470

COMMENTS ON SOME MINOR SURGICALCONDITIONS

By D. LANG STEVENSON, F.R.C.S.E. Late Lieut.-Col., R.A.M.C.Surgeon, Whipps Cross Hospital

Pilonidal sinus, phimosis, hydrocele, varicose-veins and anal complaints are familiar in the list,of conditions which commonly inflict varyingdegrees of discomfort in the younger age group ofthe population. Implicit in the undertaking oftreatment is the expectation that comfort or cure,can be achieved by a relatively minor procedurefollowed by a rapid convalescence and return towork. The most mutually satisfying extent towhich this expectation may be realized is condi-tioned in the majority of cases by the method ofsurgical technique and management. True, onemethod may differ from another only in detail, butit is the detail that may in large measure decide the.smoothness of the post-operative course, thequality of the end result, and the time spent inhospital or off work. In these respects thesubsequent modifications and details of techniquehave proved valuable in the treatment of theconditions already mentioned. Some commentshave also been made on evaluation of treatmentparticularly in regard to varicose veins.

Pilonidal SinusThe difference between primary and secondary

healing in these cases almost implies the differencebetween three weeks and three months in hospital.'The essentials for success in primary suture arewell recognized in complete excision, meticulousasepsis, and a method of closure which eliminatesdead space. The last is of first importance sincemost failures are initiated by tenting of the super-ficially healed skin and subcutaneous tissues. Thecardinal point is to ensure that the soft parts are not-only in mutual apposition but that they are also inclose contact with the aponeurotic covering of thesacrum. Indeed, the principles are the same as inthe application of a full thickness skin graft to anawkward contour. The two factors which militateagainst success are the relatively avascular sacralbed and the forces of tension.which are constantlypersuading the sutured soft parts to assume themore relaxed position away from the sacrum. Forthese reasons a pressure dressing is a sine qua nonand must be maintained for at least I4 days. Ifremoved too soon, the skin and subcutaneoustissues tend to spring away from the sacrum at the

first movement which increases local tensions.Sero-sanguinous exudate is the natural reaction,and superadded infection is not far behind. Thisprobably accounts for a number of disappointingresults in cases which seemed at first to be doingwell, and also indirectly for the multiplicity oftechniques now advocated.

All active infection must have settled beforeoperation is contemplated. Incision and drainageof an abscess may be a necessary first phase intreatment and the opportunity should be taken ofcuretting away gently as much debris as possible.A very fine probe may establish to which side ofthe mid line the main sinus deviates. The skin isprepared for three days before operation and thebowels for six days confinement. At operation theskin of the whole area is thoroughly treated with asuitable antiseptic and the anus is sealed off with adressing. The orifice of the sinus is given anapplication of pure carbolic acid and laterobliterated by approximating the skin edgesresulting from the eliptical incision.

After excision of the sinus an anchor type ofpressure dressing is essential, and is the keystoneof success in this operation. Although this formof dressing has been described and used in manyways, an outline of the following modification isjustified by the end results. Three or four pairs ofspecially placed deep sutures of strongest nylonare distributed over the length of the wound andthe ends of each pair are secured with forceps.With a large curved needle the suture commencesone inch from the skin edge at the upper extremityof the wound, passes through the full thickness ofthe soft parts, takes a good bite of aponeurosis justto the same side of the mid-line, and returnsthrough the full thickness of the soft parts againemerging about three-quarters of an inch belowthe starting point. Three or four such sutures areso placed that pairs do not cross in the mid-line(see diagram). The skin edges are brought to-gether with fine interrupted vertical mnattresssutures which are tied lightly. It is well to em-phasize here that the minimum of skin should besacrificed at the excision of the sinus. Before in-serting the final stitch any blood that may havecollected in the wound is expressed. The anchor

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September 1948 STEVENSON: Comments on some Minor Surgical Conditions 47r

Showing themethod placingI/f $V \\three pairs of

deep sutures.

The completed Anchor dressing. A separate steriledressing is tucked loosely under the anal end of the

long gauze roll.FIG. I

dressing (which consists of one long and threeshorter rolls) is now applied. The large roll isplaced along the wound and the three shorter rollsare laid across it in such a manner that each pair ofdeep sutures may be tied over the correspondingextremity. These sutures are tied, first on oneside and then with the short rolls drawn tightlyacross the long one, the remaining sutures areknotted (see diagram). It is important to tightenthe nylon slowly feeling for the optimum tensionto make the knot. Finally a sterile dressing istucked under the lower end of the long roll.The secret lies in making the anchor dressing of

generous size and soft consistency and in tying thedeep sutures at the right tension. Twice dailv etheris run over the dressing to maintain dryness of thesurrounding skin. The bowels are confined forsix days and on each future occasion when thebowels have moved the sterile dressing under thelower end of the long roll is changed. Parenteralpenicillin is given if indicated. When the anchordressing is, remnoved on the i4th day the wound isfound to be soundly healed by first intention andall sutures are removed. The patient is able toleave hospital on the i6th day.Many people would *prefer to tolerate the

nuisance of a slight discharge and an occasionalabscess than endure three months of daily dressingwhile lying in an uncomfortable or restrictedposition. In fact simple incision, gentle curettageand, penicillin may achieve quiescence for months.It is only by making primary healing the rule that

surgical treatment in terms of hospital days can bejustified in relation to the minor nature of thedisability.

PhimosisAn oedematous and ulcerated suture line may

keep a man in hospital or 'off work for severatweeks quite apart from the alarm such an appear-ance may invoke in the patient. Certain points inthis operation must be observed if these com-plications are to be avoided. The areolar tissue inthis region, like that of the eyelid, quickly reactswith oedema to the most trivial' irritant. Theobject of the following technique is to avoid allsources of tissue irritation as far as possible.Forcipressure and torsion with a fine type ofmosquito forceps is all that is used and all that isnecessary for haemostasis. Buried catgut shouldnever be employed. Nylon as a suture materialhas few equals judged by the kindly way it is.tolerated by all tissues and experimental workendorses this experience.

It is hoped that the diagram demonstrates themethod and how these requirements are satisfied.Fine nylon on a straight cutting needle is used toplace the six necessary sutures. The first is at thefraenum and is the well-known corner stitchmodified by wider spacing. The ends are leftuntied (see diagram). The next suture, placed atI2 o'clock, is returning in type and makes the loopon the corona. The ends again are left untied andsecured with forceps. Two sutures are now in-serted at approximately io o'clock and 2 o'clock,and these differ from the 12 o'clock suture only inthat the loop is on the foreskin. The last pair areat 8 and 4 o'clock, the loop being once more on thecorona. All stitches must be accurately madeclose to the margin of the integument. Two gauzerolls are now prepared about as thick as the littlefinger and preferably sewn with a rapid bastingstitch. The long roll is made to surround thecorona like a collar and the short one is laidlengthwise on the fraenum. Before this is doneeach is smeared lightly with a little Vaseline on thenarrow strip of gauze which is to lie in contact withthe suture line. Firstly the short roll is placed onthe fraenum and the nylon is gently tied over itleaving the ends long. When the large roll is.placed in position the free ends of the suturesshould lie on their respective and alternate sides(see diagram). The ends of the 12 o'clock sutureare then tied to the adjacent ends of the io and zo'clock sutures, while the two opposite ends aretied to the adjacent ends of the 4 and 8 o'clocksutures. Gentle traction on the two remaining ends.fixes the dressing in position and these are finallytied to the long ends of the suture at the fraenum.It will be'seen that the nylon now takes a con-

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472 POST GRADUATE MEDICAL JOURNAL September I948

The final position ofthe sutures and Anchor dressingson the ventral aspect of the penis. Note the short

gauze roll is laid proximal to the meatus.

00,00Commnencing at A and F, the corres-ponding sutures are tied over thecollar dressing gently taking up the

slack as each is knotted.

This well-known suture at theFraenum is tied lightly over the An 'end on' view of the completed dress-short gauze roll as the first step ing. It is removed by cutting on eitherin fixing the Anchor dressings. side of each knot.

FIG. 2 FIG. 3

tinuous spiral course over the gauze roll andobtains apposition of the skin edges by lineartension, no knot being tied on the skin. The gauzeroll on the fraenum is trimmed to lie behind themeatus and the patient is instructed to dry themeatus after urination with a pledget of cottonwool. The suture is removed on the third dayby cutting on either side of the knot over thegauze. The dressing falls off and the suturesslide out so easily that the patient is usuallyunaware of the fact.

Adult circumcision is. an operation whichdemands more care and precision than the averagesurgical textbook seems to indicate. If the edgesof the foreskin and corona are cut cleanly and alldetails in the above technique are observed, exacthealing by first intention can be obtained inevery case. The combined protective and pressuredressing has also the advantage that it is extremelycomfortable, allowing the patient to be ambulantfrom the day of operation.

HydrocoeleThe difference between the uncomplicated

operation for hydrocoele and the case which is

complicated by an infected haematoma may bethe difference between six days and six weeks inhospital, quite apart from the unpleasant endresult. It is therefore of first importance that theoperation is as far as possible avascular and thathaemostasis is meticulous.The following technique fulfills these require-

ments. Apart from minor modification it is amethod which I learned from my former chief,Mr. E. T. C. Milligan. The scrotum is com-pressed and steadied 'with the left hand and anincision is made through the skin and dartosmuscle, the length according to the size of thehydrocoele. (The belief that scrotal incisions havea tendency to become infected is without founda-tion and indeed these wounds heal with apractically invisible scar if care is taken to use aneverting form of suture. 'Dislocating the scrotalcontents into the inguinal. region is a more trau-matic and vascular procedure which should becondemned.) All fascial coverings are divideduntil the blue translucent parietal tunica vaginalisis exposed, which must be done with great caresince the delicate membrane is easily ruptured. Acombination of blunt and sharp dissection com-

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STEVENSON: Comments on some Minor Surgical Conditions

pletes the mobilization of the cyst. If the closedlimbs of a pair of non-toothed dissecting forcepsare insinuated beneath a layer of tissue and allowedor compelled to open, the tissue is placed ontension and elevated from deeper structures: thismanoeuvre greatly facilitates division of the tissuewith scalpel or scissors and is of particular use inthis operation. Incidentally, th'e correct useand application of tension is one of the greatsecrets of technical surgery. The tunica vaginalisis now divided down the middle and reflectedbehind the testicle. The edges are clipped to-gether for two or three minutes with Kocher forcepswhich usually suffices to effect adherence. AnIybleeding point must be ligated at sight although asa rule there are few or none at all. The testicle isnow gently replaced by holding up the edges ofthe scrotum with four strategically positionedtissue forceps. The wound is closed without drain-age by a few interrupted vertical mattress suturesof fine nylon. A sterile suspensory bandage linedwith a layer of wool makes a satisfactory and com-fortable dressing. The sutures are removed onthe third day and the patient leaves hospital onthe next day with a support.

This operation is effective in all simple un-complicated hydrocoeles. Although it is allegedthat these modified Jaboulay types of operationhave the defect of occasional recurrence, thewriter has not seen this. It is well to remember thatmany patients can get along quite comfortablywith repeated tappings, but if operative cure is tobe preferred to this form of treatment or injectiontherapy, it should be a simple procedure involvingonly a short period off work.

Varicose VeinsIn modern practice the two chief indications for

obliteration or ablation of varicose veins in thelower limbs are improvement of appearance andimprovement of function. In the former, wheretreatment is almost restricted to women, theresults, on the whole, attain the objective. In thelatter the problem is neither as simple nor assatisfactory, and there are several factors whichcontribute to this state of affairs.The too mechanistic approach, which identifies

the ache with visible varicose veins, assumes thatremoval of the vein must in-all cases remove theache. This belief tends to overlook physiology,pathology, psychology, and even experience itself.It is common knowledge that some possessors ofthe most gross varicose veins have no troublethroughout an active lifetime and indeed may beable to walk 20 miles over rough country. Thisdemonstrates that the size and extent of the veinsbear no constant relationship to the disability andthat there is, therefore, no true causal relationship.

On the assumption that symptomless varicoseveins do not require treatment in Lthe male, andthat a cosmetic operation is rarely desired by aman, the only indication for treatment in this sexis disability. Since clinical assessment of thedegree of disability depends in large measure onthe patient's subjective evidence, there can be noguiding rule in selection which must remain amatter for individual judgement. However, un-necessary treatment can at least be avoided byrecognizing that there are certain groups of menwith symptomless varicose veins who may never-theless be subjected to surgical procedures. Thelimitations of modern therapy must also be bornein mind. Firstly, there are those cases where thereal disability lies in foot strain, pes planus orother orthopaedic defect. Secondly, there arethose who seek treatment because they believethat varicose veins, like certain dread diseases,must be caught early to be cured, and not becausethe veins are giving trouble. This can be under-stood since the unpleasant complications inadvanced cases are widely known to the public butin most instances convincing reassurance relievesthe apprehension and the veins are forgotten. Thethird group comprise candidates for variousservices, foremost among which is the PoliceForce. Here, treatment before acceptance isobligatory. This means that a young man ofi8 or i9 with an early incompetency of thesaphenous system is compelled to undergo anoperation for ablation or obliteration of the veins.This policy is not in the interests of long andefficient service as his veins might be symptomlessfor another ten years or never trouble him at all.On the other hand an untimely operation may takehim off his beat in half that time by antedating theonset of a disability or even by causing an avoid-able one. It would seem that at some pointthis policy has been endorsed by the medicalprofession.

Since varicose veins are in most cases familialand have a tendency to increase in size and extentthroughout life, treatment, at the best, merelymodifies the effects of the tendency by improve-ment in appearance or function for a varyingperiod of time. How long the improvement is main-tained depends, of course, on the presence offavourable or unfavourable factors. In the lattergroup long standing occupations and pregnancyare the first to be indicted. Conversely, asedentary job is one of the best guaranteesof a reasonably lasting result, and indeed allthe treatment that some cases require. Moreover,there appears to be a limit in the extent to whichthe superficial venous svstem of a varicose subjectmay be removed by repeated obliterations andexcisions without jeopardizing muscular circula-

September 1948 473

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POST GRADUATE MEDICAL JOURNAL

tion and function. A limb that has been denuded ofthe varicose saphenous systems may show littleevidence of visible varicosities yet a bursting painis experienced on slight exercise. This conditionmight well be called varicose veins sans varicoseveins. Any major ablation must throw an in-creased strain on both deep veins and the re-maining superficial veins. The latter being un-supported by muscle and suffering from the sameinherent structural defect gradually becomevaricose. Taking the mechanistic approach to itslogical conclusion, the belief that repeated removalof these further varicose veins as they appearwill maintain normal function cannot be re-conciled with experience.

Treatment should, therefore, be planned in re-gard to the active life span of the individual so thatthe maximum benefit accrues at the optimumperiod. Also, judicious selection of the patientand the treatment for the patient are of equal im-portance. The writer now reserves injection ofsclerosing agents mainly for cosmetic treatment inwomen. Where disability exists, excision of theveins gives better results and the possibility of deepthrombosis is greatly diminished if not eliminated.Operative treatment is avoided in men below theage of 30, which incidentally is also a good rulein the case of other varicose conditions. Thecase with a single large localized group of veinsin the calf is the type of case which seems tobenefit the most from excision. The extensiveincompetency of the great saphenous system withdisability is treated, in the first place, by simpleligation at groin and knee. Two or three monthslater the case is reviewed since a number of thesecases are improved quite appreciably by ligationalone. If indicated, excision can then be under-taken. Lastly, in suitable cases considerable use ismade of a well-made elastic stocking both as anadjuvant or alternative to surgical treatment.Wound infection is generally ascribed to faulty

asepsis, haematomata, or ' dead space.' A possibleexplanation of the characteristic sullen indurationwhich may keep a man in bed several weeks, isdamage to infected lymphatics at dissection. Atleast where simple ligation is performed suchcases are rarely encountered.Some points in regard to technique may be

worth mentioning. Th'e removal of a length ofvein may be easily performed with the writer'sball-ended needle originally designed for syn-chronous injection (Lancet, Jan., 1938). The ballend is passed down the vein as far as possible and asmall incision is made over it: when the vein hasbeen exposed a ligature is tied above and belowthe ball. The vein is divided between the liga-tures and by withdrawing the needle forcibly, thevein is turned inside out as it follows the needle.

Further segments of vein can be removed in thesame way through small incisions. A new methodof obliterating varicose veins in continuity is atpresent being tried out by means of a ball-endedelectrode and a further report will be made at alater date since the results so far are most promis-ing. The technique has the advantage that a certainsclerosis is obtained with the minimum of intra-luminal altered blood and without the risk of theirritating agent entering the deep veins, which isone of the disadvantages of injection therapy.To sum up, the problem of selection is of equal

importance with the matter of technique. In themale at any rate where cosmetic considerationsare not important, the criterion for treatment mustbe the maintenance of optimum function through-out the active life span. In this context the con-cluding aphorism is perhaps apposite smallveins with symptoms not yet, large veins withoutsymptoms never.

Anal ComplaintsOccasional bleeding at defaecation is a not un-

common complaint in a young man and as a rulethere is no call for treatment other than liquidparaffin and local ointment for a few days. Thesingle thrombosed external haemorrhoid is anotherfamiliar condition at this age which is treatedaccording to size and pain, conservatively or byevacuation of the clot. The cause is probably to befound in the common systemic venous pool whichdrains both the genital and anal regions, congestionin the former being shared by the latter. Thewriter avoids operating on internal haemorrhoidsbelow the age of 35 if possible. Many patients withmoderate internal haemorrhoids can be madecomfortable by correcting faulty habits and byinstruction in defaecation. Quite large prolapsinginternal haemorrhoids can be treated successfullybv injection although it is preferable to admit thesepatients to hospital for two days. The bowel isprepared as for haemorrhoidectomy and a largeinjection of io to I5 ml. 5 per cent. phenol in oilis given. For large haemorrhoids this regime hasbeen found to be more satisfactory than multipleserial injections. Should the haemorrhoids pro-lapse during the first ten days, the patient is in-structed to replace them digitally.

Acute, and even in some cases chronic, fissurein ano may often be healed by correcting the bowelaction and by local baths and ointment. A furthervaluable adjunct to treatment is to instruct thepatient to carry out digital dilation in a hot bathwith soapy water, which, incidentally, is a goodpractice after pile operations. In the matter ofcorrecting causes, it is interesting to observe thatnot infrequently emotional conflict or disturbancetakes first place in the chain of aetiological factors.

-September X1948474

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Setptember I948 ELLIOTT and YOUNG: Treatment of Acute Empvema Thoracis 475

For chronic fissure in ano, surgical excision andsuture has been practised with surprisingly goodresults. A stay suture is inserted at the proximaland distal extremities of the fissure which is madeprominent by tension on each stay. The fissure isthen easily excised with the subjacent portion ofthe subcutaneous external sphincter. Two or threefigure-of-eight sutures of fine nylon are placed,one of which approximates the cut ends of thesphincter. A layer of gauze is wrapped round asmall soft rubber tube and the sutures are tiedlightly over it. The bowels are confined for sixdays and the dressing remains clean until thesixth day when the sutures are removed and anolive oil enema is given. The sutures are easilyremoved by cutting over the dressing. Liquid

paraffin by mouth and local Vaseline beforedefaecation are used for two subsequent weeks, andit is interesting to note that the writer has not seenfistula formation after this procedure. There isalso an economy in hospital days as compared withwounds allowed to heal by second intention.Time lost from work in the treatment of a

minor disability, although of secondary signifi-cance to successful treatment, is nevertheless ofmajor importance to the individual and to thecommunity. The aim of the modificatioins intechnique and management which have beendescribed, has been to achieve cure or comfort inthe shortest possible time. The guiding principlehas been close attention to the smaller clinical andtechnical details.

TREATMENT OF ACUTE EMPYEMA THORACISWITH INTRAMUSCULAR AND INTRAPLEURAL

PENICILLINBy W. A. ELLIOTT, M.D. (Camb.), M.R.C.P.

Trainee Specialist Physicianand

> B. A. YOUNG, M.D.(Lond.), M.R.C.P.Physician Superintendent, St Alfege's Hospital, Greenwich

This paper is based on a series of 22 cases ofacute empyema admitted to this hospital betweenMarch, 1945, and August, 1947. The underlyingdisease was lobar pneumonia in i8 cases, broncho-pneumonia in one case, lung abscess in one caseand neoplasm in two cases. The duration ofsymptoms before admission to hospital variedfrom three days to six weeks. (The onset ofsymptoms is reckoned from the first day on whichthe patient felt ill, as the date of onset of theempyema cannot be accurately determined.)While acute toxaemic symptoms were present,

the patients were given intramuscular penicillinin doses sufficient to maintain a continuous bac-teriostatic concentration of the antibiotic in theblood-stream (usually 6o,ooo units four-hourly).In addition, the pleural cavity was aspirated ascompletely as possible through a wide bore needleon alternate days and intrapleural penicillin(usually 250,000 units) was injected. (Smallerdoses were given in some of the earlier cases inthe series.) The fluid withdrawn was culturedand the sensitivity to penicillin of the organismsgrown, was estimated.' Breathing exercises werestarted as early as possible in all cases.

This method of treatment gave good results in14 of the pneumonic cases and in the lung abscesscase. Details are given in the table below. Theaverage time spent in hospital in these cases was52 days; the average time after this for the chestradiographs to become clear was five weeks.Good functional results were obtained in all I5cases. In four other pneumonic cases, rib resectionand drainage was carried out after a course ofintramuscular and intrapleural penicillin. In oneof these four cases, the culture of the pus fromthe pleural cavity grew bacterium coli which wasresistant to penicillin. In another case, in whichthere was a large pneumococcal empyema (61pints) on admission, a pyo-pneumothorax occurredduring treatment. The remaining two cases whichwere treated surgically, were early in the seriesand received relatively small doses of penicillin;one of them having no intramuscular penicillin.In the light of our later experience we considerthat both these cases would probably have clearedup without operation had larger doses of penicillinbeen given. The remaining pneumonic caseimproved considerably with intramuscular andintrapleural penicillin and the patient was dis-

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