48 CALIFORNIA STATE JOURNAL OF MEDICINE.

SUTURING OF MUSCLES AND .*

By D. D. CROWLEY, M. D.

Professor of Principles and Practice of Surgery and of Clinical Surgery, Oakland College of Medicine and Surgery, Oakland, California. THE subject which I have to-day introduced a few of its or in the entire thickness of to .you may not elicit as much interest as one muscle or several muscles. many that have preceded it on occasions like -In the usual rupture- of large- muscles the con- this. The invasion of the surgical field, during ditions are so well defined that only a cursory the past decade, has been prosecuted with un- examination is necessary to determine the con- usual vigor and the most remote parts of the hu- dition of the part. It results generally from sud- man anatomy have been visited by the surgeon's den and violent muscular exertion; and while knife. I am inclined to think that the unusual this condition- may take place in a trained athlete, surgery ihas- crowded aside that -which is com- it is more apt to occur in those who are not used monly met with, and the technique of ordinary to muscular- exercise. work is greatly neglected. In my experience I have observed that persons There is but little danger to life in the surgery of sedentary habits have more frequently experi- of tendons and muscles, but it is a work that re- enced this injury than the trained athlete, and in quires a definite knowledge in order to effect the my surgical attention to the football team and continuity and to re-establish a usefulness in to the Athletic Association of the University of these structures, and in -this reference the medi- California for three consecutive years, I have cal literature of the day is sadly wanting. observed rupture of the muscle only in the be- * I have given some little attention to this sub- ginning of the training period. It may be stated ject, but the resutlts of my researches have thus that nearly- all serious injuries to- athletes occur far been unsatisfactory, and I have come before- in their early training. The pugilist scarcely ever this assembly of professional confreres not alto- experiences rupture of muscle or , and this gether satisfied with the work I have undertaken. is owing to his superior training in the com- When a muscle is divided there is immediate mencement of his work. retraction of its fibers. The more active and the The rupture of muscular fibers is not always stronger the muscle, the greater the separation a result of extreme -muscular exertion. I have of - its divided ends. This is well marked in the known it, in several instances, to result from di- flexors and extensors of the thigh, of the armn, rect violence. In one instance the knee of one and muscles of the shoulder and hip. In rup- person violently struck the thigh of -another and ture of the rectus abdominis there is frequently a ruptured the quadriceps extensor of the person separation of from one to two or more inches. struck. In another, direct violence caused a par- When the ends of the divided muscle are per- tial rupture of the deltoid, and in another the mitted to remain widely apart during the repair, gastrocnemius. In one instance a large dog col- the new material, which fills the space, has little lided with a person standing on the sidewalk; the or no -contractile -power; it is merely a cellulo- dog's head striking the femoral biceps. The per- fibrous material and almost tendinous in appear- son fell to the ground and was thereafter unable ance and to the touch. The muscular fibers that to stand, the ruptured muscular ends being have contracted toward their muscular attach- several inches O.part. It may be said almost with ments have adhered to their sheath and are prac certaintv that the rupture of a muscle taking tically useless. place at the point of impact is due mostly to di- In- wounds of the abdominal muscles, where rect violence. the same fibro-cellular material tries to effect a In all cases of- ruptured muscle there is a muscular compensation, the pressure outward of separation of the ruptured ends. The physician the abdominal contents elongates and attenuates can usually discern the well defined muscular this reparative material, and at last the muscular ends, especially in long and important muscles deficiency permits a complete hernia to take place with a- well defined depression between. These -a condition that sometimes follows a laparot- signs, however, are frequently masked within a omy where the wounded tissues have not been few hours after -the injury by- a considerable carefully opposed. hemorrhage which results in a tumorous mass. .The rupture of a muscle generally, occurs This tumor can be removed by incision, drain" where- the. muscular fibers meet the tendon; but age and pressure, and after its rerhoval an inter- in a few instances is situated in the body of the val may be -felt betweell the torn ends. If this muscle. *The laceration of a muscle- may be in bleeding is permitted to continue, without opera- * Read before the Medical Society of the State of California, at the annual meeting, held in San Francisco, April 14417, 1902. CALIFORNIA STATE JOURNAL OF MEDICINE. 119. tive interference, a free separation of the muscle In continuing the operation I removed al- takes place and a tumor of coagulated blood fol- most all of this tendinous structure and with lows that wlll cripple the limb for months: some- the mattress suture effected relaxation and co- times permanently. The condition can, in a few aptation. Several sutures were used for this pur- weeks, be remedied by incisions and drainage. pose. Then the edges were united by a con- Afterwards, when the blood is permitted to re- tinued catgut. The sheath was sutured main, it becomes disorganized but not septic. and the muscular structure was stitched The pain accompanying the rupture of a muscle to the sheath for from two to four is fairly characteristic. It is sudden and severe inches on each side of the coaptation. The and limited to th-e site of the injury. sheath stitches were used to give the muscular The circumstances occasioning the injury, with fibers a greater rest and for a time to destrov severe and sudden pain, with prominent tumor- their activity. The leg was then fixed in an zan- ous masses, and, if no hemorrhage, a space gular position and the patient made a good re- where there should be muscle, or the character- covery with a normal use of the leg. istic pain with a fluctuating swelling, are suffi- A carpenter had the triceps severed by a buzz- cient to indicate the rupture of a muscle. In in- saw. He could flex the arm, but could not ex- stances where the muscles are ruptured and the tend it. The wound of the muscle was stitchetd rupture is sufficiently well defined to be recog- with chromicized catgut.-(Quilt sature). nized by the prominence of the ruptured ends, an The muscle was well retracted under the skin incision should be made over the injury; the mus- but during the suturing the skin was retracted cle sutured and the ends accurately approxi- from the wound, exposing the ends of the muscle., mated. The muscle should be relaxed as miich and the skin was so retained while the deeper as possible by the position of the limb and the suture loops were being introduced, including parts immobilized by splints and bandages, after the muscle and skin; at least two inches on each the usual care is given to the external wound. side of the wound interrupted sutures were use(d Rupture of the tendon does not frequently oc- for coaptation purposes, but the deep quilt cur, and when it does, if subcutaneous and with loops were mostly depended upon for relaxa- but little separation, the position of the limb and tion and coaptation. rest may be sufficient to bring about the desired The arm was retained in an extended position result. for four to six weeks, with, from time to time, In all instances of open wounds where the ten- passive motion. The patient was subsequently dons are divided I advise their careful approxi- enabled to continue his work as carpenter, and mation, and "The Best Means of Suturing Ten- was able to extend his arm with the necessary dons and Muscles" will be the purpose of this streng-th. paper. The secret of muscle suturing is to include A case that I have already referred to is perti- in the suture the muscular structure a sufficient nent to this subject in that Mr. C., who, while distance from the wounded end. The loops of standing on the sidewalk was run into from be- the quilt suture are more effective than the in- hind by a large Newfoundland pup. The impact terrupted stitch as it incloses and gives a greater of the dog's head was sufficient to rupture the purchase and support to the muscular . "ham- muscles." The patient instantly EXPERIMENT NO. I. fell to the ground, became faint with pain and could not walk. After a tew weeks he Martch iith, I9o2. was able to go about, but could not flex The dog was anaesthetized with chloroform. his leg. A long, compact, tumorous mass no ether being at hand. Severed the heel tendon. took the place of the separation in the The proximal end of the tendon retracted three- muscle, and this caused him so much continuous quarters of an inch. The distal scarcely at all. pain that he concluded that surgical interferenice By firm pressure with the- hand over the muscle might be required. I saw him first ten weeks af- the space between the divided ends was lessened, ter the injury, and discovered an unyielding mass though I considered it expedient to slit the along the flexors of the thigh, which might have sheath of the tendon in order to reach it; used a been an organized blood clot. After the usual mattress suture of chromicized catgut for ap- preparations for an operation I made an incision proximation purposes. eight to ten inches long over the painful part. The suture was entered first into the proximal Qpened the sheath of the muscle longitudinally; tendon about one-half an inch from end, and sponged out a large quantity of semi-sanguinous was brought out at the-center of its end, (J). fluid and discovered within the sheath, where the Again it was entered into the center of the dis- belly of the muscle should have been, a tendin- tal end and brought out one-half inch beyond. ous structure from six to eight inches in length. Again we return a couple of lines from the last This took the place of the muscular fiber and point of exit (K) and carry it back through the was of very little assistance to muscular contrac- tendon and tendon ends to the side of the in- tion. itial point of entrance of the suture and there CALIFORNIA STATE JOURNAL OF MEDICINE.

tied. This completed Post Mortem. a loop; all of the suture The post mortem of Experiment No. 2, was was buried at the ends, held on April ioth, twenty-six days being allow- (L). ed for the healing. The tendon being So far as to the operation of March 15th, Pirst step. small I concluded it there was slight attenuation of the tendon of would not bear two one-half of an inch; a thickening of same tendon loops as the repeated towards muscle. puncture of the ten- EXPERIMENT NO. 3. don by a comparatively large and cutting March 15th, I902. Severed the Gluteal muscle. There was but needle would too little retraction of its fibers. Separated the skin greatly wound it, so I unitedsheathwith other peritendinous tissues. I did not and could Second not suture the sheath of the tendons which, when split, had become lost in the other tissues, I.

K -I except where it might be caught up with other tissues. ;'.e The wound was dressed and the limb Third atep s was immobilized with plaster of paris. The animalbrokethe plaster Itlli splint soon after apply- L ing, and died twelve J. K. and L. hours after from the Introducing mattress suture and tylig. The suture pierces both ends effects of the chloro- of divided tendon twic,. form. II. EXPERIMENT NO. 2. March I5th, I902. Anasthetized the dog. Commencing with chloroform, and after a few minutes, continuing with ether. MUSCLES. Shaved over the tendons and used three per I. MATTRESS SUTURE. II. MATTRESS Su I URE. cent carbolic solution for preparing the skin. a-Continued for apposition of edges ending at b, and tied. Severed two tendons (tendo achilles) above the hoc joint and thereby permitted the leg to be- come flail-like. The ends of the tendon did not separate more than one inch, most of which took place in the proximal end, or the end attached to the muscle. Used a mattress (No. 2.) as in the first expenrment, except that two were used in- stead of one. The second tendoni was united like the first. The sheath was fairly isolated an(I sutured; after sutturing the skin, applied a dress- i-ng, and immobilized with plaster of paris. II) this dperiment smaller needles were used, but they were cutting and were inclined to unneces- sarilv wouind the tendon. MUSCLES. A sharp cutting needle should not be used in a-Bejipning of suture. b-Suture exposed on surface of muscle c-Suture pierces end of muscle. d-Return of suture to e. f-Conclu- tendon suturing. sion of suture. CALIFORNIA STATE JOURNAL OF MEDICINE. from the surface of the muscle to permit the and therebv, in this small tendon, destroy all pos- suturing of the muscle without including, the sibility of forming a flap that would easily reach skin. Three loops of No. 3 catgut, (I) mattress the other (E. a). An effort was then made to sature, were used which included one and one- approximate the flap from the proximal tendon half inches of each end of the muscle. After (E. a) to the split distal tendon (E. b). It was accomplished with fine ,- -but the traction was sufficient to com- pletely separate the flap from its tendinous attachment (E. c).. There being now not sufficient desirable tendinous tissue to effect a- a union, the ends were stitched to a neighboring tendon, or rather to its peritendinous structure. Observations:-A narrow knife X blade should be used for splitting purposes. There should be little or no b- traction on flaps and if the flaps do not easily approximate, relaxa- tion should be brought about from the more remote part of the tendon. The knife should not be with- drawn until the flap is completed, Ii// otherwise the incision might be lost. rv. The secondary observation, or IV. the peritendinous suturing, may SUTURING A LACERATED SPHINCTER ANI IN COMPLETE LACERATION OF be an object lesson in this method THE PERINEUM. of suturing, though the activity of a-The needle enters carrying suture to b and returned. c-Divided ends of muscle. d-Return of suture. e-end of suture. The end to the dog is prone to interfere with be tied. repair. forming the last lopp I made a closed approxima- Post Mortem. tion of the edges of wounded muscle by a con- tinued suture. (II-a.) The post mortem was held on this dog on April 9th, 1902. Post Mortem. Found slaughing tissue over \\\ the hoc joint and at the lower end ! \ The post mortem of April 5th, I9o2, proved of the part upon. E perfect union. operated There was pus in the region of the joint. a-Flap made proP- EXPERIMENT NO. 4. No separation in the tendnous erly. b-Fla p cut March i6th, I902. structure to the feel. utdmaby nltq. Made a careful dissection of the `eRned af d "The peritendinous suture after an effort to tendon for the purpose of discern from tetdon. do the double flap." ing the repaired F. I ends. Found Following thX usual necessary preparations four - or five silk sutures in ten- Peritendinous s v remnoved one inch of the longest tendon entering don, but th¢ repair had obliterated the Oi into the tendo achilles. Pierced the center of the points ofsuturing, and I could the proximal 'tendon about one-half inch fron nzot discern thPe exact tendinous points that hid- the end and splitting to within one-eighth of an undergone repair. inch of the end (E. a) with a knife, cut from In the experiment, even though paration of the beginning of the micision (c) outward, there- end had by divi4ing one4Wlf of the tendon and making tendqp taken. place, it did not nateri4ly a flap whicl wIld partly take the plac.e of the interfere with peritendipous nWion.. part. of the tendon cut away. In this instance I believe the ten4pns are prone ta,{union, even the flap did not reach the disal extremity, and a under- adverse ciretlmstane -god *te sheath flap from that od was necessary. A flap was though poorly sutured, will readily conform itself begun from the aWe opposite to that whi was to the tendon. made in tbe proximal tendon. As to the adhesions interfering with the In splktt the diAtal extrermity I pennitted utility of the tendon, to d4nite copclusiqn otld the knife to cut to far and pass through (E. b) be reached by this experiment. sa CALIFORNIA STATE JOURNAL OF MEDICINE.

EXPERIMENT NO. 5. To all outward appearances the tendon was March igth, 1902. thicker to the feel than the normal. The dog Removed three-quarters of an inch of tendon had been able to walk. and split each tendon about one-half of an inch On removal of the skin there appeared to be to within one-eighth of an inch of the ends (A. a union of the tendon. At the end of twenty-

ELONGATION OF TENDON. a

G. Incision in the tendon, or the splitting.

H. a-Cutting transversely to right from Ion- gitudinal incision. b-Cutting to left.

~. K. II J 111An!

b ''Id I. Tendon elongated and sutured; a and b sep. arated from original positions c and d. thl!",

TENDONS. a-a)-. Cut o'utward from the beginning of the two days there seemed to be a strong and use- slit in the proximal tendon tb)' and inward in the ful union between the divided ends. dista'l (bT), thereby making two flaps; these 'were There were no signs of chromicized catgut united with catgut (C.-c). I placed a stitch present. I was obliged to split the tendon longi- transversely in each of th'e ends to prevent the tudinally to find the points of repair, that mani- flaps from tearing through (D. a. a.) if they ex- fested themselves by new tissue which did not perienced a'nv traction. I believre this suture possess the glistening white appearance of old p-laced transversely and at the termilnus of the tendon tissue. It had a darker and more watery in'cision made for flap purposes will greatly for- appearance. tify against complete splitting. This operation is only called for following EXPERIMENT NO. 6. trauma where a portion of, a tendon is destroyed. March 20th, 1902. When a tendon is contracted a sufficiently long "Operation on a flexor tendon with the object incision should be made longitud'inallv in the of shortening or elongating the tendon as con- tendon. This will permit a tendinous substance, dition might indicate." for repair as long as the split in the tendon I first split the tendon along the center one to (G. a). two inches (G. a) and cut transversely through Post Mortem. one-half of the tendon at opposite- sides of each The post mortem was held on the dog on April end (H. a. b.); one transverse incision being on gth, I90o2. the opposite side of the tendon to the other. CALIFORNIA STATE- JOURNAL OF MEDICINE.' .53

This procedure gives two flaps (H. e. f.) one to. An interval of about five-eighths of an inch on the proximal tendon and one on the distal of was between the cut ends with apparently no equal lengths and with cut surfaces apposed. fibrous or tendinous structure between. Trac- These tendons were pulled apart, causing the tion on this tendon had direct effect on its tendons to slip one over the other and sutured, muscle. thereby elongating the tendon. By cutting away the ends of the flaps (a. b-.) EXPERIMENT NO. 8. they could be drawn towards (c. d.) thereby shortening the tendon. March 25th, I9o2. I am inclined to think that if the plastic work The experimental work of to-day upon two was done under aseptic conditions and surround- tendons that entered into the heel was more satis- ings and with great care in the suturing of the. factory than the preceding experiment. sheath, that a good result might follow. It The usual proceedings of anasesthetizing, shav- would be scarcely reasonable to conclude that ing the parts and antisepticizing the skin were after an operation on an active animal with the carried out. muscles in play, and without the necessary after- treatment, we should expect a satisfactory result. Then a logitudinal incision was made over the It is next to impossible to have an aseptic atmos- tendons; the sheath split and the tendons ex- phere, aseptic ligatures and aseptic assistants in posed. handling operations on dogs. The tendons were severed transversely and re- united with a mattress suture (J. K. L.); one with silk, No. 2; the other with catgut No. 2; EXPERIMENT NO. 7. using a small round needle with no cutting March 22nd, I9o2. edges. The suture was entered about one-quarter of In this experiment I severed one of the heel an inch from the end of the proximal tendon, terndons; there was slight retraction of the prox- carried through its end, entering again at the imal end. It was sutured with a small Hagadorn end of the distal tendon and brought out one- needle armed with catgut, and with a single loop quarter of an inch from the end. The needle of mattress suture, the ends were fairly well was again entered at the side of the point of exit approximated. (J. K. L.). and carried back in a like manner to neat the This suture included about one-quarter of an point of entrance, and there tied, completing the inch of each end of the tendon, and was carried mattress suture. through the ends. The suture was only'exposed While the mattress suture maintains relaxation at the beginning and at the point of return. of the segments it does not effect a perfect co- There was another and a larger loop made-in a aptation of the edges of the segments; one or similar manner to the first, and though it in- two interrupted superficial sutures were used for cluded more of the tendon was not carefully this purpose, and a perfect coaptation was. buried in the tendon structure. Its purpose was brought about. a relaxation that prevented traction on the sutur- ed ends. A few hours later the animal tore off The No. 2 catguit was rather unyieldy for the the plaster of paris and dressings. small round needle, and required considerable force to carry it through the tendon. It had Retnarks:-A cutting needle should not be more tendency to split the tendon than the silk. used in suturing tendons. Very small needles The round needle without the cutting edges should be used. They should be round with no merely punctured the tendon and in trying -to cutting edges. Large needles in small tendons make taut the suture, a greater force could be will destroy most of their continuity. Care should used without splitting the tendon than when a be taken in carrying a curved needle through a cutting needle had been used. The sheath was tendon not to deviate from its original arc. The suturated en masse with other peritendinous struc- same care should be used in drawing through tures. the suture; any considerable deviation from the course of puncture will tear the tendon. Post Mortem. Post Mortem. The post mortem of this last experiment was The post morte-m on this dog was held on held on April 3rd, allowing eight days for heal- April ioth, I902. ing. It showed the distal fragment of cut tendon There was sloughing over site of operation. fairly well adhered to adjacent structures. The Sloughing also found two inches below the site proximal end was quite firmly attached to the of operation. underlying tendinous structures. The sheath of The tendons were exposed and a necrosed con' cut tendon was continuous- with sheath adhered dition present. 54 54 CALIFORNIA STATE JOURNAL OF MEDICINE.

In the eight days that intervened between the In the repair of tendons the ends should be operation and the post mortem there was slough- permitted to fall together; in other words, the ing of both tendon and muscle, and though only sutures for coaptation purposes should not be a week had lapsed, there was found sloughing strained. between the tendon and the muscle with no dis- If the ends of a tendon are not easily approxi- position to repair. mated, relaxation sutures should be used, catch- ing the tendon a half an inch or more from its EXPERIMENT NO. 9. ends, one suture being tied to the other. April 3rd, I902. I have suggested the suturing of the terminus Incised tendons or several tendons comprising of a split for flap purposes. This suture practi- the tendo achilles. The structure cut through cally includes the end of the tendon and is to was at the junction of the tendon with the muscle prevent the flaps splitting through. I think the and the surfaces were not altogether muscle or suture may be of utility in plastic work. tendon. The tendinous portion was well sur- In suturing of tendons no cutting needle rounded with a fibrous sheath and retracted more should be used; only round needles, and they than the muscle. After catching up a certain should be used with care. A needle should be portion of the proximal end, mostly muscular carried through the puncture of tendon in the fiber, I made an attempt to stitch it to the distal line of puncture as also should be the suture. end. This had retracted within its sheath and The mattress suture is the most useful in ten- was coaxed well out towards its companion end don work. In small tendons the suture should before the stitches were introduced. be carried transversely one-half inch from end: The suturing was as follows--The needle the suture only showing on the sides. In small was introduced transversely in the proximal ten- tendon suturing the peritendinous structures don one inch from the end, and again one and may be united by a small suture and this will be one-half inches from the end, so that a greater sufficient to make a proper apposition to the ten- purchase might be had. The usual mattress suture don ends. was then used, except additional small loops were In experimental work on the animal it is al- transversely used in the substance of the tendon most impossible to prevent infection. In apply- before the ends were pierced. Ihe sheath was ing dressings and splints on a part to prevent sutured, the outer wound closed and the leg motion too great a pressure is required, slougb- placed in splints. ing ensues, and a poor result follows. A suture should always be smaller than the Post Mortem. needle, otherwise the suture will lacerate an im- The post mortem held on this dog on April portant part. ioth, showed muscular and tendinous structures The needle should not be too much curved, as in wound and almost the entire leg undergoing it is difficult to use such a needle in piercing the a rapid sloughing, with no tendency towards re- tendinous structure a sufficient distance to be of pair. value. In large tendons, I believe the chromicized CONCLUSIONS. catgut to be the proper suture, if the suture is Tn the suturing of divided tendons I have sterile. However, it is easier to suture tendons come to the conclusion that it is not proper to with silk, and under aseptic conditions I believe use a large needle in a small tendon. Neither do the silk to be very efficient; but as to their com- I think it expedient to pierce the ends of such ten- parative value I ask for further time to arrive dons with needles, though the tendon is more at an intelligent conclusion. accurately approximated at its wounded ends. I wish to state here that the destruction of a I have not concluded, however, that these ends sheath of a tendon is followed by rapid repair. will not repair under such a circumstance, but I Also that the repair of the tendinous sub- do know that the needles piercing the ends stance is much more rapid than I had anticipated. separate the tendonous fibers and destrov the con- I believe that a tendon when properly sutured tinuity of the parts. will have an excellent union in two weeks, and It is easier to suture with silk than with cat- at the most in three weeks. gut. Catgut, sufficiently large to be of much Gentlemen, in this paper I have given you the utility, occupies a large portion of the tendon and facts as I have found them; if the-results of the is apt to injure a small tendon; it also requires various experiments are not satisfactory I do not a larger needle than the silk, yet silk will re- know that it is quite my fault. It is better for main in the tendon for twenty to thirty days us all to analyze and act upon facts as they are without dissolution, and unless in an aseptic presented. I desire, however, to confess that this case, is apt to be harmful as an irritant. Chro- work has not been altogether satisfactory to my- micized catgut, I think in the majority of cases, self, but it may be at least the starting point in could take the place of silk; and yet I do not wish good work hereafter upon this subject, and such to put silk aside. work is sorely needed.