3rd to that of the 5th cartilage; the upper end of the incision is then continued towards the left along the line of the 3rd cartilage and the lower end of the vertical incision is carried downwards and towards the left along the line of the 6th cartilage. The musculo- cutaneous flap is raised and turned outwards, the 4th, 5th, and 6th cartilages are removed, the internal mammary vessels are tied and divided (which is best done after removal of the 6th cartilage), triangularis sterni is cut through and displaced, the pleural edge being carefully avoided, and the pleura displaced by gauze pressure.
2. The Duval-Barasty operation. This operation opens both thorax and abdomen but does not divide ribs; it gives free exposure of the heart without opening the pleura but demands good vitality in the patient and seems unsuitable for possibly septic cases. It was used in several successful cases by French surgeons in the World War. It is thus carried out: (l) Make a median incision from the level of the 3rd cartilage to the mid-point between xiphoid and umbilicus. (2) Separate the attachments of the muscles to the xiph- oid and insinuate two fingers of the left hand behind the sternum, so as to protect the pericardium and the anterior margins of the pleura. (3) Divide the sternum transversely opposite the 3rd car- tilage, and below the section split the gladiolus and xiphoid longi- tudinally. (4) Open the peritoneum along the line of the median incision in the upper abdomen. Open the pericardium in the middle line then divide the diaphragm between the two halves of the xiphoid cartilage, one blade of the scissors being within the peri- cardium and one in the abdominal cavity. While this cut is being made the heart must be gently lifted out of the way. The diaphragm is divided as far back as the coronary ligament. (5) The halves of the sternum can now be widely separated and " the whole contents of the pericardium are an open book to the surgeon. We have by this operation removed a bullet from the intra-pericardial portion of. the vena cava inferior." (Bull, et Mem. de la Soc. de Chi., Paris, June 1918.) (6) At the close of the operation the reconstitution of the divided structures is perfect. The incisions in the diaphragm and pericardium are sutured. The sections of the sternum fall together and do not require suture.
3. The Spangaro operation. Spangaro makes a long incision in an intercostal space, generally the 4th, and then divides or dis- articulates the 4th and 5th costal cartilages at their union with the sternum, and in some cases the 3rd and 6th cartilages may also be divided. The 4th and 5th ribs are then forcibly drawn apart by a rib-spreader and a fine view is obtained.
4. The method of Duval as modified by Moynihan. " An in- cision is made exactly in the line of a rib following its curve from the edge of the sternum for about five inches outwards, down to the pectoralis major muscle a pair of forceps is pushed through the muscle until it touches the rib, the blades are opened and the muscle is split, and the separation carried from end to end of the incision. All bleeding vessels are ligated. The rib and costal cartilage are cleared. Two incisions are made through the periosteum close to the upper and lower edges of the rib, and from them the periosteum is stripped upwards and downwards and from the posterior surface. The perios- teum which lies between the two incisions is left attached to the rib throughout the operation. As soon as the periosteum is freed from the posterior surface for half an inch the periosteal elevator of Doyen is slipped round the rib and pushed backwards towards the axilla and forwards to and along the costal cartilage until a length of about 5 in. is cleared. Here and there a little help may be needed with the knife or scissors to make the way easy for the instrument. The costal cartilage is now divided by two incisions meeting at a point, this allows the divided ends to dovetail together when the operation is nearing completion. When the cartilage is divided a gauze strip is passed underneath the rib, which is lifted gently upwards and outwards. In young patients the elasticity and suppleness of the rib are remarkable. It is quite easy to raise the bone out of the way throughout the operation and then to replace it.
" When the rib is elevated the periosteum is seen as a thickening of the pleura exposed in the wound. Through periosteum and pleura a small incision is made with the result that in the absence of ad- hesions air slowly enters ihe pleural cavity and the lung begins to collapse. The incision in the pleura is then lengthened always along the line of the periosteum, until there is room for the hand to pass through it. The rib-spreader is then introduced " (Sir B. Moynihan, Brit. Journ. of Surgery, vol. vii., 457). At the conclusion of the opera- tion the rib is replaced and fixed by a suture.
5. Tuffier's method. Transverse sterno-thoracotomy. Trans- verse incision in the 4th intercostal space, prolonged over the sternum to the right side, opening the intercostal space, division of the ster- num by Lister's forceps, retraction of the divided sternum to the maximum.
In many cases of injury to the heart the pleura has also been wounded, and in these the Spangaro or Duval operation has the advantage that the pleura and lung can also be examined. The dangers of pneumo-thorax on one side seem to have been exaggerated, and experience has shown that a differential pressure apparatus formerly considered essential is not necessary.
The danger of opening the pleura is not respiratory difficulty but infection. Moynihan lays stress on the patient being deeply anaesthetized before the pleura is opened, and on the opening in the pleura being made small at first so that the lung may slowly collapse.
6. The method of Petit de la Villeon. This operation is carried out under the guidance of the X rays; a small incision is made in an intercostal space and a special forceps thrust through it and pushed on closed until its shadow on the screen touches that of the foreign body ; the forceps are then opened, the foreign body grasped, mobilized and pulled out. The method was elaborated by its author for removing foreign bodies from the lung, and has been applied by him to 15 cases of foreign body in the wall of the heart.
Manipulation of the heart. The pericardium having been widely opened the heart may be safely palpated and grasped in the gloved hand ; it feels like a live fish, and it may be steadied and drawn for- wards and upwards by a fixation suture passed through the apex.
The specially dangerous regions of the heart are :
(1) The coronary arteries between their origin from the aorta and their bifurcation. A wound or ligature in this situation is fatal : the heart becomes arrested in diastole from the failure of its own mitrition. Domenici, from experiments on dogs, concluded that the prognosis is more favourable when both artery and vein are ligatured than when the artery alone is tied (Policlinico Romana, 1916, p. 155). Sir G. H. Makins made the same observation respecting the femoral artery and vein. A branch of the coronary artery may be tied with- out ill effects.
(2) The inter-auricular septum and the cardiac ganglia and nerve plexuses which are found chiefly at the base of the right auricle and along the auriculo-ventricular groove. Krpnecker and Schurey (quoted from Turner) have described a ganglion centre at the level of the auriculo-ventricular septum near the left border of the heart, a wound of which causes immediate arrest of the heart.
(3) The bundle of His. Carrel and Tuffier say " the starting point of the cardiac contractions is at the opening of the vena cava at the base of the right auricle, the fibres of the auriculo-ventricular bundle of His, which transmit the auricular excitation to the ventricles, traverse the inter-auricular septum, then the inter-ventricular septum and bifurcate and anastomose with the ventricular fibres." A sudden lesion of the bundle of His produces irregularity of con- traction and dissociation of function of the two sides of the heart. A case published by Keith and Miller (Lancet 1906. II. 1429), in which the commencement and upper half of the main auriculo- ventricular bundle was destroyed by a gumma and the coronary arteries were partially obliterated, shows that the normal mechanism of the heart may be profoundly changed without a great disturbance of function, provided that these changes are not brought about too suddenly. The bundle of His is fully described by Keith and Flack (Lancet 1906. II. 359).
The control of haemorrhage. Free haemorrhage from a wound in the heart is a great and imposing emergency : the heart, relieved from compression by the incision in the pericardium, contracts tumultuously, the field is obscured by the escaping blood, the blood- pressure is rapidly falling and death is imminent. Rapid, precise, and correct action can alone save life. The surgeon, just as in a case of ruptured spleen or of ruptured tubal gestation he plunges his hand into the abdomen through a mass of blood and seizes the bleed- ing vessel, so he must now plunge his hand into the pericardium, grasp the heart and by digital compression control the bleeding, and proceed to suture the .wound. Suture is the method by which haemorrhage from the heart is permanently controlled, though ligature has been used in a wound of an auricular appendage. The vena cava may be compressed digitally or with suitable forceps as an aid in the arrest of haemorrhage.
When an incision is to be made into an unwounded heart, the sutures should be placed, and the loops drawn out of the way before the incision is made; tightening the sutures arrests the bleeding.
In experimental work tpn the heart the effect of compression of the great vessels has been tried. Carrel and Tuffier found that the en- tire vascular pedicle could be compressed for 45 seconds, the pulmon- ary artery for 10 minutes, the aorta for 6 minutes, the two venae cavae for 35 minutes, which could be prolonged to 10 minutes if an oxygenated solution were injected into the carotids; compression of the four pulmonary veins was rapidly fatal, but isolated com- pression of one pulmonary vein was of no gravity. The times would probably not apply to the human heart; Trendelenburg found that the aorta and pulmonary artery must not be obstructed for more than a minute and a half.
Drainage of the pericardium. In clean wounds this is unnecessary and even harmful; in infective pericarditis efficient drainage is a necessity, but is by no means easy to carry out. As fluid collects in the pericardium it accumulates mainly in the two postero-lateral pouches of the pericardium on each side of the partition formed by the projection of the two venae cavae and the right auricle, and in the dome-shaped space above, the heart is pushed forwards, ap- proaching the chest wall more closely as the tension of the fluid increases, and the pouches formed by the reflexion of the pericardium on to the great vessels become distended. The chief of these recesses is that described by French anatomists as the cul-de-sac of Haller, in English works as the oblique sinus, and by Prof. Keith as the bursa of the left auricle. It is situated behind the left auricle and extends upwards between the right and left pulmonary veins and arteries to the upper border of the left auricle and towards the right as far as the superior vena cava. It is 4 to 5 cm. in depth and behind it is the oesophagus. The lower end is widely open below at the level
