Surgery of the sympathetic nervous system

SURGERY OF THE SYMPATHETIC REVIEW PAUL G.

OF loo SYMPATHETIC

FLOTHOW, M.D., F.A.C.S. AND

NERVOUS

SYSTEM

GANGLIONECTOMIES*

GEORGEW. SWIFT,M.D., F.A.C.S.

SEATTLE, WASH.

S

URGERY of the sympathetic nervous system originated in the Iatter part of the nineteenth century IargeIy as

on spasticities has not proved entireIy successfu1, it initiated a wave of investigation and surgery out of which has grown a

FIG. 1. Dorsal

FIG.

the resuIt of Jonnesco’s work. Before the war, Leriche’s work on perivascmar sympathectomy had aroused considerabIe interest. During the war the sympathetic system was practicahy forgotten from a surgica1 standpoint. RoyIe is reaIIy the father of modern sympathetic surgery. AIthough his work

remarkabIy rationa therapeutic surgica1 measure. The history of sympathetic surgery since the impetus of RoyIe’s work is most interesting. First came a wave of enthusiasm for the operation in spastic cases. After a comparativeIy short time the penduIum swung back and at present, most authorities fee1 that the operation in these cases

ganglionectomy. Showing common attachment of trapezius and rhomboids severed and muscIes turned back as flap, exposing spIenius muscle.

* Read at Pan American

MedicaI

2. DorsaI gangIionectomy. Splenius mediaIIy exposing second rib and transverse

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hIarch

25, rg33.

retracted process.

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is worthIess, a feeIing with which we do not agree. Then, initiated by RoyIe’s observation of the increase in temperature of

FIG. 3. DorsaI gangIionectomy. CIearing second rib and transverse process showing exposed pleura.

the affected extremities folIowing sympathectomy, there arose a wave of enthusiasm for the operation in cases of vascuIar insufficiency of the extremities, both of the vasospastic and the obIiterative types. Owing to earIy resuIts in Raynaud’s disease the operation was haiIed as a positive cure. During the height of this phase Lewis made the assertion that the disease was due entireIy to a periphera1 vascuIar reflex. This conflict of ideas stiI1 exists, but again the rationa position is a conservative one in the midground. Enthusiastic reports of resuIts in Buerger’s disease and aIIied conditions then appeared. These were soon foIIowed by reports of numerous faiIures and again the penduIum swung too far to return to a

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IeveI with the advent of diagnostic procedures for seIection of suitabIe cases. The next great wave was in the apphca-

FIG. 4. DorsaI ganglionectomy. Portion of second rib and transverse irocess removed. PIeura retracted. Svmoathetic trunk beine cIeared above and below. Siohol;ing blood vesseIs oc:asionaIIy encountered.

tion of sympathetic surgery in cases of arthritis. At this point we entered the fieId with enthusiastic reports. Again the penduIum has swung and recentIy there is a noticeabIe absence of reports in the Iiterature of sympathectomy for arthritis. Here again the penduIum has swung too far and is now ready to swing back. The Iatest phase of the work has been in reIation to pain. But now having become wary by reason of previous over-enthusiasm we are approaching the subject more sIowIy and rationaIIy. A very significant point in the whoIe picture which must be borne in mind is the fact that in no instance of any condition where over-enthusiasm was dispIayed has

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there been a compIete reversa1 to an admission of faiIure. Out of every wave has come a therapeutic measure which if properIy evaIuated and properIy appIied has become a vaIuabIe addition to our surgica1 armamentarium. It is with the foregoing facts in mind that we are reporting the resuIts of our first 100 sympathetic gangIionectomies. A Iarge part of this work was done before the advent of reIiabIe diagnostic procedures and we fee1 certain that with this experience behind us, the resuIts of our future work wiII show a much higher percentage of success. RAYNAUD’S

DISEASE

AND

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pathectomy does not remove the cause, it mereIy ameIiorates some of the resuIts of the disease.

SCLERODERMA

We cIass these two conditions together since a11 of our cases of scIeroderma show a Iarge eIement of vasospasm, and a Iarge percentage of our cases of Raynaud’s disease show evidences of scIeroderma if carefuIIy examined. In a11 we have done 23 operations on IO patients. EIeven of the operations were for the Iower extremity and 12 for the upper. Of the I o patients, 3 were considered primariIy scIeroderma with a secondary eIement of vasospasm, and 2 cases were primariIy vasospastic with secondary scIeroderma. The other 5 patients had uncomplicated Raynaud’s disease. The 7 cases which were primariIy Raynaud’s disease have a11 been cured foIIowing operation. The scIeroderma cases have not done as we11 and the postoperative improvement is slower. In each of the three, however, the improvement in skin mobiIity and in vascuIarity has been marked. UnfortunateIy they have been advanced cases of scIeroderma; one patient practicaIIy a Iiving cadaver, who died severa months after the Iast operation, apparentIy as a resuIt of the disease, affecting her visceral organs. Her skin and the circuIation in the extremities had been markedIy improved by operation. We fee1 that the earIier these cases are treated the better the prognosis. The uItimate prognosis is, however, not good since this is, no doubt, a metaboIic disease affecting the entire body. Sym-

FIG. 5. Lumbar ganglionectomy.

Line of incision.

It is worth noting that the resuIts of sympathectomy in Raynaud’s disease of the Iower extremities is better than that for the uppers. Two of our patients and several patients of other men that we have seen stiI1 have a certain amount of vasospasm after dorsa1 sympathectomy. This, however, is not a source of discomfort and is apparentIy of no consequence. It is no doubt due either to regeneration of sympathetic nerves or to incompIete denervation. Since we do not see this phenomenon after Iumbar gangIionectomy, we fee1 that the Iatter expIanation is the more IikeI>-. THROMBOANGIITIS

OBLITERANS

(BUERGER’S

DISEASE)

The resuIts in this disease are remarkabIy good when one considers the pathoIogy. Success is dependent, however, on properIy is seIecting suitabIe cases. OperabiIity

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dependent upon the degree of vasospasm present. Where the Iesion is entireIy obIiterative, operation obviousIy cannot be of

in which the tests did not give a very good vascuIar index.’ FortunateIy a11 of these turned out very weI1. Two cases in which

FIG. 6. Lumbar gangIionectomy. ExternaI and interna oblique muscIes cut. Transversalis being separated in direction of its fibers.

FIG. 7. Lumbar gangIionectomy. TransversaIis cut. Peritoneum pushed forward exposing muscle.

benefit except for its possibIe effect on coIIatera1 circulation. Diagnostic injection of the sympathetics or spina anesthesia accurateIy determines the question of operabiIity. A good vascuIar index on the diagnostic text indicates aImost certain success. A poor vascuIar index however does not aIways precIude improvement foIIowing sympathectomy. We have done 13 operations, g Iumbar and 4 dorsa1, on I I patients. The immediate resuIts have been exceIIent in every case. OnIy one case has come to major amputation. This one was a borderIine case with a Iarge gangrenous area foIIowing amputation of the toe. This gangrenous area heaIed after operation and the resuIt was apparentIy very good. We have recentIy heard, however, that amputation was done Iater. Two other patients have Iost fingers or toes by amputation because of osteomyeIitis; in each case the stump heaIed. There is one death in this series foIIowing transabdomina1 sympathectomy. We may say then that the resuIts in g of the I I cases have been exceIIent. In this group are severa in which diagnostic injections were not done, and severa

operation was done at the request of the patient in spite of a poor prognosis were remarkabIy successfu1. This may be due to the fact that the possibIe effects on coIIateraI circuIation cannot be judged by a diagnostic procedure. CHRONIC

fascia psoas

ARTHRITIS

Most of our earIy operations were done for this condition.2x3 The resuIts have not been a11that we hoped for. There have been 23 operations on IO patients, 15 Iumbar and 8 dorsa1. There was one death foIIowing the transabdomina1 operation. (This death and the one previousIy mentioned, both foIIowing the transabdomina1 approach, constitute the entire mortaIity from the Iumbar operation. Since adopting the retroperitonea1 approach we have done over 50 operations without a death.) In 7 of the IO patients the resuIts have been we11 worth whiIe, with reIief of arthritic pain and improvement in joint function. Two of the patients obtained some reIief of pain for a time but Iater had recurrence and are cIassed as faiIures. Both are women; the men have a11 done weI1.

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Our attitude regarding arthritics is that where pain is the predominant symptom and a source of great discomfort it can usualIy be reIieved by sympathectomy. Where joint changes are marked, however, Iittle improvement can be expected, although in some cases considerabIe increase in mobiIity has occurred as the resuIt of reIeasing the spIinting muscIe spasm by reIieving the pain. The optimum case is the young individua1 having coId clammy painfu1 extremities with apparent vasomotor spasm. The suitabIe cases may be quite accurateIy seIected from this group by choosing those in which diagnostic injection brings relief of pain and marked increase in temperature. Sympathectomy for arthritis is one of the conditions in which the penduIum has swung too far both ways. Some cases are suitable and it is to be regretted that many of these unfortunates are denied the undoubted benefits of sympathectomy. SPASTIC

PARAPLEGIA

There have been I 7 operations, IO Iumbar and 7 dorsa1, on g patients. The resuIts are cIassified as good in 6, fair in 4, and faiIures in 7. Most of the poor resuIts were in cases of spasticity of the upper extremity. Of the IO operations for the Iower extremity, 6 were classified as good, 2 as fair, and 2 as faiIures. Of the 7 operations for the upper extremity, 2 are cIassed as fair and the other 3 as faiIures. Of these cases 3 cIassified as good resuIts realIy were exceIIent. AI1 were inteIIigent youngsters with spasticity of the Iower extremities. The improvement in these cases foIIowing gangIionectomy was reaIIy extraordinary. In this group were 3 patients having spastic chorea of the upper extremities. The resuIt in onIy one of these was good, this one showing a marked improvement in speech and moderate improvement in spasticity. The other 2 cases were faiIures. One case was a spastic paraIysis of both Iower Iimbs and bIadder, foIIowing a

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buIIet wound of the spina cord. The bladder function was markedIy improved by the operation, the spasticity of the

FIG. 8. Lumbar ganglionectomy. AbdominaI contents retracted medially. Psoas retracted IateraIIy. Rena1 fascia cut. Ureter and iIiac vein retracted medially exposing sympathetic trunk.

Iimb was but sIightIy affected. This operation was done severa years ago before Learmonth’s work on cord bIadders. From the foregoing work we have come to definite concIusions. We fee1 that the penduIum has swung too far. The operation for spasticity is not a faiIure. Cases shouId be chosen onIy among normaIIy inteIIigent chiIdren that are abIe to waIk. ChiIdren that have never waIked wiI1 probabIy not waIk as a resuIt of sympathectomv. Painstaking training and care which ‘is unceasing must be given after operation. The operation for spasticity of the upper extremity is so ineffectua1 as to be useIess and we have given it up. For the Iower extremities in seIected cases it is we11 worth whiIe. MEGACOLON

AND

CHRONIC

CONSTIPATION

We have had 3 cases of megacoIon on whom Ieft Iumbar gangIionectomies have been done. In each of the three the resuIt has been highIy successfu1. RemovaI of the Ieft Iumbar chain incIuding the first Iumbar gangIion is indicated in

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this disease and is apparentIy rareIy unsuccessfu1 in producing a functiona cure. We now venture into a fieId which wiI1 probabIy cause adverse comment; the treatment of chronic constipation in the aduIt by Ieft Iumbar ganglionectomy. In a11 of our previous work we had noted that patients who were constipated before operation were invariabIy reIieved foIIowing Ieft Iumbar gangIionectomy. The physioIogic basis of this resuIt is cIear. Sympathetic impuIses cause sphincter spasm and act as inhibitors of the propuIsive mechanism of the bowe1. FoIIowing their remova1, sphincter spasm is reIieved and the motor propuIsive mechanism is unopposed. On the basis of these observations and this physioIogy we base the indications for operation. Cases chosen are naturaIIy 0nIy very severe ones in which the constipation is disabIing or a definite threat to the patient’s weIIbeing. Furthermore, onIy those which do not respond to medica measures are deemed suitabIe. As aIready noted, many patients in whom the operation was done for other conditions have been reIieved of constipation. The operation has been performed primariIy for constipation in 5 aduIts. In each instance it has resuIted in compIete success and the estabIishment of norma bowe1 function in from four to six weeks after Four of the 5 patients were operation. epiIeptics in whom excessive uncontroIIabIe constipation was apparently reIated to their seizures. The fact that these patients are on a rigidIy restricted fluid intake increases their distress. WhiIe the operations were done primariIy to reIieve constipation, a surprisingIy beneficia1 effect has been noted upon their genera1 heaIth and in a Iessened severity and number of convuIsive attacks. They aIso show a marked menta1 improvement. We fee1 that the occasiona case of severe disabIing chronic constipation, not controIIed by medica means, shouId have the benefit of physioIogic reIease of the bowe1

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by sympathectomy. The operation is apparentIy invariabIy successfu1 and since it is practicaIIy without mortaIity and with no untoward after effects it seems to us that it is warranted in these cases. TRAUMATIC

SYMPATHALGIA

(CAUSALGIA)

This describes a condition for which we have coined the foregoing descriptive term. This syndrome consists of a painfu1 extremity, usuaIIy coId, subject to cyanotic changes when exposed to coId, often associated with increased perspiration, and frequentIy associated with a certain degree of non-pitting edema. Pain and diminished function of the parts are the primary comFrequentIy cursory examination pIaints. reveaIs nothing, but a more carefu1 examination brings out the presence of sIight cyanosis, increased perspiration, and slight edema which couId easiIy pass unnoticed. The trauma which is the inciting cause is often negIigibIe, and is frequentIy a crushing type of injury. The patients are often cIassified as maIingerers since their injury may have been sIight and there is often IittIe objective evidence to justify their compIaints. We have operated upon 6 cases, 5 in the upper extremity and one in the Iower. The inciting trauma was a crushing injury or bruise without apparent bony damage in 3 instances, a tearing injury of the hand in one, a pheno1 burn of the hand in another and a compound fracture of the tibia and fibuIa in the sixth case. In each case diagnostic injection produced reIief of pain and marked increase in the temperature. Operation resuIted in reIief of the origina pain in a11 cases. In 2 cases where the eIement of compensation was strong the origina pain was reIieved but other compIaints deveIoped which we beIieve are in the nature of compensation neurosis. We fee1 that traumatic sympathaIgia is essentiaIIy a traumatic neurosis deveIoping from a pain fixation and associated with vasospastic eIements. It is directIy attributabIe to trauma and aIthough probabIy functiona in nature it becomes a fixed

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neurosis which can be reIieved onIy by attacking the sympathetic nerves which mediate the painfuI stimuIae. It is possible that blood vesse1 injury plays a part in the picture. This is a condition frequentIy overlooked and usuaIIy diagnosed as either neurosis, hysteria or maIingering. PAINFUL

STUMP

AND

PHANTOM

EXTREMITY

Our earIy reports in this type of case were very optimistic.4 Later resuIts have not justified this optimism. Our first case was one of fiai1 arm with a painfu1 phantom arm foIlowing brachia1 pIexus avuIsion. Ganglionectomy gave marked reIief of pain and greatIy diminished the phantom arm sensation. Three cases of painfu1 stump have since been operated on. In onIy one case has there been any improvement. Since the advent of diagnostic injections we have been able to ruIe out the sympathetics as a factor in severa cases. There is no doubt but that some of these cases may be benefited, but our experience convinces us that most of them are due to centra1 pain, possibly a cerebra1 pattern. The onIy type apt to be suitabIe is the coId stump with excessive perspiration. Even diagnostic injection is not too accurate as at times psychic influences may Iead to an erroneous concIusion and a useIess operation. ATYPICAL

FACIAL

PAIN

Two dorsa1 operations, both previousIy reported,4 have been successfu1 in this type of case. The first case, one of recurrent pain foIIowing sensory root section for tic douIoureux, gave compIete reIief of pain for three years. Pain then recurred but a different type of pain, apparentIy entireIy functiona1. Other men have had compIeteIy successfu1 cases of the same type. The second case, a severe pain running from the Ieft eye to the mastoid region in an apparentIy psychoneurotic individua1, has remained a successfu1 resuIt for over three years. Both of these were done before the advent of diagnostic injections.

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MISCELLANEOUS

J~~~MI

of surgerJ

34

I

CASES

Epilepsy: BiIateraI dorsa1 gangIionectomy was done in a subnorma chiId of five who had never taIked or waIked and was subject to severe convuIsive seizures. The operation was in the nature of an experiment. There seemed to be some diminution in the severity of the speIIs and the chiId became Iess irritabIe, but the resuIt was not briIIiant. We believe, however, that some cases of epilepsy are due to vasomotor spasm of cerebra1 blood vesseIs and expect to do further work aIong these Iines. Varicose Ulcer of Leg: We have operated in but one such case. Lumbar gangIionectomy caused a rapid heaIing of the uIcer, but after the patient resumed activity it soon broke down again. Since this experience we have relied on aIcoho1 injections and the resuIts in some cases have been exceIIent. Angina Pectoris: OnIy one patient has been operated on, a very severe case in which the patient made the choice of surgery rather than injection. He expired on the operating tabIe, apparentIy in an angina1 attack, before we had reached the sympathetics. Th is is our 0nIy operative death to date in over $0 dorsa1 gangIionectomies. We have treated our angina cases by aIcoho1 injection. The results are exceIIent, the mortaIity Iow, and we fee1 that the method is preferabIe to gangIionectomy, unIess some other factor is invoIved.

DIAGNOSTIC

INJECTIONS

Diagnostic injection of the sympathetic nerves or some equaIIy accurate diagnostic and prognostic method shouId precede sympathetic operations.5 Since the advent of these injections unsuccessfu1 operations have been very few in our hands. As our experience increases we fee1 that unsuccessfu1 operations wiI1 be reduced to practicaIIy ni1. The day of haphazard sympathetic surgery has passed.

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SURGICAL

TECHNIQUE

LittIe need be said about technique. From the standpoint of anatomy and physioIogy there is IittIe pIace for any surgica1 attack Iimited to the cervica1 chain. For the upper extremity and head, the approach of choice Iies posteriorIy by way of the first or second rib and transverse process. The inferior cervical and first and second dorsa1 gangIia shouId be removed and a11 their connections severed, for any of the conditions we have described. The technique has been simpIified by using the common tendon of the trapezius and rhomboids as a flap from the midline, and the cosmetic and tensiIe resuIt is better than the origina mu&e cutting operations. (Figs. 1-4.) For the Iumbar gangha we use the retroperitonea1 approach of RoyIe. We have modified the incision somewhat. The incision is made more anteriorIy and superior to the crest of the iIium. Instead of separation of the muscIe attachments at the crest of the iIium a muscIe-cutting incision simiIar to a kidney incision is made. (Figs. 5-8.) This gives exceIIent exposure and aIIows for a firmer cIosure. We have abandoned the transabdomina1 approach, because we find this method easier and safer. If necessary both sides can be done at one sitting with greater safety. Since this approach was adopted we have had no deaths and no serious compIications in over 50 operations. ANOMALIES

OF

SYMPATHETICS

The occurrence of frequent anomaIies of the Iumbar chain shouId be emphasized. We find anomaIous arrangement of the trunks and gangIia in approximateIy one out of every 5 cases. There have been as many as six gangIia between the second and fourth Iumbar segments. In severa cases we have found muItipIe trunks, as many as five in one case and in this case no gangIia were present. In severa instances 0nIy one or two gangIia were present; this is most apt to be the case where there are muItipIe trunks.

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A very significant point Iies in the fact that we did not discover anomaIies in our earIy cases, and since we are on the Iookout for them we find them quite frequentIy. No doubt faiIures in some instances are due to incompIete denervation. AnomaIies of the dorsa1 chain fortunateIy occur infrequentIy. When present, however, they present technica dif%cuIties. In a recent case of Raynaud’s disease, no weIIformed chain and no formed gangIion was found on one side. The trunk was smaI1 and pIaced very deepIy, aImost on the anterior aspect of the vertebrae. It was removed with diffIcuIty. The other side was normaI:

SUMMARY

Ruynaud’s Disease: Twenty-three operations were performed on IO patients; I I for the Iower extremity and 12 for the upper. Three of the cases were primariIy scIeroderma with secondary vasospasm and 2 were primariIy Raynaud’s disease with secondary scIeroderma. The rest of the cases were typica Raynaud’s disease. In a11 of the cases of Raynaud’s disease the resuIts were exceIIent. In the cases where scIeroderma was primary the resuIts were very good but not as good as in the other cases. Thromboangiitis Obliterans: There were 13 operations on I I patients; g for the Iower extremity and 4 for the upper. The immediate resuIts were exceIIent in every case. OnIy one case has since come to major amputation. There was one death in this series foIIowing transabdomina1 sympathectomy. Chronic Arthritis: There were 23 operations on IO patients; 15 for the upper extremity and 8 for the Iower. There was one death foIIowing the transabdomina1 operation. This death, together with the one the entire before reported, constitute operative mortaIity from the Iumbar operation. Both of these deaths occurred foIIowing transabdomina1 sympathectomy. Since we have adopted the extraperitonea1 approach there have been no deaths. Seven

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of the patients have been distinctly improved. There have been 3 faiIures. Spastic Paraplegia: There have been 17 operations on 9 patients; IO for the Iower extremity and 7 for the upper. Of the IO operations for the Iower extremity, the resuIts were cIassified as good in 6, fair in 2, and faiIures in 2. Of the 7 operations for the upper extremity, 2 were cIassed as fair and the other 3 as faiIures. Three cases of megacoIon are reported in which Ieft Iumbar ganghonectomy was done. The resuIts in a11 cases were entireIy satisfactory. There were 3 cases of chronic constipation treated by Ieft Iumbar gangIionectomy; a11 of these have been entireIy reIieved. Traumatic Sympathalgia: There have been 6 cases; 3 maIe and 3 femaIe. The operation has been performed 5 times for the upper extremity and once for the Iower extremity. The resuIts were cIassified as exceIIent in 4 cases, good in one case, fair in one case, the Iast 2 being cases in which the eIement of compensation was strong. Painful Amputati on Stump: There have been 4 patients operated upon, a11 for the upper extremity. Three of these cases have been faiIures and one has had a fair resuIt. Among the group of misceIIaneous cases reported were 2 of atypica1 facia1 pain, one of epiIepsy, one of varicose uIcer and one of angina pectoris. The cases of atypica1 pain in the face were very successfu1. The rest of the cases were unsuccessfu1. AnomaIies of the Iumbar sympathetic chain occur in about 20 per cent of cases. There may be muItipIe trunks or muItipIe gangIia, and at times fewer gangIia than norma are found. These anomaIies may be overIooked and thus Iead to incompIete denervation. AnomaIies of the dorsa1 trunk are infrequent, but when they do occur may Iead to technica difficulties in their remova1. The trunk may Iie quite anteriorIy on the bodies of the vertebrae. These anomaIies shouId aIways be borne in mind.

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CONCLUSIONS

Sympathetic ganglionectomy is very successfu1 in properIy seIected cases of Raynaud’s disease, Buerger’s disease, scIeroderma, and other conditions where vasospasm is present. I n properIy seIected cases of chronic atrophic arthritis it affords considerabIe reIief but has not proved the panacea that earIy reports might indicate. The Iumbar operation is h’ghIy successfu1 in Hirschsprung’s disease and in chronic disabIing constipation. There have been no faiIures in this type of case. In cases of spastic parapIegia of the Iower extremities due to birth injury the operation is we11 worth whiIe in carefuIIy seIected cases. In spasticity of the upper extremity it is of IittIe.or no vaIue. Traumatic sympathaIgia is offered as a name for those painfu1 conditions caused by trauma and mediated by sympathetic nerves. The resuIts in this type of case are exceIIent. Operations in cases of painfu1 amputation stumps are rareIy successfu1. The majority of these cases have a centra1 type of pain. The suitable cases may be determined by diagnostic injection. Some cases of atypical facia1 pain may be reIieved by sympathetic gangIionectomy. A group of misceIIaneous conditions is reported, in most of which the resuIts were not successfu1. Diagnostic injection is indicated to seIect cases suitabIe for operation. With the benefit of this procedure we fee1 that unsuccessfu1 cases of sympathetic gangIionectomy shouId be rare in the future. The mortaIity of the extraperitonea1 Iumbar approach has been ni1. OnIy one dorsa1 gangIionectomy has resuIted fataIIy, in a severe case of angina pectoris. Sympathetic gangIionectomy in properIy seIected cases is a very successfu1 operation attended by an exceedingIy Iow mortality. [For References see p. 357.1

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but this requirement is much Iess absoIute in case of the index finger. 4. In al1 amputations through the proxima1 phaIanx, the flexor subIimis tendon shouId be sutured to the common extensor tendon, or considerable Ioss of flexion, and even some Ioss of extension, is IikeIy to foIIow. 5. No tendon anchoring is required in the thumb, dista1 to the base of the proxima1 phaIanx. In disarticuIations through the metacarpo-phaIangea1 joint, the adductor poIIicis, at Ieast, shouId be anchored. When you must remove part of a digit because of an acute injury, do not cut any tendon unti1 you have exposed aI1. This can probabIy be more cIearIy iIIustrated than described. George L., a sash maker for a Iumber company,

caught

his middIe

finger

in a saw and

REFERENCES

P. G. thromboangiitis

I. FLOTHOW,

Sympathetic obIiterans.

OF DRS.

gangIionectomy in J. Surg.,

Western

39: 192-203, 1931. 2. FLOTHOW, P. G. Sympathetic ganglionectomy. Med. Sentinel, 38: 169-176, 1930. 3. FLOTIIOW, P. G. Surgery of the sympathetic nervous

system

and

chronic

arthritis.

Nortbwest

Med.,

severed it aIong an obhque corona1 pIane beginning on the paImar surface at the dista1 paImar crease and emerging through the dorsum of the nai1. The flexor tendons were cut just proxima1 to the metacarpo-phaIangea1 crease whiIe the extensor tendon was intact. The second phaIanx was split throughout its whoIe Iength so the finger was disarticulated through the proxima1 interphaIangea1 joint and the extensor brought around into the paIm and sutured to the flexor sublimis. Had the extensor tendon been prematureI>- severed, a splicing operation wouId have been required. SUMMARY

I have given directions for the diagnosis of tendon injuries and for the exposure and identification of the cut ends, from nerves as we11 as from other tendons. In addition, I have expressed my persona1 concIusions regarding the disposa1 of the tendons in operations invoIving the Ioss of part of a digit.

FLOTHOW

SWIFT*

4. FLOTHOW, P. G. Surgery of the sympathetic nervous system. A report of fourteen sympathetic gangIionectomies. AM. J. SURG., n.s. 10: 8-18, 1930. P. G. Diagnostic of the sympathetic

5. FL~THOW, tions

ns. 14: 591-604. 1931.

29: 518, 1930. *Continued

AND

from p. 353.

and therapeutic injecnerves. AM. .J. SURG.,