INTERILIO-ABDOMINAL AMPUTATION.

WITH REPORT OF A CASE

BY JOSEPH RANSOHOFF, M.D., F.R.C.S. (Eng.),OF CINCINNATI, OHIO.

MY reasons for presenting this paper are that the casereport which gives it foundation is the third of its kind tobe recorded in the United States, and I feel justified in count-ing it among the operative successes. Had Billroth's interilio-abdominal amputation performed in I89I been a success, itis quite certain that it would not have remained unknown foreleven years, to be recorded finally on verbal testimony alone.If a name is to be attached to the operation it should be thatof Jaboulay of Lyons, who in three years had three oppor-tunities of performing it. He reported no successful opera-tion, and only one of his cases survived the fourth day.

The case which I beg to report is the following.

James F., colored, at. 45. Was admitted to the CincinnatiHospital September 29, I908. The family history is negative.There is a history of an initial lesion twenty years ago, and ofrepeated attacks of gonorrhoea. Six years ago the patient waskicked in the right hip by a mule. Three years later he noticeda swelling in the right groin, which, gradually increasing insize, caused a swelling of the foot and leg. He entered thehospital the first time February I8, I908, for this swelling inthe groin.

Examination on admission showed the patient to be normal,save for the inguinal swelling and the cedema of the leg. Theswelling in the inguinal region was the size of two fists, veryhard and attached to the ilium. The tumor was painless. Thefemoral vessels were displaced forwards. On the inner sidethere were several distinct and isolated inguinal glands about thesize of a pigeon egg. Hip movements at this time were not im-paired except in abduction. The entire extremity was cedematous.

925

JOSEPH RANSOHOFF.

On February 24, I908, the bony tumor was removed by Dr.E. W. Walker. The laboratory report showed the tumor toconsist of cancellous bone with no evidence of malignancy, but aslight round-celled inflammatory infiltration into a portion of it.Recovery from this operation was seemingly complete. The re-sult was good and the patient left the house May 2, I9o8; hasbeen at work at commnon labor until two weeks ago, September 12,I908, when an abscess in the region of the former tumor ruptured.The discharge has been very free ever since.

Status Praesens: September 29, I908. Head, neck, chest, andabdominal examinations negative. The right leg much largerthan normal, from cedema. Little or no motion in the hip joint.Bony proliferations are felt on the right pelvis and the upper partof the shaft of the femur, and about the trochanter. There is afluctuating painless mass on the inner side of the ankle. A sinusat the site of the former operation leads to exposed bone. Itradiates in various directions. Pus channels have been formedall along the anterior part of the thigh. The general condition ofthe patient is not good; his appetite is poor, the pulse rate isfast and there are irregular elevations of temperature. Thepatient is septic.

On October 5, I908, a long incision was made on the front ofthe thigh for drainage, and a large piece of necrotic bone removed.From this time on the wounds were irrigated two or three timesa day and packed with gauze. From time to time the localtreatment varied, iodoform and bismuth injections being used.The patient's condition failed to improve, the discharge continuingvery free and foul.

X-rays taken of the patient show a tumor the size of a fist,involving the iliac bone, the upper end of the femur and thetuberosity of the ischium.

December 28, I908. The wound was enlarged under localanasthesia and curetted for better drainage. Before this wasdone, an amputation was highly recommended to the patient, buthe refused. From this time forth a typical septic coursecontinued.

From day to day the evening temperature rose from one anda half to three degrees; the pulse fluctuated between go andiio; night sweats were frequent and the patient was bedridden.From a number of sinuses on the anterior and outer portions of

926

INTERILIO-ABDOMINAL AMPUTATION.

the thigh and gluteal regions large quantities of pus were beingdischarged, notwithstanding the use of frequent irrigations. Itwas in this condition that as a last resort an interilio-abdominalamputation was done.

Operation, March 8, I9o9. Ether anaesthesia. Esmarchbandage applied to the entire leg to preserve its blood for thepatient. The right common iliac artery was next tied througha median abdominal incision. On account of the numeroussinuses in the region of the trochanter and over the gluteal mass,it was possible only to make use of an internal flap. The firstincision was made a little below the crest of the ilium andPoupart's ligament, from the posterior superior iliac spine to thecentre of the ligament. The incision was continued through thevarious layers of soft parts until the fascia transversalis wasreached. In doing this a number of sinuses with exceedinglyindurated walls and dense cicatricial tissue were cut through.Nevertheless, the fascia and underlying peritoneum were reflectedwithotut opening the abdominal cavity until the brim of the truepelvis was exposed for nearly its entire length on the side affected.The next step of the operation consisted of making the longinternal flap, the incision beginning at the centre of Poupart'sligament and coursing down the anterior surface of the thigh andterminating with a long curve in the posterior incision whichterminated above at the point of starting. This long internalflap was quickly dissected from the surface of the femur withvery little bleeding. With a very broad chisel the iliac bone wasnext divided in front of the sacro-iliac joint, the cut being rapidlymade from the crest to the sciatic notch. An inch to the outerside of the symphysis the chisel was next applied and driven tothe thyroid foramen. It was similarly used to cut through be-tween the ischium and pubes. I am sure that the use of thechisel greatly shortened the time of the operation. On the otherhand, the forceful blows necessary to cut through the bone wereassociated with shock, as evidenced by the rapid fall of bloodpressure. At this time an intravenous transfusion of normnal saltsolution, for which preparation had been made, was given. Theremoval of the lower extremity with the resected part of the iliacbone in one piece was then very quickly accomplished with a fewstrokes of the knife. During the operation the patient did notloose more than a few ounces of blood, and most of this, strange

92,

JOSEPH RANSOHOFF.

as it may seem, came from the femoral artery when it was divided.Doubtless the anastomotic circulation with the other side hadbeen very free. I have recently seen the same free bleeding froma divided femoral artery immediately after the common iliac wastied. We encountered no enlarged glands in the operation. Thewound was dosed with buried muscular sutures and ample drain-age for the mzany and irregular sinuses and thick walled pus cavi-ties encountered in the course of the operation. The patient leftthe operating table in very fair condition.

The subsequent history was that of a continuous and unequalstruggle with the sepsis present before the operation. As hasoccurred so often -where the long internal flap was used, gangreneof the wound margins developed in two or three days and neces-sitated removal of many of the sutures. The repair power ofthe patient was at a minimum. The use of streptolytic serumespecially prepared failed to make any impression on the septiccondition. An enterocolitis, septic in character, developed fourweeks after the operation and could not be controlled.

The autopsy revealed caseating pulmonary tuberculosis, acutetoxic nephritis, myocardial degeneration, and advanced fattydegeneration of the liver. The clot in the common femoral waswell organized. The wound in the peritoneum over the arterywhere it was tied could scarcely be found.

An examination of the specimen which I beg to present andof which I submit X-ray plates, showed it to be, in my judg-ment, an osteosarcoma (Fig. i).

The following is the report of Dr. Marion Whitacre.Specimen presented for examination consisted of upper end

of femur, the hip joint and a part of the pelvis.After removing the soft parts, the tumor mass seemed to be

very hard, not bony hard, as the surface seemed to be made up ofa dense tissue almost of a cartilaginous tissue. There weresinuses extending into the growth at various places from whicha purulent fluid ran when the packing was removed.

Small pieces were taken from various parts of the growth inthe soft parts above mentioned for mnicroscopic examination, thereport of which will follow. The tumor mass was then sawed intwo, the endeavor being to pass through the head of the bone andat same time get a good view of the tumor growth. Small piecesof bone were taken at different places for examination.

928

FIG. I.

X-ray plate. Osteosarcoma of pelvis.

:.:1.;:,:.AR-:f P

..m-n,"'.-e

INTERILIO-ABDOMINAL AMPUTATION.

The specimen gave the appearance of being a hard osteomasurrounded bv a large amount of chronic inflammatory matter.

MIcRoscoPIc EXAMINATION.-The sections of the hard fibrous tissuewere made up of a large amount of dense connective tissue with con-siderable evidence of degeneration in places. Other places showed arather vascular condition with considerable evidence of acute inflamma-tion in the presence of leukocytes throughout the tissues. At one or twoplaces the sections showed distinct evidence of sarcomatous growth inthe presence of large number of round and spindle cells. The blood-vessel walls were very poorly formed, many of them being made up ofthe cells of the tumor. There was also evidence of capillary hemorrhagein places.

The bony section after decalcification showed for the most part ahard cancellous bony growth, but on one side showed evidence of theinvasion of the sarcomatous elements. The trabeculae of the bone wereinvaded by a connective tissue growth, which were of the spindle shape.

From the examination, I should be inclined to think that the growthwas originally an osteoma surrounded by a considerable area of inflam-matory tissue, and that the mass on one side had undergone a malignantchange and this had also invaded the bone, thus giving the diagnosis ofosteosarcoma.

The indications for interilio-abdominal amputation havethus far been neoplasmns of the upper end of the femur andof the pelvis and intractable tuberculous coxitis involving theacetabulum and iliac pan. In regard to prognosis these casesshould be separately classed according to the nature of thedisease, whether tumor or tuberculosis. A further divisionshould be made between the operation done in one stage andthose in which after a varying interval the amputation at thehip is followed by a more or less extensive resection of theinnominate bone. I have endeavored in the following tablesto record all of the operations hitherto published. Of the totalnumber, thirty-four cases, nineteen were tabulated by Keen andDacosta in I904.

TABLES.

It will be seen from Table No. i that the postoperativemortality of this amputation " the most extensive operationin all the realm of surgery," is 68 per cent., counting thecases of death after twenty days with the operative recoveries.In this I have followed the lead of Keen. In the cases where

929

JOSEPH RANSOHOFF.

the resection of the pelvis was preceded by amputation at thehip, no deaths followed the second operation. From this itmight be inferred that this course is preferable as a routineprocedure. Unfortunately, in tumors of the pelvis, thetwo-stage operation is not feasible, and in those for tuber-culosis none other is ordinarily applicable. In the caserecorded by Freeman, the amputation at the hip was immedi-ately followed by resection of the pelvis. The extent of thedisease was evidently not apparent until the hip-joint amputa-tion had been done. In the cases of Girard and Pringle thesecond operations were made for recurrent disease after dis,articulation at the hip.

Doleful as are the immediate results of interilio-abdominalamputation, the end results have been even more unpromising.The cases of Girard classed with recoveries, died within sixmonths of recurrence. Pringle's case died in five monthswith metastases. Salistcheff's case was reported well withinfour months of the operation. The end result I do not know.The record case is probably that of Freeman. Although heleft the anterior third of the acetabulum and of the ilium, thecase belongs in the category of interileo-abdominal amputa-tion. Freeman's case was well at the end of sixteen monthswhen reported, but died twenty months after operation fromrecurrence in the abdominal wall (personal communication).Of the end results of the operation for tuberculosis, the dataare extremely meagre. The case of Bardenheuer gained inhealth and strength four months after the operation, and itis presumed was a permanent recovery. The case of Pringlewas without recurrence seven years after the operation.

In the face of these unpromising results, it may be ques-tioned whether the operation is justified. The same questionhas been put for every major operation in surgery, and has inthe course of time with unvarying uniformity been answeredaffirmatively. By limiting the operation to suitable cases andperforming it at a time when there is at least a probabilitythat the patient can bear the shock connected therewith, it isalmost certain that the prognosis will improve as it has so

930

INTERILIO-ABDOMINAL AMPUTATION. 93Imarkedly for amputation at the hip. Disseminating theknowledge that the operation is feasible will, by bringing thecases earlier to the surgeon, contribute much towards thisdesirable end. With two exceptions, I know of no text-bookin which the operation is even mentioned.

In an operation of such magnitude, the initial mortalityis largely due to hemorrhage and to shock. Of all the casesthat are not included under postoperative recoveries, only twosurvived the fourth day. The prevention of hemorrhage hasin most of the cases been sought by preliminary tying of thecommon iliac, the internal iliac or the external iliac. Manybelieve that the tying of the corresponding veins ought alwaysbe practiced. Kocher and Kadjan encountered severe venousbleeding. Tying of the thin-walled large veins doubtlesswould increase the difficulties of the operation. Faure, aftera median laparotomy, applied a temporary ligature to theaorta just below the common iliac. Nevertheless, a severevenous hemorrhage from subcutaneous and subperitonealveins necessitated abandonment of the operation. Nanu,Jaboulay, Cacciopoli, and Salistcheff also ligated the commoniliac. Bardenheuer tied both the external and the internaliliac vessels. Freeman tied the external iliac and, later in theoperation, the common iliac. Keen tied the internal iliacartery. That by the tying of the common iliac artery pre-ventive hamostasis can be accomplished, has been amplydemonstrated in the case reported, and it was most satisfactory.Unfortunately where a long internal flap is, as in our case, amatter of necessity, there is great danger of gangrene. Thishad already commenced in Keen's case, although the patientlived only thirty-three hours. The gangrene strangely de-rveloped in the superior flap and not in the margin of the longinternal. In my case the gangrene involved the long flap only.Were a similar case to come under my observation, I wouldtie the external iliac and the posterior trunk of the internal.In that manner the obturator artery would be left intact forthe nutrition of the long internal flap.

What promises to be a decided addition to our methods of

JOSEPH RANSOHOFF.

preventive haemostasis is the method of Momburg. He en-circles the abdomen below the costal border with three or fourturns of a tourniquet, thereby controlling the circulationthrough the aorta itself. It seems that in the cases thus farcared for in this manner no harm has come to the viscera. Itwould seem, however, that the placing of the strap in suchclose proximity to the wound margin might make one feelthat it would slip after the amputation is completed. Thisobjection, it must be confessed, is a theoretical one on my part.It has been answered by a successful operation done by Bier,where the strap was kept in place for eighteen minutes.

The prevention of shock is a further desideratum. Inour case there was no manifestation of shock until the chiselwas used. While the use of the chain or wire saw mayminimize this shock, it cannot in this way be entirely overcome.In a future case I shotuld attempt the operation under spinalanaesthesia, which method was used by both Bier and Pringlewith success. At all events, I should use the lumbar anaesthesiain conjunction with the general.

In regard to the amputation proper, there comes the ques-tion as to the extent of the pelvic bone to be removed. Inthe earlier cases the entire innominate bone from synchon-drosis to symphysis was removed. One should be guided inthis matter by the extent and site oif the disease for which theoperation is performed. Most of the primary tumors of theinnominata spring from the iliac pan or the tuberosity of theischium. Where it is possible, the ramus of the pubes andof the -ischium should be left, since they give attachment tothe rectus muscle and the corpus cavernosum. The likelihoodof a hernia would be lessened.

In regard to the method of operating, writers differ.Where it is possible, a disarticulation at the hip may withadvantage, as was done by Bardenheuer and Freeman, im-mediately precede the resection of the pelvis. A glance atthe X-ray plate of the specimen removed in my case, showsthat this procedure would have been unfeasible. This is trueprobably of the majority of cases of sarcoma springing from

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INTERILIO-ABDOMINAL AMPUTATION. 933

the pelvis. In this regard, as in that of securing adequateflaps for covering the extensive wound, every case must beconsidered on its own merits. This is doubtless the reasonwhy so many methods have been devised for the interilio-abdominal amputation.

The original operation of Jaboulay consisted of making onelarge posterior flap. The first incision was made from thesymphysis parallel to and over Poupart's ligament and theentire length of the iliac crest. By retracting the upper woundmargins the soft parts are lifted from the iliac fossa and thevessels easily reached for tying. A circular incision is nextmade at the upper third of the thigh, through the centre ofwhich on the anterior surface the two incisions divergetowards the pubes and the iliac crest. Thus a very largeposterior flap is left which completely and easily covers thewound.

Girard operated in three cases by making internal andposterior flaps. Bardenheuer formed external and internalflaps, and Salistcheff in his successful case operated by theracquet method. He begins his incision below the twelfthrib and passes over the anterior superior spine of the iliumto Poupart's ligament, wlhich it follows to the pubes. Throughthis incision the vessels are secured. The wide end of theracquet incision sweeps over the internal surface and backof the thigh and over the buttock to the point of starting.The simplest method, from an operative standpoint, is thatof the long internal flap, the method of Savariaud slightlymodified by Keen and adopted by me. It has the signal dis-advantage of having to be exceedingly long to cover thewound. The risks of gangrene I believe to be larger afterthis operation than after any other. Where it is feasible, itappears to me that the incision of Salistcheff has superioradvantages.

Tnterilio-abdominal amputation must always remain adesperate operation. It should never be resorted to where aless mutilating procedure is possible. Partial resection of theos innominatum for tumors of the iliac pan ought to be per-

JOSEPH RANSOHOFF.

formed in preference to the interilio-abdominal amputation.Strange as it may seem, the three complete hemipelvic resec-tions performed by Kocher (2) and Roux (i) all recovered.WVhereas according to Croisier, of the partial resections therewere eight deaths and seven operative recoveries. It is need-less to add that these conservative operations have a place onlyfor limited neoplasms. So far as the usefulness of the iliumis concerned in hemiresection of the pelvis, there has been lessimpairment of stability and usefulness than one might imagine.In the cases of interilio amputation that have survived, therehas been no tendency towards eventration, a condition whichone would judge to be a certainty after removing so much ofthe bony support of the abdominal viscera.

TABLE I.-OPERATIONS IN ONE STAGE FOR SARCOMA.

i. Billroth (I89i). Death in a few hours. Verbal communication,Savariaud, Rev. de Chir., vol. xxvi, p. 350.

2. Jaboulay (I894). Death in 36 hours. Lyon Med., x894 p. 507.3. Jaboulay (i895). Death in 24 hours. Province Med., i896 (Pringle).4. Jaboulay (i895). Death in 5 days. Girard, verbal communication

(Pringle).5. Cacciopoli (1894). Death in 3 hours. Cent. f. Chir. (quoted), I894,

p. 988.6. Gayet (I895). Death in I hour. Province Med., I894, No. xxxv.7. Girard (i895). Recovery. Congres Chirurg., I898.8. Faure (I89g). Operation abandoned. Savariaud, Rev. de Chir., vol.

xxvi, P. 365.g. Freeman (i899). Recovery. ANNALS OF SURGERY, vol. xxxiii, p. 318.

1o. Nanu (Tgoo). Recovered from operation; gangrene of other leg.Congres Internat., Paris, Igoo.

TI. Salistcheff (igoo). Recovery. Archiv. f. klin. Chir., vol. lx, p. 57.12. Savariaud (Tgoi). Death in 2 hours. Rev. de Chir., vol. xxvi, p. 360.13. Gallat (igoi). Death in I hour. Annal. de Chir. (Belge), vol. ix,

p. 569.I4. Morestin (Igo2). Death in 9 hours. Bulletin Arch. Gen., I903, vol.

cxii, p. I665.I5. DeRuyter (1902). Death in an hour. Henri Myer, Inaug. Thesis,

Leipzig, I902.i6. Keen and DaCosta (x9o3). Death in 33 hours. Internat. Clinics,

vol. iv, Series 13.17. Kadjan (1903). Death on 2nd day. Yahresbericht f. Chir., I902, p.

I104.I8. Kocher (I9o3). Death on 2nd day. Yahresbericht f. Chir., 902,

p. 603.

934

INTERILIO-ABDOMINAL AMPUTATION. 935ig. Lastaria (igo7). Died on table. Reforma Med., Napoli, vol. v, p. 457.20. Orlow (Igoi). Lived 35 days. Yahresbericht f. Chir., I9o2, p. II04.2I. Bier (Igo8).* Recovery. Momburg, Centblt. f. Chir., igo8, p. 657.22. Ransohoff (i9o9). Recovery. Lived 38 days.

* In a personal communication Professor Bier informs me that hispatient died two months after operation, of recurrence in the abdominalwall.

TABLE II.-OPERATIONS IN TWO STAGES FOR SARCOMA.

I. Girard (i895). Amputation at hip. Some months later resection ofpelvis. Recovery. Rev. de Chir., vol. xxvi, p. 365.

2. Pringle (i9o8). Amputation at hip. Death 6 months after resectionof os innominatum. Lancet, Feb. 20, I909.

TABLE III.-AMPUTATIONS FOR TUBERCULOSIS.*

I. Girard (i895). Died in 50 minutes. Rev. de Chir., i898, p. II41.2. Bardenheuer (I897). Recovery. Gesellsch. d. Chir., xxvi, 1, p. 130.3. Gallet (igoo). Died in six hours. Gesellsch. d. Chir., xxvi, I, p. 130.4. Ribera (Madrid) (I902). Died, collapse. Luis y Simon, Siglo Med.,

1903, vol. v.5. Ribera (I902). Died 8th day. Luis y Simon, Siglo Med., I903, vol. v.6. Ribera (I9o2). Died, collapse. Luis y Simon, Siglo Med., i903,

vol. v.7. H. Vermeuil (I905). Died in 2 hours. Jour. de Chir. (Belge), vol.

v, p. 406.8. Morestin (igo8). Recovery. Bull. Soc. de Chir., Paris, vol. xxxiv,

p. Io6o.9. Pringle (i9o8). Recovery. Lancet, Feb. 20, I909.

io. Pringle (igo8). Death on Ist day. Lancet, Feb. 20, I909.* The operations for tuberculosis were practically all done in two

stages, the first being either a hip resection or amputation. The extentof the resection of the pelvic bone varies much. I have, however, ex-cluded all cases in which the resection did not involve the major partof the iliunL