retracted, 473
tumors of, 473
Nodular lymphatic keratoconjunctivitis,
125
Nodules of tongue, tuberculous, 290
singers', 222
Non-gonorrheal conjunctivitis, 122
Non-infective meningeal effusion, 68
thrombosis of sinuses of dura mater, 72
Non-penetrating wounds of abdominal wall,
535
of chest wall, 397
Non-perforating wounds of intestine, with
wounds of mesentery, 568
Non-specific purulent conjunctivitis, 121
Non-suppurative otitis media, chronic, 319
peritonitis, acute, 554
Non-tuberculous empyema, chronic, 409
rarefying osteitis of spine, 326
Nose, 179
accessory sinuses of, 179
anatomy of, 179
bleeding from, 184
blowing of, in nasal infections, 186
cavities of, infections of, 180
foreign bodies in, 188
hemorrhage from, 184
infections of, blowing nose in, 186
inferior meatus of, 179
injuries of, 183
middle meatus of, 179
operations on, 179
anesthesia in, 181
antiseptic preparations in, 183
cleansing preparations in, 183
hemostasis in, 183
instruments for, 180
local anesthesia in, 181
vasoconstriction in, 183
saddle-. See Saddle-nose.
scab formation in, 187
septum, 179
superior meatus, 179
tumors of, 188
wounds of, 183
Nostril, deformed, with harelip, 273
Notched-lip, after operation for harelip,
273
Nutmeg liver in ascites, 558
Nutrient enemata, 620
OBLIQUE postmuscular abdominal section,
5ii
subcostal abdominal section, 513
816
INDEX OF SUBJECTS
Obliteration of frontal sinus, 202-205
of maxillary antrum, 196
Obstruction of intestines, 595. See also
Intestinal obstruction.
Occipital glands; 363
Occlusion, defective, deformities of lower
jaw with, 283
of jaws,fc8i
of duodenum, 615
of nasal duct, 136
Ochsner's method in stricture of esophagus,
436
treatment of peritonitis, 548
Ocular torticollis, 377
Odontoma, 280
of jaws, 286
O'Dwyer instruments for intubating larynx,
237
method of intubating larynx, 237
Oil enema, 620
Olfactory sensory center of brain, 45
Olive bougies, 434
oil to prevent adhesions in abdominal
operations, 521
Omental grafts in intestinal suture, 629
Omentum, 620
adhesions of, in abdominal operations, 522
cysts of, 620
inflammations of, 620
preservation of, in resection of trans-
verse colon, 646
strangulation of, 620
torsion of, 620
tumors of, 620
Opacities, corneal, 126
in vitreous, 134
Operations on conjunctiva, 149
on eye, 138
on eyelids, 138
on intestines, 621
on lungs, 453
on mediastina, 458
on nose, 179
on pharynx through neck, 367
on skull. See Skull, operations on.
on spleen, 787
on stomach, 730
on tonsils through neck, 367
Operative wounds of scalp, 19
Ophthalmia. See Conjunctivitis.
sympathetic, 130
Ophthalmic artery, ligation of, 137
Opium in peritonitis, 547
Optic nerve, atrophy of, 135
diseases of, 135
intra-ocular edema of, 135
tumors of, 135
wounds of, 135
neuritis, orbital, 135
papilla, engorgement edema of, 135
Orbicularis muscle, spasm of, 120
Orbit, abscess of, 137
diseases of, 137
outer wall of, resection of, 163
periostitis of, 137
sinus infections perforating into, 201
transplantation of fat into, after enu-
cleation, 160
Orbit, tumors of, 137
removal, 163
Orbital muscles, 116. See also Muscles of
eye.
optic neuritis, 135
Organic scoliosis, 354
Orthodentistry, 280
Osmosis treatment of glaucoma, 131
Ossicles of ear, 299
removal of, in chronic suppurative
otitis media, 311
Osteitis of cranial bones, prevention, 41
of spine, non- tuberculous rarefying, 326
Osteoma of jaws, 286
of skull, 42
Osteomyelitis of jaws, 283
of spine, 326
Osteoplastic craniotomy, 30. See also
Craniotomy, osteoplastic.
laminectomy, 344
thoracotomy, anterior, 458
posterior, 459
Osteotome, spiral, Cryer's, 28
Othematoma, 303
Otic abscess, usual site, 50
Otitis media, acute, 306
incision of tympanic membrane in
307
indications for mastoid operation in,
308
suppurative, 307
chronic non-suppurative, 319
labyrinthine and perilabyrinthine in-
volvement following, 321
suppurative, 308
bismuth paste in, 310
curettage of middle ear in, 311
drying powders in, 309
ear-drops in, 309
gauze drainage in, 309
hot air in, 309
operation in, indications for, 310
radical, 312. See also Mastoid
operation, radical.
through membrana tympani in,
3ii
removal of ossicles in, 311
suction treatment, 310
vaccines in, 310
Oxycephaly, 42
Oxygen after abdominal operations, 531
Ozena, 187
PACHYMENINGITIS externa, 65
hemorrhagica, 57
syphilitic, 65
Paget's disease of nipples, 473
Pain after abdominal operations, 532
lumbosacral, 350
Painful back, 350
Palate, cleft-, 257. See also Cleft-palate.
perforations of, 266
soft, abscess of, 255
acute infections of, 255
adhesions of, 256
diseases of, 255
tumors of, 255
ulcers of, 255
INDEX OF SUBJECTS
817
Palpebral fissure, canthoplasty for enlarg-
ing, 142
portion of lacrimal gland, removal of,
178
Panas' operation for ptosis of eyelids, 141
for staphyloma, 152
Pancreas, 778
abscess of, 781
anatomy, 778
approach to, 779
cysts of 783
drainage of, 780
necrosis of, 782
tumors of, 782
wounds of, 779
Pancreatic calculi, 783
Pancreatitis, acute, 780
chronic, 781
subacute, 781
Pannus, 124
Panophthalmitis, 130
Panse's method in radical mastoid opera-
tion, 315
Papilla optic, engorgement edema of, 135
Papillomatous cysts of breast, 477
Paracentesis of cornea, 152
of right auricle, 425
ventricle, 425
Paraffin injections in saddle-nose, 194
Paralysis agitans, rhizotomy for, 348
in Pott's disease, 337
spastic, rhizotomy in, 346
Paralytic ileus, 552
pituitrin in, 553
torticollis, 377
Parasitic stomatitis, 246
Parathyreopriva, 394
Parathyroid glands, anatomy, 380
diseases of, 394
transplantation of, 394
Parenchymatous acute glossitis, 288
senile hypertrophy of breast, 475
Parotid glands, 363
abscess of, 379
anatomy, 377
cellulitis of, 379
salivary fistula, 377
Pars anterior of pituitary body, 83
intermedia of pituitary body, 83
nervosa of pituitary body, 83
Partial cataract, 133
laryngectomy, 231
Patient, preparation of, for abdominal
operations, 499
for operations on alimentary canal, 564
Pendulous abdominal wall, 540
Penetrating wounds of abdominal wall, 535
of chest wall, 397
of esophagus, 431
of heart, 429
Penetration of chest wall, wounds of lung
with, 413
Percy's radical cautery operation for can-
cer of breast, 492
Perforating duodenal ulcer, 579
typhoid ulcer, 580
ulcer of stomach, 726
wounds of intestines, 567
VOL. 11—52
Perforation of colon, 582
of gaseous cysts, 581
of intestines, 581
of intestines, 576
malignant, 581
suppurative, 581
tuberculous, 581
of nasal septum, 195
of palate, 266
of stomach, perigastric abscess from,
.727
Pericardial adhesions, cardiolysis for, 424
Pericardiocentesis, 422
Pericardium, 422
empyema of, 423
operative exposure, 424
serous effusion in, 422
tumors of, 445
wounds of, 422
Pericardotomy for serous effusion, 423
in empyema, 423
Perichondritis, 223
of auricle, 303
Pericolic adhesions, 602
veils, 602
Pericolitis, 576
membranous, 602
Pericranial pneumatocele, 24
Perier's method of laryngectomy, 234
Perigastric abscess from perforation of
stomach, 727
adhesions, 702
Perilabyrinthine involvement following
middle-ear suppuration, 320
Periostitis of cranial bones, prevention, 41
of jaws, 283
of orbit, 137
Periotomy in vascular keratitis, 127
Peripheral sarcoma of jaws, 286
Peritoneal abscess, chronic, 554
collapse, 549
sac, foreign bodies in, 544
Peritoneum, 498, 541
anastomosis of saphenous vein with, in
ascites, 560
anatomy, 541
closure of, in abdominal operations, 516
denuded surfaces of, 542
fibroma of, 563
injuries of, 542
lipoma of, 563
protection of, in abdominal operations,
jo
sarcoma of, 564
toilet of, in abdominal operations, 515
traumatism of, 542
tumors of, 557
Peritonitis, 546
acute, 546
general, 548
local, 548
non-suppurative, 554
septic, 548
adhesions in; 546
best time for operation in, 546
calcium hypochlorite in, 551
camphorated oil in, 551
chlorinated oil in, 551
818
INDEX OF SUBJECTS
Peritonitis, dichloramin in, 551
drainage in, 547, 549
gastric lavage in, 547, 550
hypodermoclysis in, 550
intestinal obstruction in, 553
iodin in, 550
irrigation in, 546, 549
local suppurative, 548
localized abscess in, 553
of duodenal region, 557
operation in, 549
opium in, 547
period of constitutional reaction in, 547
prevention of spread, 546
proctoclysis in, 547
rectal injections in, 549
secondary abscess in, 553
sodium hypochlorite in, 551
subphrenic abscess in, 553
suction drainage in, 549
sulphuric ether in, 551
suppurative, local, 548
tuberculous, 554
acute miliary, 554
dry, 554
exudative, with serum, 554
suppurative, 556
vasomotor disturbance in, 549
Peritonsillar abscess, 212
Perityphlitis, 576
Permanent fecal fistula, 687
Pernicious anemia, 785
Peronin in eye diseases, 1 1 8
Peterson's method of drainage in ascites,
559
Pharyngitis, membranous, Klebs-LofBer,
207
Pharyngotomy, lateral, 368
subhyoid, 229
suprahyoid, 229
Pharynx, foreign bodies in, 216
lupus of, 207
operations on, through neck, 367
tuberculosis of, 207
Phlebotomy. See Venesection.
Phlegmon, sublingual, 362
woody, 362
Phlegmonous gastritis, 702
inflammation of intestines, acute, 574
Phlyctenular conjunctivitis, 123
keratitis, 125
Phonation after laryngectomy, 236
disturbed, after cleft-palate operation,
266
Phrenic neurectomy in bronchiectasis, 420
Physostigmin salicylate as miotic, 118
Pia mater, anatomy, 43
Pia-arachnoid anatomy, 43
wounds of, 61
Pilocarpin hydrochlorid as miotic, 118
Pinguecula, 124
Pituitary body, nasal approach to, 89
operations on, 82
anesthesia in, 83
approach by bucconasal route, 92
by frontal route, 85
by nasal route, 88
choice of, 83
Pituitary body, operations on, combined
frontal and nasal, 90
high nasal, 90
nasal, with removal of septum, 88
routes of approach, 82
simple transnasal, 88
surgical anatomy, 83
total removal, 83
tumors of, 83
Pituitrin in acute intestinal stasis, 614
in paralytic ileus, 553
Plaster-bed, reclining, in Pott's disease,
327
Plaster-of-Paris jackets in Pott's disease,
329-335
Plastic linitis, 702
Pleth's knitting needle method of intestinal
anastomosis, 677
Pleura, 399
anatomy, 399
cervical, 399
costal, 399
diaphragmatic, 399
infection of, with wounds of lung, 414
operations through, with increased in-
trapulmonary pressure, 446
pulmonary, 399
tumors of, 445
wounds of, 399
Pleural shock from artificial pneumothorax,
417
Pleurisy with effusion from artificial pneu-
mothorax, 417
Plexiform neuroma of scalp, 24
Plug, epithelial, in external auditory canal,
306
Pneumatocele, pericranial, 24
Pneumectomy, 456
in bronchiectasis, 420
in tuberculosis, 416
Pneumolysia, interpleural, in tuberculosis,
418
Pneumolysis in bronchiectasis, 420
in tuberculosis, 418
Pneumonia after abdominal operations,
534
Pneumothorax, 400
artificial, gas embolism from, 417
in tuberculosis, 416
indications for, 417
length of treatment, 418
mortality in, 417
pleural infection from, 417
shock from, 417
pleurisy with effusion from, 417
results, 418
subcutaneous emphysema in, 417
Pneumotomy, 456
in bronchiectasis, 419
Point, auricular, 45
condyloid, of inferior maxilla, 45
midsagittal, 45
midzygomatic, 45
superior Rolandic, 46
supra-auricular, 45
Sylvian, 46
Poliomyelitis, anterior, 326
Politzer's bag for inflating middle ear, 301
INDEX OF SUBJECTS
819
Polymastia, 472
Polypoid adenomata of intestines, 582
Polyps of maxillary antrum, 197
Polythelia, 472
Pope's method of preventing adhesions in
abdominal operations, 522
Portal vein, anastomosis of, with vena cava,
in ascites, 561
Posterior cervical nerves, resection of,
in torticollis, 376
sclerotomy, 157
Postmeatal triangle of ear, 300
Postmuscular oblique abdominal section,
S1.1
vertical abdominal section, 512
Postoperative dilatation of stomach, 615
intraabdominal hemorrhage, 524
vomiting, 615
Posttraumatic neuroses, 102
Postural scoliosis, 352, 353
Pott's disease, 327
abscess in, 335. See also Abscess in
Pott's disease.
after-treatment on recumbent frame,
334
ambulatory treatment, 329
Bradford's frame in, 328
care of skin in, 334
corset in, 334
duration of treatment, 338
head support in, 333
horizontal fixation in, 327
jacket applied in, for cervical and upper
dorsal disease, 332
high, 332
suspension hammock in, 329
with patient in prone position, 329
on back, 331
suspended, 331
jury-mast in, 333
Lorenz's reclining plaster-bed in, 328
lumbar involvement in, 334
metallic braces in, 333
operations on bodies of vertebrae in,
337
operative treatment, 338
paralysis in, 337
prognosis, 335
recumbent treatment, 327
puffy swelling of cranial bones, 41
Pressure-pad in gastroptosis, 711
Processus pyramidalis, 380
Proctoclysis after abdominal operations,
533
in peritonitis, 547
Prognathism, 281
with malocclusion, 283
Prolapse of intestines, 616
of lacrimal gland, 136
of spleen, 784
Psammoma of brain, 75
Pseudomembranous conjunctivitis, 123
Psoas abscess in Pott's disease, 337
Psoriasis of tongue, 289
Psychoses, traumatic, 102
Pterygium, 124
operations for, 149
Ptosis of eyelids, 119
Ptosis, of eyelids operations for, 138
of hepatic flexure of colon, 616
of splenic flexure of colon, 616
of transverse colon, 616
of upper eyelid, 1 20
Puffy swelling of cranial bones, 41
Pulmonary emphysema, rib resection in,
419
pleura, 399
Pulsating exophthalmos, 137
in arteriovenous aneurism of cavernous
sinus, 73
Puncta lacrimalia, malposition of, 136
Puncture, lumbar, 348. See Lumbar punc*
lure.
Purse-string suture for closing lumen of
intestines, 681
of intestines, 635
Purulent non-specific conjunctivitis, 121
Pus in vitreous, 134
Pylorectomy, 747
partial, 751
gastrojejunostomy after, 755
shock in, 776
Pyloric end of stomach, cancer of, opera-
tion for, 756
resection of, 751
gastrojejunostomy after, 755
stenosis, 717
acquired hypertrophic, 720
cicatricial, 720
congenital, 717
indications for operation in, 719
mortality from, 719
of infancy, 717
posterior gastro-enterostomy in, 719
simple, pyloroplasty in, 740
spasmodic, 720
ulcer, ruptured, pyloroplasty in, 740
Pylorodiosis, 737
Pyloroplasty, 740
angular clamp for, 747
by single incision, 740
feeding after, 778
in duodenal ulcer, 578
indications for, 740
with gastroduodenostomy, 741
Pylorospasm, pyloroplasty in, 740
Pylorus, anatomy, 698
carcinoma of, 720
exclusion of, 771
permanent occlusion of, in duodenal'ulcer,
578
Pyorrhea alveolaris, 277
Pyothorax, 402. See also Empyema.
QUININ and urea injections in hyperthy-
roidism, 390
Quinsy, 212
RACHITIC spine, 350
torticollis, 377
Radical mastoid operation. See also Mas-
toid operation, radical.
Radium in hyperthyroidism. 390
Ranula, 291
Reaction, electric, of motor areas of brain,
testing for, 51
820
INDEX OF SUBJECTS
Reading, brain center of, 44
Receptaculum chyli, septic infection of,
361
Rectal drainage in abdominal operations,
528
injections in appendicitis, 549
tube after abdominal operations, 531
Rectum, upper part, cancer of, 591
Rectus muscle, advancement of, 176
folding operation on, 176
internal, tenotomy of, in strabismus,
i7S
shortening of, 176
Recurrent laryngeal nerve, anatomy, 380
Redundant sigmoid, chronic intestinal sta-
sis from, 612
Reid's method of craniocerebral localiza-
tion, 49
Relaxation of ligaments of spine, 357
Relaxed abdominal wall, 540
Resection, double, in non-toxic goiter,
385
intestinal, 636
of ascending colon, indications for, 642
of cardia for cancer, 756
of cecum, indications for, 642
of colon, preventing obstruction to pas-
sage of gas in, 644
of costal cartilages in rigidity of chest,
422
in tuberculosis, 419
of esophagus, of lower segment, 470
of eyelids, blepharoplasty for, 147
of outer wall of orbit, 163
of part of lobe of thyroid gland, 389
of posterior cervical nerves in torticollis,
376
of pyloric end of stomach, 751
gastrojejunostomy after, 755
of spinal accessory nerve in torticollis,
376
of spleen, 787
of thoracic esophagus, 463
of trachea, 237
of transverse colon, with preservation of
omentum, 646
of ulcer of stomach, 759
submucous, of nasal septum, 190
Retina, detachment of, 134
diseases of, 134
glioma of, 135
hemorrhage into, 135
Retinitis, 134
diabetic, 134
hemorrhagic, 134
leucocythemic, 134
nephritic, 134
syphilitic, 134
Retracted nipples, 473
Retractors for abdominal operations, 514,
SiS
Retro-auricular glands, 363
Retro-omental route of approach to pan-
creas, 779
Retro-orbital tubercle, 46
Retroperitoneal abscess, 563
cysts, 564
disease, 563
Retroperitoneal infection 563
umors, 563
etropharyngeal abscess, 205
in Pott's disease, 335
glands, 363
Rheumatic iritis, 129
torticollis, 377
Rhinitis, acute simple, 186
in children, 186
atrophic, 187
chronic, 186
simple, 1 86
hyperplastic, 187
membranous, 186
suction treatment, 186
Rhinoliths, 188
Rhinophyma, 188
Rhinorrhea, cerebrospinal, 73
Rhizotomy, 344
in gastric crises of tabes 347
in neuralgia, 346
in spastic paralysis, 346
Ribs, caries of, 398
cervical, 373
necrosis of, 398
resection, in pulmonary emphysema, 419
syphilis of, 398
tuberculosis of, 398
Rib-trephining for empyema, 407
Richardson's double figure-of-eight suture,
.519
Ridge, superciliary, 46
of supra-orbital arch, 46
Riggs' disease, 277
Rigidity of chest, 421
Ripening, artificial, in cataract, 133
Robinson's apparatus for intratracheal in-
sufflation, 450
method of thoracoplasty, 410
muscle implantation in empyema, 411
Robson's decalcified bone bobbin for intes-
tinal anastomosis, 675
technic for jejunostomy, 697
Rogers' laryngeal intubation tube, 220
Rolandic fissure, 46
lower end, 46
point, superior, 46
Roller forceps operation in trachoma, 150
Root infections of teeth, 275
Rosenstein's method of drainage in ascites,
56i
Round shoulders, 351
Routte's method of drainage in ascites,
560
Roux's method of anterior gastrojejunos-
tomy, 771
of esophagogastrojejunostomy, 464
Rovsing's method of gastropexy, 713
Rubber ligature method of intestinal anas-
tomosis, 675
Running ear, 310
Rupture of abdominal muscles, 535
of choroid, 131
of esophagus, 432
of intestines, 566
of lung, 413
of spleen, 784
of stomach, 702
INDEX OF SUBJECTS
821
Rupture of thoracic duct in abdomen, 361
in thorax, 361
traumatic, of tympanic membrane, 306
ulcerative, of tympanic membrane, 306
Ruth's operation in cancer of breast, 489
Rydygier's method of splenopexy. 787
SAC, lacrimal. See Lacrimal sac.
Sacro-iliac joint, diseases of, 355
tuberculosis of, 355
Saddle-nose, 192
hard-rubber bridge in, 194
paraffin injections in, 194
swinging up half of lateral cartilage in,
193.
Safety-pin hemostat, Friedman's, in scalp
operations, 20, 22
Sagittal suture, 46
Salivary calculi, 291, 379
fistula, parotid, 377
glands, 377
tumors of, 379
Saphenous vein, anastomosis of, with
peritoneum, in ascites, 560
Sarcoma of abdominal wall, 538
of gums, 280
myeloid, 280
of intestines, 583
of jaws, 286
myeloid, 286
peripheral, 286
of peritoneum, 564
of skull, 42
of stomach, 703
of thyroid gland, 381
formation in nose, 187
Scalp, 17
abscess of, 24
accidental wounds of, 18
avulsion of, 23
complete, 23
cellulitis of, 23
contusions of, 17
erysipelas of, 24
hematoma of, 1 7
infections of, 23
preparation of, for operation, 19
tumors of, 24
wounds of, control of hemorrhage in, 18
infection in, 18
operative, 19, 20
suture of, 19
Schede's method of approach for resection
of thoracic esophagus, 463
operation for obliterating empyema
cavities, 411
Schultz's adenotome, 209
Sclera, diseases of, 128
foreign bodies of, 1 29
operations on, 156
simple trephining of, in glaucoma, 162
staphyloma of, 1 29
trephines, 163
tumors of, 129
wounds of, 129
Scleritis, 128
Sclerokerato-iritis, 128
Sclerotomy, anterior, 156
Sclerotomy combined with iridectomy, 157
for glaucoma, 161
internal, 157
posterior, 157
with trephine in glaucoma, 162
Scoliosis, 352
causes, 352
corset for, 353
decompression corset in, 354
exercises in, 353
functional, 353
hammock for lateral correction in
354
inclined plane seat in, 353
organic, 354
postural, 353
posture in, 352
prophylactic treatment, 352
self-suspension in, 353
structural, 354
Scopolamin hydrobromid as mydriatic, 118
Sebaceous cysts of face, 115
of scalp, 24
Seborrhea of eyelids, 119
Secondary cataract, operations for, 174
Section, abdominal, 504. See also Ab-
dominal section.
Self-suspension in scoliosis, 353
Senn's method of gastrostomy through
internal cone, 731
Sensory area of brain cortex, 45
Septic infection of receptaculum chyli, 361
peritonitis, acute, 548
Septum, nasal, 179. See Nasal septum.
Seromuscular intestinal suture, 629
Serous effusion in pericardium, 422
Serum treatment of hyperthyroidism, 390
Seventh nerve, injuries of, 63
intracranial operations on, no
operation on, in acoustic vertigo, 112
in tinnitus, 112
two-stage, by mastoid route. 113
tumors of, removal of, 113
Shield for eye, 138, 140
Shock in abdominal operations, 532
in stomach operations, 776
Shortening of rectus muscle, 176
Shoulders, round, 351
Sigmoid, acute flexures of, chronic intesti-
nal obstruction from, 610
anatomy, 625
angulations of, chronic intestinal ob-
struction from, 6ro
carcinoma of, 589
lower part, cancer of, 591
middle and upper, cancer of, 592
redundant, chronic intestinal stasis from,
612
Sigmoidostomy, anterior, 693
inguinal, 685
high, 689
low, 690
Silver, colloidal, in bronchiectasis, 419
Simple rhinitis, acute, 186
chronic, 186
Singers' nodules, 222
Sinuses, accessory, foreign bodies in, 188
of nose, 179
822
INDEX OF SUBJECTS
Sinuses, cavernous, arteriovenous aneurysm
of, 73.
thrombosis of, 72
cerebrospinal, 73
cranial, drainage of cisterna magna
into, in hydrocephalus, 98
ethmoid, 180
suppuration of, 197
operation by orbital route in, 198
frontal, 179. See Frontal sinus.
infections of, intranasal treatment, 201
perforating into orbit, 201
intestinal, closure of, 616
maxillary, 179. See Maxillary antrum.
meningeal, injuries of, 64
of brain, 44
lateral, 47
pericranii, 24
sphenoid, 180
suppuration of, 198
superior longitudinal, of brain, 47
venous, infections of, 318
thrombosis of, 318
Sixth nerve, injuries of, 63
diseases of auricle, 304
involving conjunctiva, 1 24
Skull, 26
base of, anatomy, 43
bones of, atrophy, 41
diseases of, 41
effects of pressure on, 41
infective diseases of, 41
osteitis of, prevention, 41
periostitis of, 41
pott's puffy swelling of, 4 1
syphilis of, 41
tuberculosis of, 41
tumors of, 42
brain and, relations, 46
cancer of, 42
defovmities of, 42
landmarks of, 45
measure for determining thickness of, 32
operations on, 26
head prepared for, 33
instruments for, 26
osteoplastic craniotomy, 30
trephine for, 26, 27.
osteoma of, 42
sarcoma of, 42
steeple, 42, 178
sutures of, 45, 46
topography of, 48
Smithies' nonoperative treatment of gastric
ulcer, 720
Smith's operation in cataract, 1 70
preliminary capsulotomy for immature
cataract, 168
Soap enema, 620
Sodium hypochlorite in peritonitis, 551
Soft palate. See Palate, soft.
Sound, introduction of, in stenosis of esopha-
gus, 433
lacrimal, 177
Spasm of esophagus, 442
of glottis, 221
of larynx, 221
of orbicularis muscle, 120
Spasmodic stenosis of pylorus, 720
torticollis, 376
Spastic paralysis, rhizotomy in, 346
Special sensation, brain areas of, 45
Specific nasal infections, 188
Specula, aural, 302
nasal, 181
Speech, brain center of, 44
Sphenoid sinuses, 180
suppuration of, 198
Spiller-Frazier method of dividing sensory
root of Gasserian ganglion, 107
Spina bifida, 349
Spinal accessory nerve, resection of, in
torticollis, 376
canal, anastomosis of anterior nerve
roots in, 348
cord, concussion of, 324
contusion of, 324
extrapial hemorrhage compressing, 325
hemorrhage into, 325
tumors of, 338
medullary, extrusion treatment, 342
laminectomy in, 341
spinal decompression in, 344
ganglia, excision of, in gastric crises of
tabes, 348
nerves, anastomosis of anterior roots of,
in spinal canal, 348
posterior roots of, division of, 344.
See also Rhizotomy.
operations on, 344
Spine, 322
abscess of, non-tuberculous, 327
anatomy, 322
hysterical, 355
joints of, sprains of, 324
lateral curvature of, 352. See also
Scoliosis.
ligaments of, relaxation of, 357
neurotic, 355
osteitis of, non-tuberculous rarefying, 326
osteomyelitis of, 326
rachitic, 350
relation of nerve roots to, 323
sprains of ligaments of, 357
tuberculosis of, 327. See also Pott's
disease.
tumors of, 338
wounds of, bullet, 325
stab, 325
Spiral osteotome, Cryer's, 28
Spleen, 784
abscess of, 784
anatomy, 784
cysts of, 785
effects of removal of, 784
hydatid cysts of, 785
hypertrophy of, 785
injuries of, 784
operations on, 787
physiology, 784
prolapse of, 784
resection of, 787
rupture of, 704
tuberculosis of, 785
tumors of, 785
twisted pedicle of, 785
INDEX OF SUBJECTS
823
Spleen, wandering, 785
wounds of, 784
Splenectomy, 787
Splenic anemia, 785
Splenopexy, 787
Splints, nasal, 180
Spondylitis deformans, 326
traumatic, 326
tuberculous, 327. See also Pott's dis-
ease.
typhoid, 326
Spondylolisthesis, 350
Sponging in abdominal operations, 515
Spontaneous cerebral apoplexy, 58
temporal craniotomy in, 58
thrombosis of sinuses of dura mater, 72
Sprains of ligaments of spine, 357
of spinal joints, 324
Spurious meningocele, 25
Squamous blepharitis, 119
suture, 46
Stab wounds of brain, 62
of spine, 325
of spleen, 784
Stagnation mastitis, 473
Stapes, 299
Staphyloma, 128
of sclera, 129
operations for, 152
Stasis, intestinal, acute, 614
chronic, 610
chronic constipation in, 613
colostomy for, 574
from redundant sigmoid, 612
Status lymphaticus, 395
thymicus, 394
Steeple skull, 42, 178
Stenosis, acquired, of larynx, 218
of trachea, 218
congenital, of larynx, 218
of trachea, 218
of cardiac orifice of stomach, 715
of esophagus, cicatricial, 433
congenital, 433
pyloric, 717. See also Pyloric stenosis.
Stephanion, 45
Sternoclavicular joint, arthritis of, 398
Sternomastoid muscle, excision of, in torti-
collis, 375
Sternothoracotpmy, transverse, 459
Sternum, median division of, to expose
mediastina, 459
Stewart's method of posterior gastro-
enterostomy, 768
Stitch-hole abscesses in abdominal wall,
537
StoffePs method of partial rhizotomy, 347
Stomach, 698
adenoma of, 703
anatomy, 698
benign tumors of, 703
cancer of, 703. See also Cancer of
stomach.
cardiac orifice, stenosis of, 715
cirrhosis of, 702
cysts of, 703
dilatation of, 713
acute, 615, 714
Stomach, dilatation of, chronic atonic, 713
gastroplication in, 714
foreign bodies in, 714
removal, 244
fundus of, 698
hemorrhage of, 727
operation for, 728
hour-glass, 706
gastroplasty for, 709
by transverse incision in, 709
inflammations of, 702
lavage, 700. See also Gastric lavage.
lipoma of, 763
lymphatics of, 699
myoma of, 703
nerve supply, 700
operations on, 730
operative exposure of, 700
perforation of, perigastric abscess from,
727
postoperative dilatation of, 615
pyloric end, resection of, 751
gastrojejunostomy after, 755
rupture of, 702
sarcoma of, 703
syphilis of, 702
tube, 700
introduction of, 700
tuberculosis of, 702
ulcer of, 720. See also Ulcer of stomach.
volvulus of, 715
wall, canalization of, gastrostomy by,
736
posterior, route of approach, 780
suppuration in, 702
washing out, 700. See also Gastric lavage.
wounds of, 702
Stomatitis, 246
gangrenous, 247
gonorrheal, 247
membranous, 247
mycotic, 246
parasitic, 246
Stone's dietetic treatment of ulcer of
stomach, 421
Strabismus, 174
alternating, 175
complete tenotomy of internal rectus in,
175
indications for operation in, 175
open operation in, 175
special conditions in, 176
subconjunctival operation in, 175
unilateral, 175
Strangulation of omentum, 620
Strauss's method of reconstruction of
pylorus by transplantation of tissue, 773
Streptococcus infection of teeth, 276
viridans theory of arthritis deformans,
613
Stricture of bronchi, 422
of esophagus, 433
dilatation of, by electrolysis, 438
rapid, 438
with mercury, 435
with sound, 433
gastrostomy in, 436
internal esophagotomy in, 438
824
INDEX OF SUBJECTS
Stricture, of esophagus, introduction of sound
for, 433
operative treatment, 436
of intestines, 609
chronic obstruction from, 610
Stridulous laryngitis, 221
Structural scoliosis, 354
Struma, 381
Strumitis, acute, 380
chronic, 381
Stye, 1 19
Subarachnoid hemorrhage, 57
Subconjunctival injections, 151
in eye diseases, 179
operation in strabismus, 175
Subcostal oblique abdominal section, 513
Subcutaneous drainage in ascites, 559
emphysema in artificial pneumothorax,
417
tenotomy in torticollis, 374
Subdiaphragmatic abscess, treatment, 470
Subdural hemorrhage, 56
meningitis, 65
pyogenic organisms in, 66
Subglottic laryngitis, hypertrophic, 219
Subhyoid pharyngotomy, 229
Sublingual phlegmon, 362
Submaxillary glands, 363
Submental glands, 363
Submucous resection of nasal septum, 190
Suboccipital osteoplastic craniotomy, 36
Subparotid glands, 363
Subperitoneal drainage in congenital ven-
tricular hydrocephalus, 97
Subphrenic abscess in peritonitis, 553
Subpleural diaphragmotomy for subphrenic
abscess, 554, 555
Substernomastoid glands, 363
Subtemporal craniotomy, 106
for exposure of Gasserian ganglion,
1 06
drainage in congenital hydrocephalus, 96
Sucking thumbs, prevention, 280
Suction apparatus for removing brain
tumors, 78
treatment of rhinitis, 186
of suppurative otitis media, 310
Sulphuric ether in peritonitis, 551
Summers' method of resecting transverse
colon with preservation of omentum, 646
Superciliary ridge, 46
Superficial glossitis, acute, 288
chronic, 288
Superheated air inhalations in bronchiec-
tasis, 419
Superior bronchoscopy, 242
Supernumerary auricle, 303
Suppuration in stomach wall, 702
of ethmoid sinuses, 197
operation in, by orbital'route, 198
of sphenoid sinuses, 198
Suppurative choroiditis, 130
otitis media, acute, 307
chronic, 308
perforation of intestines, 581
peritonitis, diffuse, 548
local, 548
Suppurative tonsillitis, 212
Supra-auricular point, 45
Supraclavicular glands, 363
Suprahyoid pharyngotomy, 229
Supra-orbital arch, 46
Suspension hammock to apply jacket in
Pott's disease, 329
Suture coronal, 45
Sutures, figure-of-eight, for closing abdom-
inal wound, 519
in abdominal operations, 519
intestinal, 628. See also Intestinal su-
ture.
lambdoid, 46
of heart, 427
of scalp wounds, 19
sagittal, 46
Swallowing tongue, 287
Sylvian fissure, 46
line, 46
point, 46
Symblepharon, 119, 120
operations for, 150
Sympathetic ophthalmia, 130
Synchysis, 134 _
Synechia, anterior, division of, 156
nasal, 195
Syphilis of bones of skull, 41
of brain, 75
of larynx, 223
of ribs, 398
of stomach, 702
of thyroid gland, 381
of tongue, 290
Syphilitic iritis, 129
meningitis, 68
nasopharyngitis, 205
pachymeningitis, 65
retinitis, 134
Szymanowski-Kuhnt operation for ptosis
of eyelids, 145
TABES, gastric crises of, excision of spinal
ganglia in, 348
rhizotomy for, 347
Tapping arachnoid space, 348. See Lum-
bar puncture.
in ascites, 557
Tarsorrhaphy, 143
lateral, 143
Tattooing cornea, 152
Teale's operation for symblepharon, 150
Teeth, 274
alveolar abscess of, 277
caries of, 275
condition of, as factor in surgical treat-
ment, 274
cysts of, 280
dead, filling and crowning of, 276
decay of, prevention, 274
extraction of, 278. See also Extraction
of teeth.
grafting of, 279
prophylactic care of, 276
root infections of, 275
streptococcus infection of, 276
tumors of, 280
INDEX OF SUBJECTS
825
Temporal craniotomy, high, for exposure of
Gasserian ganglion, 106
in spontaneous cerebral apoplexy, 58
low, for exposure of Gasserian gang-
lion, 1 06
osteoplastic craniotomy, 34, 36
Temporary fecal fistula, 686
intestinal fistula, 683
Tenon's capsule, advancement of, 177
Tenotomy, complete, of internal rectus in
strabismus, 175
graduated, in heterophoria, 176
open, in torticollis, 375
partial, in heterophoria, 176
subcutaneous, in torticollis, 374
Teratoma of brain, 75
Tetany, 394
thymic, 395
Thirst after abdominal operations, 533'
cure in bronchiectasis, 419
Thoracic duct, diseases of, 361
rupture of, in abdomen, 361
in thorax, 361
wounds of, 361
esophagus, resection of, 463
exposure of diaphragm, 467
Thoracoplasty in bronchiectasis, 420
in empyema, 410
in tuberculosis, 418
Thoracotomy, intercostal, simple, in em-
pyema, 403
osteoplastic, anterior, 458
posterior, 459
Thorax, 396
anatomy, 396
cancer of, extensive recurrent, 494
concussion of, 397
contusions of, 396
tumors of, 444
Thorner's instruments for intubating larynx,
237
Thrombosis of cavernous sinus, 72
of venous sinuses, 318
of dura mater, 70
infective, 71
Thrush, 246
Thumb sucking, prevention of, 280
Thymectomy, 395
Thymic asthma, 394
dyspnea, 395
epilepsy, 395
tetany, 395
Thymus gland, 394
enlarged, 395
epilepsy with, 101
hypertrophy of, 446
Thyreodectin in hyperthyroidism, 390
Thyreoprivic serum in hyperthyroidism,
390
Thyroid gland, anatomy, 380
cancer of, 381
enucleation of growths in, 385
inflammations of, 380
ligation of, after-treatment, 393
hyperthyroidism, 393
lobe of, resection of part, 389
sarcoma of, 381
Thyroid gland, secretion, conditions of
deficiency of, 394
syphilis of, 381
tuberculosis of, 381
glands, accessory, 380
Thyroidectomy, 382, 392
after-treatment, 393
anesthesia for, 392
Thyroiditis, acute, 380
chronic, 381
Thyrotomy, 230
Thyro toxicosis, 389
Tinnitus, operation on seventh nerve in,
112
Tongue, 286
abscess of, tuberculous, 290
actinomycosis of, 290
bifid, 286
burns of, 288
cancer of, 292
excision for, 293. See also Excision oj
tongue for carcinoma.
operation in, 364
congenital defects, 286
cracks of, 289
cysts of, 292
dyspeptic, 289
foreign bodies in, 287
frenum of, ulcers of, 290
furrows of, 289
herpes of, 288
hypertrophy of, 290
inflammations of, 288
injuries of, 287
leprosy of, 290
leukoplakia of, 289
nodules of, tuberculous, 290
psoriasis of, 289
root, tumor of, 389
swallowing, 287
syphilis of, 290
trichinosis of, 290
tuberculosis of, 290
tumors of, 291, 292
Tongue, ulcers of, 289
aphthous, 290
dyspeptic, 289
herpetic, 290
mercurial, 290
traumatic, 290
wounds of, 287
gunshot, 288
Tongue-tie, 287
Tonsillectomy, 213
after-treatment, 214
anesthesia in, 213
hemorrhage after, 214
incomplete, 213
indications for, 213
position of patient for, 213
results, 214
Tonsillitis, acute, 212
catarrhal, 212
caseous, 212
chronic, 212
follicular, 212
membranous, 212
826
INDEX OF SUBJECTS
Tonsillitis, suppurative, 212
Tonsillotome, 213
Tonsillotomy, 213
Tonsils, adherent, 216
diseases of, 212
enucleation of, 213, 214
hypertrophy of, chronic, 212
imbedded, 216
lingual, diseases of, 290
mycosis of, 212
operations on, through neck, 367
removal of, 213
partial, 213
with guillotine, 216
tumors of, 216
palliative treatment, 216
Tooth powders, formulae for, 275
Torek's method of exposing thoracic
esophagus, 462
Torsion of omentum, 620
Torticollis, 373
acute, 373
bilateral, 375
chronic, 373
stretching and manipulation in, 373
division of posterior muscles in, 375
excision of sternomastoid muscle in, 375
fixation in, 373
habitual, 377
ocular, 377
open tenotomy in, 375
paralytic, 377
rachitic, 377
resection of posterior cervical nerves in,
376
spinal accessory nerve in, 376
rheumatic, 377
spasmodic, 376
subcutaneous tenotomy in, 374
treatment after operation, 375
Total laryngectomy, 231
Tower head, 42
Toxemia, chronic intestinal, 610
Trachea, 217
acquired stenosis of, 218
burns of, 219
congenital stenosis of, 218
contusions of, 219 •
examination, 217
foreign bodies in, 224
removal, 244
fractures of, 219
inflammations of, 220
injuries of, 219
malformations of, 218
operations on, 217. 226
resection of, 237
treatment, '217
tumors of, 224
wounds of, 220
Trachepscopy, 225, 239
position of patient for, 240
Tracheotomy, 226
high, 227
indications for, 225
low, 228
operative complications, 228
Tracheotomy, postoperative care, 229
complications, 229
tubes, 227
with excision of non- toxic goiter, 389
Trachoma, 123
operations for, 150
true, 124
Transmesocolic route of approach to pan-
creas, 779
Transplantation of cornea, 153
of fat into orbit after enucleation, 160
of nasal cartilage, 192
of parathyroid glands, 394
Transverse laryngotomy, 230
Traumatic cataract, 133
immediate removal, 173
hysteria, 103
insanity, primary, 102
neurasthenia, 103
psychoses, 102
rupture of tympanic membrane, 306
spondylitis, 326
thrombosis of sinuses of dura mater, 72
ulcers of tongue, 290
Traumatism of peritoneum, 542
Trephine, 26, 27
sclera, 163
Trephining of sclera, simple, in glaucoma,
162
Triangle, mesenteric, 625
postmeatal, of ear, 300
Trichinosis of tongue, 290
Trigeminal nerve. See Fifth nerve.
Tropical dysentery, 570
Tube, Eustachian, 299. See also Eusta-
chian tube.
Tubercle, retro-orbital, 46
Tuberculin in nodular lymphatic kerato-
conjunctivitis, 125
Tuberculosis, artificial pneumothorax in,
416
drainage of lung cavities in, 416
interpleural pneumolysia in, 418
of bones of skull, 41
of brain, 75
of breast, 475
of cecum, 575
of choroid, 130
of intestines, 574
of larynx, 222
of pharynx, 207
of ribs, 398
of sacro-iliac joint, 355
of spine, 327. See also Pott's disease.
of spleen, 785
of stomach, 702
of thyroid gland, 381
of tongue, 290
pneumectomy in, 416
pneumolysis in, 418
resection of costal cartilages in, 419
of lungs in, 416
thoracoplasty in, 418
Tuberculous abscess of tongue, 290
adenitis, 368
nonsurgical treatment, 369
technic of operation for, '3 70
INDEX OF SUBJECTS
827
Tuberculous empyema, 413
hydro thorax, 413
lymph-glands of neck, 368
non-surgical treatment, 369
technic of operation for, 370
meningitis, 68
nodules of tongue, 290
perforation of intestines, 581
peritonitis, 554
spondylitis, 327. See also Pott's disease.
Tubes, tracheotomy, 221
Tumors, brain, blindness with, 178
epilepsy from, 101
intraspinal, 338
of abdominal wall, 538
of brain, 75
active treatment, 76
antisyphilitic treatment in, 76
blindness with, 178
curative treatment, 77
dangers of lumbar puncture in, 77
decompression in, 78
indications for operation, 75
localizing indications, 75
palliative operations in, 78
results of operation, 82
suction apparatus in, 78
two-stage operations in, 78
of breast, mixed, 475
of chest wall, 444
of choroid, 130
of conjunctiva, 124
of cornea, 128
of cranial bones, 42
of diaphragm, 470
of esophagus, 445
of eyelid, 120
of face, 115
of gums, 280
of intestines, 582
chronic obstruction from, 610
of iris, 1 29
of jaws, 286
of lacrimal gland, 136
of lips, benign, 254
of lung, 445
of male breast, 497
of maxillary antrum, 197
of mediastinum, 446
of meninges, 75
mesenteric, 563, 564
of nasal cavity, benign, 188
of nasopharynx, 208
of neck, 372
solid, 372
of nipples, 473
of nose, 1 88
of omentum, 620
of optic nerve, 135
of orbit, 137
removal of, 163
of palate, 255
of pancreas, 782
of pericardium, 445
of peritoneum, 557
of pituitary body, 83
of pleura, 445
Tumors of root of tongue, 389
of salivary glands, 379
of scalp, 24
of sclera, 129
of seventh nerve, removal of, 1 13
of spinal cord, 338
medullary, extrusion treatment, 342
laminectomy in, 341
spinal decompression in, 344
of spine, 338
of spleen, 705
of stomach, 703
of teeth, 280
of thorax, 444
of tongue, 291, 292
of tonsils, 216
palliative treatment, 216
of trachea, 224
of umbilicus, 537
of vertebrae, 338
retroperitoneal, 563
Turbinated bones, 179
hypertrophy of, 186
removal of, 186
Turck's mattress interlocking stitch for
intestinal suture, 636
Turpentine enema, 620
Tympanic deafness, advanced, 319
membrane, 299
examination of, 302
incision of, in acute otitis media,
307
traumatic rupture of, 306
ulcerative rupture of, 306
wounds of, 301
Typhlitis, 576
Typhoid spine, 326
spondylitis, 326
ulcer, perforating, 580
ULCERATION of esophagus, 432
Ulcerative rupture of tympanic membrane,
306
of cornea, 125
Ulcer, gastrojejunal, 580
jejunal, 580
of cornea, 125
simple, 125
of duodenum, 576. See also Duodenal
ulcer.
of esophagus, 433
of frenum of tongue, 290
of intestines, 576
of lips, 246
of soft palate, 255
of stomach, 720
actual cautery in, 724
dietetic treatment, 721
excision of, 723
gastro-enterostomy in, 722
hyperchlorhydria in, treatment, 722
indications for operation in, 722
limitations of medical treatment, 723
near pylorus, 723
non-operative treatment, 720
perforating, 726
resection of, 759
828
INDEX OF SUBJECTS
Ulcer of stomach, results of operation in, 724
of tongue, 289
aphthous, 290
dyspeptic, 289
herpetic, 290
mercurial, 290
traumatic, 290
of uvula, 255
perforating typhoid, 580
Ullmann's inyagination method of intestinal
anastomosis with ring or b&bbin, 658
Umbilicus, cysts of, 537
diseases of, 537
fistula of, 537
infections of, 537
tumors of, 537
Unilateral strabismus, 175
Urachus, cysts of, 538
diseases of, 538
fistulas of, 538
Urine, retention of, after abdominal opera-
tions, 533
Uveitis, 130
Uvula, bifid, 255
diseases of, 255
elongation of, 255
Uvulotomy, 255
VACCINES, Coccobacillus foetidus ozoenae,
in ozena, 188
in chronic intestinal stasis, 611
suppurative otitis media, 310
Micrococcus catarrhalis, in ozena, 188
Vacuum extraction of cataract, 1 74
Vascular goiter, operation on, 388
keratitis, 127
Vasoconstriction, local, in nasal operations,
183
Vena cava, anastomosis of, with mesenteric
vein, in ascites, 563
with portal vein, in ascites, 561
Venesection in compression of brain, 54
Venous sinuses, infections of, 318
thrombosis of, 318
Ventricle, lateral, of brain, 48
right, paracentesis of, 425
Verhoeff's method of tattooing cornea, 152
Vernal conjunctivitis, 123
Vertebrae, operations on bodies of, in Pott's
disease, 337
tumors of, 338
Vertical postmuscular abdominal section,
512
Vertigo, acoustic, operation on seventh
nerve in, 112
Visceral injuries, 535
Visual sensory center of brain, 45
Vitreous, diseases of, 134
fluidity of, 134
foreign bodies in, 134
hemorrhage into, 134
opacities in, 134
pus in, 134
Vogel's method of preventing adhesions in
abdominal operations, 522
Voice, training of, after cleft-palate opera-
tion, 266
Volvulus, 608
of stomach, 715
Vomiting after abdominal operations, 531
postoperative, 615
von Hacker's method in stricture of esoph-
agus, 436
von Leube's treatment of ulcer of stomach,
721
WALKER'S circular occlusion method of
intestinal anastomosis, 660
Wandering spleen, 786
Wedge-isolation operation of Herbert in
glaucoma, 161
Wen of scalp, 24
Witzel's method of gastrostomy by canal-
ization of stomach wall, 736
Woody phlegmon, 362
Wounds of abdominal wall, 535
of air-passages with cut-throat, 360
of auricle, 303
of blood-vessels, cut-throat with, 360
of brain, 61
bullet, 62
stab, 62
of breast, 472
of carotid artery, 360
of chest wall, non-penetrating, 397
penetrating, 397
of choroid, 130
of ciliary body, 130
of conjunctiva, 121, 124
of cornea, 121, 128
of diaphragm, 398, 536
of dura mater, 61
of esophagus, 360, 431
of external auditory canal, 304
of eyeball, 121
of eyelids, 121
of face, 115
of heart, 428
penetrating, 429
of intercostal artery, 398
of internal jugular vein, 360
mammary artery, 398
of intestines, non-perforating, with
wounds of mesentery, 568
perforating, 567
suturing of, 635
of intracranial structures, 61
of iris, 129
of larynx, 220
of lips, 246
of lung, suturing of, 414
with penetration of chest wall, 413
with pleural infection, 414
of meninges, 61
of mesentery, 568
non-perforating wounds of intestine
with, 568
of nerves of neck, 360
of nose, 183
of optic nerve, 135
of pancreas, 779
of pericardium, 422
of pia-arachnoid. 61
of pleura, 399
INDEX OF SUBJECTS
829
Wounds of scalp, accidental, 18
control of hemorrhage in, 18
infection in, 18
operative, 19, 20
suture of, 19
of sclera, 129
of spine, bullet, 325
stab, 325
of spleen, 784
of stomach, 702
of thoracic duct, 361
Wounds of tongue, 287
gunshot, 288
of trachea, 220
of tympanic membrane, 301
Writing, brain center of, 44
XANTHELASMA, 120
Xerotic keratitis, 127
X-rays in hyperthyroidism, 390
ZIEGLER'S V-shaped iridotomy, 156
Zonular cataract, 133
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