Manual of operative surgery

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Preface To Seventh Edition

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

Kansas City, Missouri.

Preface To Sixth Edition

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

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

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

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

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

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

J. F. BiNNIE.

vn

Preface To The Fifth Edition

K. M. Blakiston, Esq.,

Philadelphia, Dear Sir:

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

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

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

, Yours sincerely,

J. F. BiNNIE.

IX

DEDICATORY LETTER

Twelfth and Wyandotte Sts., Kansas City, Mo.

Dr. Robert F. Weir, New York:

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

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

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

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

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

I remain,

Your friend,

J. F. BiNNIE.

XI

LIST OF CONTENTS

PART I Head and Neck

Chapter Page

I. Scalp i

II. The Skull and the Brain 6

III. Frontal Sinus 54

IV. Tic Douloureux 56

V. Plastic Operations on the External Ear 75

VI. Empyema of the Antrum of Highmore 82

VII. Osteoplastic Exposure of the Orbit 84

VIII. Excision of Upper Jaw 85

IX. Lower Jaw. Resection 93

X. Odontomata 104

XL Excision of the Cheek 105

XII. Lower Lip " 112

XIII. Upper Lip 127

XIV. Hare-lip i33

XV. Cleft Palate i43

XVI. Tongue 158

XVII. Parotid Gland i74

XVIII. Operations on the Nose 182

XIX. Torticollis, Wry-neck, Caput Obstipum 205

XX. Excision of Cervical Ribs 209

XXI. Excision of Cervical Tumors 211

XXII. Excision of the Cervical Sympathetic 219

XXIII. Retropharyngeal Abscess and Tumors 223

XXIV. (Esophagus ., 226

XXV. Pharyngotomy, Laryngotomy, Partial Laryngectomy, and Laryngectomy 233

XXVI. Tracheotomy 243

XXVII. Foreign Bodies in Trachea or Bronchus 247

XXVIII. Goitre; Bronchocele, Struma 252

XXIX. Thymus Gland 274

PART II The Thorax

XXX. Oper.\tions on the Breast 277

XXXI. Operations on the Chest 293

PART III The Abdomen

XXXII. Laparotomy; Celiotomy: Abdominal Section 339

XXXIII. The Stomach 352

XXXIV. Operations on the Intestines 404

xiii

XIV CONTENTS

Chaptkr Paqb

XXXV. The Vkrmiform Appendix and Peritoneum 458

XXXVI. The Rectum 475

XXXVII. ILemorrhoids 513

XXXVIII. Ascites 521

XXXIX. Retro-peritoneai. Neoplasms 528

XL. The Pancreas 531

XI.I. The Spleen 542

XLII. The Suprarenal Bodies 548

XLIII. Operations upon the Liver 550

XLIV. Operations on the Biliary Passages 560

XLV. Hernia 589

XLVI. Retro-peritoneal and Diaphragmatic Hernia 618

PART IV The Genito-Urinary System

XL VII. Operations upon the Kidney 625

XLVIII. Operations on the Ureter 658

XLIX. Operations on the Bladder 672

L. Perineal Section 703

LI. Urethral Stricture 714

LII. Epispadias 723

LIII. Hypospadias 727

LIV. Amputation of Penis 734

LV. Circumcision 739

LVI. Operations on the Testicles 741

LVII. Hydrocele 751

LVIII. Varicocele 753

PART V The Spine

LIX. Operations on the Spine 755

Part VI

LX. Ner\t;s 781

LXI. Arteriorrhaphy 812

LXII. Aneurysm 824

LXIII. Ligation of Arteries in Continuity 836

LXIV. Operations on Veins 856

LXV. Operative Treatment of Simple Fractures, Exclusive of Those

Involving Articulations and of some Special Fractures . . . 880

LXVI. Compound or Open Fractures 891

LXVII. Ununited Fracture, Pseudarthrosis 894

LXVIII. Fractures, Malunion 916

LXIX. Special Fractures 921

LXX. Osteomyelitis 943

LXXI. Tumors of Bone 960

LXXII. Chondrectomy 964

LXXIII. Osteotomy 965

LXXIV. Bow-leg, Genu Varum 976

LXXV. Operations on the Pelvic Bones 979

CONTENTS XV

Chapter Paqb

LXXVI. Sacro-iliac Disease 983

LXXVIL Hip 986

LXXVIII. Hip, Arthritis Deformans 997

LXXIX. Osteotomy Hip 998

LXXX. Old Dislocations of the Hip 1014

LXXXI. Congenital Luxation of the Hip 1018

LXXXII. Knee-joint 1035

LXXXIII. Patella, Tuberculosis 1058

LXXXIV. Osteotomy for Bony Anchylosis of the Knee 1061

LXXXV. Dislocation of the Patella 1070

LXXXVI. Ankle 1074

LXXXVII. Dislocation of the Astragalus 1081

LXXXVIII. SUBASTRAGALOID DISLOCATION I082

LXXXIX. Os Calcis 1083

XC. Bunion 1085

XCI. Operations on the Scapula and Clavicle 1090

XCII. Shoulder iioo

XCIII. Claviculo-humeral Nearthrosis 1121

XCIV, Operation for Subacromial Bursitis and for Rupture of the

Supra-spinatus Tendon 1124

XCV. Elbow 11 27

XCVI. Irreducible Dislocation of the Elbow 1134

XCVII, Anchylosis Elbow 1137

XCVIII. Wrist 1143

XCIX. Wrist Anchylosis 1147

C. Metacarpophalangeal dislocations 1149

CI. Syndactylism 1150

CII. Trigger; Snapping or Spring Finger 1151

cm. Operations for Infective Lesions of the Hand 1x55

CIV. Wounds of Joints 1164

CV. Indications. Joints 1165

CVI. Amputation or Disarticulation 1168

CVII. Flat-foot 1212

CVIII. Tendon Sheaths and Tenorrhaphy 1216

CIX. Tenotomy 1243

ex. Dupuytren's Contracture 1261

CXI. Principles of Plastic Surgery 1265

CXII. Methods of Drainage 1271

CXIII. Acute Abscess, Psoas Abscess 1274

CXIV. Operative Treatment of Neoplasms 1277

CXV. Ligatures and Sutures 1280

Index 131 7

MANUAL OF OPERATIVE SURGERY

Chapter I Removal Of Sebaceous Cysts (wens)

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

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

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

In cases where the cyst is not adherent and not inflamed, method A is extremely easy and gives perfect results; opening the cyst permits removal through a comparatively small cut, and the author has never seen harm result from escape of cyst contents.

ANGIOMA OF SCALP

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

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

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

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

I. At the points A, B, C, D (Fig. i) puncture the scalp with a knife. These points must be well away from the disease. With a needle introduce a stout chromicized catgut or a silk suture through .1 and bring it out at B, reintroduce at B and bring out at C; in the same manner carry the suture from C to D and from D to A. Both ends of the suture now emerge at A. Tie the suture tightly and let its knot retract under the skin through the puncture at A. Apply dressings.

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

vessels was inefl5cient in cases of large racemose (cirsoid) angiomata of the scalp; that ignipuncture, injections and excision were dangerous. He therefore

■11)

Fig. I. ^Subcutaneous ligation angioma.

Fig. 2. — Krogius' operation angioma.

devised the following method of subcutaneous ligation: Arm a full curved needle with catgut. Pass the needle from ,1 to B (Fig. 2), hugging the bone.

Fig. 3.

-Krogius' operation angioma.

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

ANGIOMA

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

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

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

1. Shave the anterior portion of the scalp.

Make a transverse incision over the head practically from ear to ear but inside the line of the hair.

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

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

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

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

Place the patient almost in a sitting posture. Anesthetize.

Step I. — Make an incision through the skin and epicranial aponeurosis skirting the growth anteriorly and laterally. ]\Iake the cut inch by inch, using compression on each side of the cut against the bone until the vessels are

Fig.

secured by forceps and ligatures. Isolate and doubly Hgate the main vessels before dividing them. This incision outlines a horseshoe-shaped flap having its base at the occiput.

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

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

Step 4. — After three or four days remove the dressings and excise the tumor from the under surface of the flap. Thrombosis of the vessels in the tumor, and

1^

<fwk i i^^^B

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Fig. 5.

Figs. 5 and 6. — Cirsoid aneurysm.

Fig. 6. {Clair mont.)

loosening of the surrounding connective tissue due to edema, make the excision of the growth easier than it would have been at the first sitting.

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

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

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

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

MALIGNANT TUMORS OF SCALP 5

would freeze to them (Whitehouse); all scabs must be removed prior to treatment.

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

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

MALIGNANT TUMORS OF THE SCALP

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

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

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

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

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