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OPERATIVE
SURGERY
BY
TH. KOCHER, M.D.
PROFESSOR AT THE UNIVERSITY AND DIRECTOR OF THE SURGICAL CLINIC AT THE BERNE UNIVERSITY
WITH ONE HUNDRED AND SIXTY-THREE ILLUSTRATIONS
NEW YORK
WILLIAM WOOD & COMPANY
1894
Copyrighted, 1894, By WILLIAM WOOD & COMPANY
ELECTROTYPED AND PRINTED BY
THE publishers' PRINTING COMPANY
132-136 WEST 14TH STREET
NEW YORK
COI^TE]^TS
PART I. General Observations,
A. Introduction, ............
B. Anaesthesia, ............
Ether spray. — Cocaine injection. — Ether. — Chloroform. — Bro- mide of ethyl. — Chloride of methylene.
C. The Treatment of Wounds,
Atmospheric infection. — Contact infection. — Infection by im- plantation.— Carbolic acid and corrosive sublimate. — Heat (steam and boiling). — Disinfection of the hands. — Asepsis and antisepsis. — The suture and open treatment of the wound. — Drainage and secondary suture. — Healing under the blood crust. — Continuous antisepsis. — Subnitrate of bismuth and iodo- form.
D. The Selection of the Direction of the Incision,
Drainage openings. — Normal incisions.
PAGE- 1 4
11
2.S
^
PART II.
Special Operations. — Incisions
The Skull,
a. Soft Parts, ....
1. Temporal artery and vein, Auriculotemporal nerve, 3. Supra-orbital artery, Supra-orbital nerve,
3. Frontal nerve,
4. Ethmoidal nerve, .
5. Occipital artery, .
6. Major and minor occipital nerves, h. The Relations of the Cerebral Convolutions to the
7. Centres of the brain cortex, . Puncture of the ventricles, .
8. Relations to the surface of the skull, c. Trephining, ......
9. Longitudinal sinus,
10. Transverse sinus, . . . .
11. Middle meningeal artery,
12. Frontal sinus, ....
13. Antrum and mastoid cells, .
14. Cerebellum
Skull
3a
33 33 34 34 35 3& 36 37 40 40 47 48 50 51 52 52 53 56 57 60
nu9
IV
CONTENTS.
F. The Face,
Normal incisions,
15. External maxillary artery,
16. Operations on the nose,
17. Nose and nasal cavities,
18. Sphenoid cavities, Naso-lachrymal canal, . Frontal sinus,
19. Antrum of Highmore, .
20. Operations on the nerves, 31. Facial nerve.
Trigeminus II. , .
22. Infra-orbital nerve,
23. Orbital nerve,
24. Supra- maxillary nerve, Trigeminus III., .
25. Mental nerve,
26. Inferior alveolar nerve,
27. Lingual nerve,
28. Auriculo-temporal nerve,
29. Buccinator nerve, .
30. Infra- maxillary nerve, .
31 . Resection of the upper maxilla,
32. Osteoplastic resection, .
33. Resection of the lower maxilla,
34. Osteoplastic resection, .
35. Transverse division of the cheek,
36. Incisions in the tongue and the floor of the
G. The Upper Lateral Cervical Triangle, The Normal Incision for the Upper Cervical Triangle,
37. External carotid artery,
38. Superior thyroid artery,
39. Lingual artery, . . -. .
40. Internal carotid artery,
41. Hypoglossal nerve,
42. Lingual nerve, ....
43. Superior laryngeal nerve,
44. Internal and common jugular vein,
45. Accessory nerve, . . ...
46. Lateral pharyngotomy. With resection of the upper maxilla, "With excision of the lower maxilla. Inferior pharyngotomj^
47. Median pharyngotomy, H. The Anterior Cervical Triangle,
48. Common carotid artery,
49. Common jugular vein, .
50. Vagus nerve, .
51. Inferior thyroid artery, Inferior laryngeal nerve.
mouth.
CONTENTS.
%■
Triangle
illary, subscapular
52. Vertebral artery, .
53. OEsophagotomy,
54. Retro (Tesopliageal space
55. Tracheotomy, Crico- tracheotomy, Inferior tracheotomy,
56. Laryngotomy,
57. Laryngectomy,
58. Innominate artery,
59. Excision of the diseased thyroid gland J. The Lower Lateral Cervical Triangle,
The Normal Incision for the Lower Lateral Cervica
60. Subclavian artery,
61. Accessory nerve (external branch), 63. Subcutaneus colli nerve,
63. Large auricular nerve, ...
64. Dorsalis scapulae, suprascapular, ax
anterior and posterior thoracic nerves, K. The Nuchal Region, .... L. The Thorax
65. Internal mammary artery
66. Intercostal artery,
67. Intercostal nerve, .
68. Thoracotomy,
69. Resection of the ribs, .
70. Resection of larger portions of the chest wall
71. Opei'ations on the lungs, M. The Spinal Column,
72. Opening the spinal canal, N. Lumbar Region,
Normal incision, ....
73. Nephrotomy and nephrectomy,
74. Ureter,
75. Splenotomy, ..... O. Abdomen,
Normal incisions, .... Hypochondrium, ....
76. Cholecystotomy and cholecystectomy, Hypogastrium, .... Common and external iliac arteries, Opening the inguinal canal,
77. Castration. Excision of the tunica vaginalis,
78. Inguinal herniotomy, .
79. Isolation of the round ligament, .
80. Resection of the vermiform apjDeudix
81. Formation of a fecal fistula,
82. Formation of an artificial anus. .
83. Resection and sutui'e of the intestine,
84. High supra-pubic cystotomj-,
85. Opening of the bladder with resection of the symphysis
PAGE
101 101 102 102 102 104 104 106 107 107 110 110 110 113 113 113
113 114 114 114 115 115 115 115 117 117 118 118 11& 119 122 122 123 123 123 124 124 125 125 125 126 127 127 128 129 130 131 132 134
VI
CONTENTS.
P. Perineum,
86. Perineal lithotomy,
87. Opening of the cavernous and bulbous portion of the
urethra,
88. Opening of the membranous and prostatic portion of the
urethra, Exposure of the prostate, seminal vesicles, and deferentia, .....
89. Internal pudendal artery, . . Internal pudendal nerve,
'Q. Sacral Region,
90. Resection and excision of the rectum, R. Upper Extremity,
a. Shoulder Region
91. Subclavian artery, ....
92 . Superior thoracic artery,
93. Thoracico-acromial artery,
94. Long thoracic artery, ....
b. Axilla,
95. Axillary artery,
96. Anterior circumflex artery,
97. Posterior circumflex artery and axillary nerve,
98 . Subscapular artery and nerves, .
99. Thoracico-dorsalis artery, .
100. Circumflexa scapulae artery,
c. Arm,
101 . Brachial artery, .... 103. Deep brachial artery, .
103. Superior collateral ulnar artery,
104. Inferior collateral ulnar artery, .
105 . Median nerve,
106. Ulnar nerve,
107. Radial nerve,
108. Musculo-cutaneous nerve,'
d. Elbow Region,
109. Brachial artery, .
110. Median nerve,
111. Ulnar nerve,
112. Radial nerve,
e. Forearm — Volar Surface,
113. Radial artery,
114. Ulnar artery,
115. Interosseal artery,
116. Median nerve,
117. Cutaneus palmaris nerve,
118. Interosseus nerve, Radial and ulnar nerves, see Radial and ulnar arteries. Incisions on the volar side,
/. Forearm — Dorsal Surface,
119. Deep branch of the radial nerve. Incisions on the dorsal surface, .
CONTENTS.
Vll
g. Wrist Joint — Volar Side,
120. Ulnar artery at the pisiform bone,
121. Median nerve
h. The Hand — Dorsal Side,
122. Radial artery on the dorsum of the hand, 133. Radial artery on the trapezium,
124. Dorsal branch of the ulnar nerve,
125. Dorsal branch of the radial nerve, i. The Palm of the Hand, .
126. Superficial volar arch,
127. Deep volar arch,
128. Median nerve,
129. Comon digital arteries, j. Fingers, .....
S. Lower Extremity, .... Gluteal Region, ..... 131. Superior gluteal artery, Superior gluteal nerve, 182. Inferior gluteal (sciatic) artery,
133. Posterior femoral cutaneous nerve,
134. Sciatic nerve,
135. Internal pudendal artery. Internal pudendal nerve.
Inguinal Region, ....
136. External iliac artery,
137. Inferior epigastric artery at its origin,
138. Circumflexa ilii artery at its origin,
139. Inferior epigastric artery at the anterior
wall,
140. Circumflexa ilii artery in its outer third,
141. Aorta and common iliac artery,
142. Internal spermatic vessels,
143. Ureter, ....
144. Inferior mesenteric artery,
145. Hypogastric artery, .
146. Obturator artery,
147. Obturator nerve. The Thigh,
148. Femoral artery,
149. Superficial artery of the knee joint, Deep femoral artery. External circumflex femoral artery,
150. Deep artery at the adductor longus,
151. Internal circumflex artery,
152. Crural nerve, ....
153. Internal saphenus nerve, .
154. Lateral cutaneous femoral nerve,
155. Sciatic nerve, .... Region of the knee joint, .
156. Popliteal artery.
abdominal
PAGE
. 160 . 160 . 161 . 161 . 161 . 161 . 162 . 162 . 162 . 164 . 165 . 165 . 165 . 166 . 167 . 167 . 167 . 168 . 168 . 168 . 168 . 170 . 170 . 170 . 170 . 170 . 170
170 172 172
173 173 173 173 173 173 176 176 177 180 180 180 181 181 181 181 184 184 184
Vlll
CONTENTS.
|
PAGE |
|||||
|
157. |
Peroneal nerve, 185 |
||||
|
158. |
Internal saphenus nqrve (see Leg) . |
||||
|
159. |
Communicating peroneal nerve (external sural) , . . 185 |
||||
|
The Leg, |
. 185 |
||||
|
160. |
Tibialis antica artery, . . . |
. 185 |
|||
|
161. |
Deep peroneal nerve, |
. 186 |
|||
|
162. |
Superficial peroneal nerve, |
. 188 |
|||
|
163. |
Tibialis postica artery, |
. 188 |
|||
|
164. |
Tibio-peroneal trunk. |
.190 |
|||
|
165. |
Peroneal artery. |
. 193 |
|||
|
166. |
Internal saphenus nerve, . |
. 194 |
|||
|
167. |
External sural and external saphenus nerves. |
. 194 |
|||
|
168. |
Tibialis posticus nerve. |
. 195 |
|||
|
169. |
Suralis medius nerve, |
. 195 |
|||
|
The Foot |
. 195 |
||||
|
170. |
Plantar arch, .... |
. 195 |
|||
|
171. |
Internal plantar artery, |
. 195 |
|||
|
173. |
Internal plantar nerve. |
. 196 |
|||
|
173. |
External plantar artery, . |
. 196 |
|||
|
174. |
External plantar nerve. |
. 196 |
|||
|
175. |
Plantar arteries at their origin. |
. 196 |
|||
|
176. |
Dorsalis pedis artery, PAET III. |
. 196 |
Excisions (Resections) .
T. General Observations, 199
U. Lower Extremity, 300
177. Excision of the phalanges of the toes and the metatarsal
bones, 300
Metatarso- tarsal and anterior tarsal resection, . . 201
Intertarsal resection, ....... 303
Excision of the talus, ....... 303
Excision of the calcaneus, ...... 205
183. Talo- calcaneus and posterior tarsal resection, . . . 305 183. Resection of the foot, . . . . . . .306
Total tarsal resection, . 209
Resection of the lower third of the leg, .... 210
Resection of the tibia, ....... 211
Resection of the fibula, . . . . . . .211
Arthrotomy and resection of the knee, .... 213
189. Resection of the patella, . . . . . . . 318
190. Osteotomy and resection of the tibia, .... 318
191. Supracondylic osteotomy of the femur, .... 219 193. Osteotomy and subtrochanteric cuneiform resection of
the femur, ......... 319
193. Resection of the diaphysis of the femur, .... 220
194. Resection of the hip, 231
195. Resection of the pelvis, ....... 225
178. 179. 180. 181.
184, 185, 186
187 188,
CONTENTS.
IX
Upper Extremity,
196. Resection of the fingers and metacarpals,
197. Resection of the hand, ....
198. Resection of the ulna, ....
199. Resection of the radius, ....
200. Resection of the elbow
201. Resection of the diaphysis of the liumerus,
202. Resection of the articulation of the humerus,
203. Resection of the clavicle, ....
204. Resection of the scapula, ....
PAGE
. 225 . 225 . 227 . 231 . 231 . 232 . 236 . 237 . 243 . 244
PART IV.
Amputations and Exarticulations.
W. X.
Y.
Introduction
Lower Extremity, .......
205. Amputation of the toes and metatarsals,
206. Exarticulation of the toes,
207. Metatarsal amputation,
208. Metatarso-tarsal exarticulation,
209. Anterior intertarsal exarticulation, .
210. Posterior intertarsal exarticulation,
211. Tarsal amputation, .... 212a. Subastragaloid exarticulation,
b. Osteoplastic subastragaloid amputation,
213. Exarticulation of the foot,
214. Osteoplastic amputation of the foot,
215. Amputation of the leg,
216. Exarticulation of the knee,
217. Amputation of the femur,
218. Intracondylic amputation of the femur,
219. Supracondylic amputation of the femur,
220. Osteoplastic supracondylic amputation of the femur,
221. High amputation of the femur,
222. Exarticulation of the hip. Upper Extremity,
223. Amputation of the fingers and metacarpals,
224. Exarticulation of the hand,
225. Amputation of the forearm,
226. Exarticulation of the elbow,
227. Amputation of the arm,
228. Exarticulation of the humerus,
229. Exarticulation of the humerus with the clavicle
scapula, ........
247 254 254 254 255 256 257 257 258 259 260 260 261 263 264 265 265 266 266 267 267 270 270 272 273 273 275 276
and
OPERATIVE SURGERY.
PART I.
GENERAL OBSEEVATIONS.
A. Introduction.
Thanks to the antiseptic treatment of wounds, we can cause the most rapid heahng by adhesion of wounds made by us as surgeons, and since then operative technique has received an extraordinary impulse. Provided we are sure of our antisepsis, we may incise any part of the body, not only for therapeutic but also for diagnostic purposes. Of course, this makes it in- cumbent upon us, now that the indications for the operative treatment of diseases have been greatly extended, to perfect our technique to the utmost, so as to remain true to the first prin- ciple of therapeusis: "?w7^ocere." A complete mastery of the technique, resting mainly on the most accurate knowledge of anatomy, is therefore a condition sine qua non in operative therapeutics, standing next to the reliability of the antiseptic treatment of wounds. In practice it is not possible to study anatomical handbooks and atlases before every operation, par- ticularly because these auxiliaries are for the most part based on purely anatomical points and fail to notice details in a man- ner desired by the surgeon. For this reason it is not our in- tention to swell the number of the many excellent text-books on operative surgery by another more explicit one ; on the con- trary, we mean to give the briefest possible directions, in the
2 OPERATIVE SURGERY.
manner of Eoser's favorite vade-mecum, for a rapid posting on an operation to be performed.
These directions may serve as a guide for practice on the cadaver, but the main purpose has been to adapt them to the performance of operations on the living patient, and the author, therefore, has recommended only those methods which he has tried and proved by many years' clinical experience. He has done so, not because he places his methods above those of other surgeons, which often differ, but he hopes, on the contrary, at some future time to fill the gaps left here, by doing justice to the originators of operations described in these pages and of such as differ from them, and he craves indulgence that in this first publication too little notice has been taken of the historical development and importance of the various methods.
The most important task of a surgical text -book applicable to the living patient appears to us to be that the reader be enabled to post himself rapidly and surely regarding the path the knife has to follow in incisions in any part of the body and to any depth desired.
The correct direction of the first incision, so as to give free access on the one hand, and positively to avoid any unnecessary incidental injury when proceeding deeper on the other hand, is the most important point in surgical interference. It is espe- cially necessary to learn to avoid, besides the vessels whose injury is manifested by hemorrhages, the larger and smaller nerve twigs ; in other words, to choose the border lines of nerve distributions for incisions.
In this sense we hold certain incisions as typical for definite regions of the body, that is to say, as alone admissible when the choice of the method is left free, and we ourselves claim the value of our contributions to lie in our having given simple rules for reliable and conservative surgical manipulations for every part of the body.
A second group of operations is formed by excisions or resec-
INTRODUCTION. 3
tions. In these the object is not only, as in the case of incisions, to reach a deep structure by the shortest road, but a portion or an entire organ is to be removed from the body; hence the field must be so exposed that the part to be removed is eas- ily visible and palpable, so that the morbid portion can be safely and readily extracted.
Eesections of the joints and bones form a type of excisions; with them, of course, we may group also extirpations of inter- nal organs and tumors.
Finally, in a third group we have to deal with the total removal of a terminal portion of a part of the body, either lim- ited or extensive. These operations are called amputations. In these we have an added factor in the technique, namely, to give that part of the body from which a portion has been removed a definite form and a covering of integument ; for by the complete loss of the parts on the one side of the wound the measures for obtaining a rapid adhesion of the injured tissues become more complicated.
In incisions, no matter how deep, it is sufficient — antiseptic treatment being presupposed — to bring the tissues which have been separated again into the mutual contact that existed before the operation.
In excisions and still more in amputations, however, tissues come in contact which before were not in juxtaposition.
In incisions the application of simple sutures through the entire depth and width of the raw surfaces suffices to bring them again into the closest contact as before the operation. This is best secured by a continuous suture, the needle being passed alternately deeply and superficially.
In excisions and amputations it is not possible by sutures to bring the raw surfaces so close that the tissues belonging to- gether are brought into direct contact.
We have omitted all reference to the choice and form of the instruments, the manipulation of knife, forceps, scissors, saw,
4 OPERATIVE SURGERY.
and the various methods of suturing. We are convinced that no directions, no matter how minute, suffice to make a surgeon ; all these numerous details can only be learned by witnessing and practising them in clinics and hospitals under skilful in- struction. In like manner the facts as to when and why ves- sels are to be ligated, nerves to be stretched, joint capsules to be laid open, articulations to be resected, and limbs to be ampu- tated— in a word, the discussion of the indications for the oper- ations— must be learned in the clinic.
As we write these instructions mainly for use on the living patient we cannot omit mention, by way of introduction, of two vital conditions in every operative manipulation, namely, anaes- thesia and antisepsis. It is not permitted to give pain to a per- son by an operation, any more than to jeopardize life by the inoculation of infectious material into the wound.
B. Anaesthesia.
The anaesthesia of a patient differs widely according to the operation to which he is to be subjected. We shall describe only those measures of whose efficacy and mode of application we are qualified to speak from personal observation and experi- ence.
Ideal ansesthesia would be approached if we could render in- sensitive only that part of the body which is to be operated on. While there are measures which fulfil this indication, they act only superficially and for a brief period.
Local Ancesthesia.
The most important local anaesthetics are ether spray and cocaine injections. The two drugs differ in their value; one having a purely physical effect, while the other acts chemically or as a poison, not only on the sensory nerves, but also on other parts of the nervous system, by absorption, thus possibly giving
ANESTHESIA. 5
rise to dangerous incidental effects. In the use of ether, con- duction along the sensory nerves is inhibited by cold. This method of anaesthesia is suitable for minor operations of brief duration. But the effect of ether continues for a short time only. If ether spray is made to act for a longer time on the skin the latter may become necrotic, especially in the case of small tumors over which the skin is tense (chondroma of the finger). Local anaesthesia by ether spray may be used when the most painful part of the operation consists in the lesion of the integument, as in simple incisions or avulsion of a nail. In such cases it is one of the best measures in our possession. The only drawback is the burning sensation when the tissue thaws. To avoid this subsequent pain the part should be dipped in warm water.
In most recent times, in place of ether spray, ethyl chloride, which acts more rapidly and certainly, has been used. This is vaporized by the heat of the hand.
Cocaine, in the form of the hydrochlorate, injected into the tissues inhibits the conduction in the sensory nerves, even the larger trunks. It also acts through the intact mucous mem- brane on which it is painted, without being injected into the tissues. This drug has disadvantages as compared with ether, because it is absorbed and may paralyze distant nerve elements ; hence it is to be used only under certain conditions. For injec- tion it is used in one-per-cent solution ; for painting, in ten-per- cent strength. Its effect lasts only a few minutes. Experience has shown that a dose of but 1.5 grains may cause untoward accidents. A dose above 8 grains may be fatal. Hence several syringefuls of a one-per-cent solution may be injected without fear. Of course, regard must be had for antisepsis; therefore the cocaine is mixed with a five-per-cent solution of carbolic acid. The solution must be injected directly into the cutis or immediately beneath it at the point where the tissues are to be severed. In intracutaneous injections the anaesthetic zone is
6 OPERATIVE SURGERY.
recognized by the small elevation produced. Minor operations, incisions, and excisions of small tumors may be performed by means of cocaine without producing any pain.
General Ancesthesia.
Our knowledge of this beneficent means dates back only to the fourth decade of this century. The first drug by means of which general anaesthesia was obtained was ether. A very few years later it was displaced by chloroform. Up to the present time it is not decided which of these two drugs is deserving of more general application. We therefore think it desirable to inform the reader, on the strength of our own experience, as to what appears to us to be the most judicious mode of employ- ment of these two agents; for the fact that competent surgeons advocate opposite opinions proves that both drugs may be judi- ciously used according to the conditions present.
The difference in the mode of employment of the two drugs is considerable in so far as ether is poisonous only in much larger doses than chloroform. In the larger doses both drugs have a toxic effect. With neither, therefore, may we exceed a certain maximum dose, as with every other poison. This maximum dose is much greater with- ether ; the proportion being about like that between quinine and strychnine. Just as we employ quinine in much larger doses than morphine and strych- nine, so we can give much more ether than chloroform. Herein lies the great advantage of ether ; for in employing anaesthesia it is necessary to give the largest possible dose of the two drugs in the shortest time. As is well known, morphine can be given in quantity greatly exceeding the maximum if the doses are distributed over a longer time. In the same way more chloro- form and ether may be used in an operation lasting five hours than could be employed in a shorter time. But the danger of exceeding the limit at a single dose is much greater with chloro-
ANESTHESIA. 7
form than with ether. Why then is chloroform not discarded entirely?
Ether has certain contra -indications. By its local irritating effect on the mucous membranes of the respiratory organs it causes congestion, swelling, and increased secretion of mucus. For this reason ether is not admissible in all cases where there is hypersemia or catarrh of the air passages, especially if asso- ciated with dyspnoea. The second reason against the exclusive use of ether is that, being effective only in large doses, it takes longer to produce anaesthesia if given, like chloroform, in slowly increasing amounts. This causes a much prolonged and more intense stage of excitement. In order to avoid this drawback ether requires a large initial dose. In this way ansesthesia is very quickly produced, as early as by chloroform if not sooner. For the same reason, when a rapid ether ansesthesia is desired, we need special large masks which cover the face completely, because the ether vapors must be quickly inhaled, in a concen- trated condition.
In addition the mask is usually covered with a towel ; we adapt to the face of the patient a ring of flexible copper wire so as to exclude the air as much as necessary. In this way it is possible to produce ether ansesthesia in two or three minutes and the stage of excitement is greatly shortened. This rapid method, however, has the drawback that the necessary exclusion of the air causes a certain degree of asphyxia. This explains the alarm- ing sensations, cyanosis of the face, and the heavy breathing of many patients under its influence.
With chloroform such measures for the rapid and concen- trated introduction of the drug are unnecessary. On the con- trary, care is taken to admit sufficient air. For years we have arranged it so that a free space is left all around between the cover of the mask and the ring which is moulded to the face (Fig. 1), In this way sufficient ansesthesia is produced within ten minutes at the most, without any obstructed respiration or
8 OPERATIVE SURGERY.
sensation of suffocation. This is one advantage of chloroform. Moreover, chloroform has no such irritating effect on the mucous membranes as ether ; hence chloroform anaesthesia is more quiet and agreeable than that of ether. A9 a matter of course, in employing a drug intended to inhibit sensation and in many- cases also to produce a paralysis of the motor apparatus to the de- gree of muscular relaxation, care must be taken that the func- tion of the respiratory and circulatory organs is not likewise suspended. The first task after beginning muscular relaxation is to make sure of respiration, particularly the ingress of air into
Fig. 1.
the opening of the larynx. This is effected by lifting the max- illa, and with it the root of the tongue, forward. As soon as the stage of paralysis begins the tongue and the maxilla, in the usual dorsal position, drop backward and the epiglottis overlaps the laryngeal opening like a valve, as we may convince ourselves by inspection during resections of the jaw and the tongue. It re- quires strong forward traction of the base of the tongue or the epiglottis to render the upper portion of the latter so tense that it remains fixed above and forward during inspiration. Pres- sure behind both maxillary angles is best adapted to raise the base of the tongue along with the jaw, provided the neck be stretched at the same time by bending the head backward, thus making the tongue tense not only forward but also upward. This stretches the glosso-epiglottic ligaments and the epiglottis is held fast. This manipulation positively prevents accidental suffocation during anaesthesia. Previous to it the patient must
ANESTHESIA. 9
be prepared so that respiration be not hindered by other causes, as by full stomach and intestines, constricting clothing, or im- proper position. At the beginning of the anaesthesia the stom- ach must be empty or have been artificially emptied, lest rem- nants of food get into the larynx from vomiting during sleep.
If free respiration before and during anaesthesia is provided for in this manner ; if a mask is employed which makes it im- possible that concentrated chloroform be inhaled; and if the amount of chloroform in the continually admitted fresh air is increased by an uninterrupted addition of the drug, drop by drop, in quantity just sufficient to produce anaesthesia, then there is no danger,' but this becomes imminent when more profound effects on the nervous system are aimed at, namely, complete muscular relaxation, and when the chloroform is given for a longer period. In this way the maximum dose is necessarily more and" more approached, and we should be able to recognize the signs of this approach. They are as follows : the dropping of the jaw and tongue with the consequent obstructed respira- tion indicate the beginning of the more profound effect ; then it is shown by the general muscular relaxation and the slowing of the pulse. The maximum is almost reached when respiration becomes labored, while the pulse becomes irregular and weaker. This shows sinking of the blood pressure, which may be followed at any moment by insufficient heart action, with the resulting cerebral anaemia and collapse. It is necessary to guard against this possibility beforehand by placing the patient in a position which favors the cerebral circulation. A patient should be chloroformed only with the trunk in a horizontal position and the lower extremities raised. In our operating table provision has been made to have the legs higher than the trunk. Of
' We have never been able to make up our minds to employ the much- vaunted apparatus of Junker and Kapi^oler, not only because the anfesthesia is rendered more complicated, but because we find tliat vrith careful supervision the dose can be mucli better adapted to individual conditions by adding the chloroform drop by drop than by means of apparatus.
10 OPERATIVE SURGERY.
course the administration of the anaesthetic is to be stopped as soon as the above-mentioned dangerous symptoms appear.
In every prolonged operation v^e advise, after complete anaes- thesia has been obtained by chloroform, to continue with ether unless contra -indicated by disease of the air passages. The maximum dose of ether is so much greater than that of chloro- form that the danger of reaching that point suddenly is incom- parably less than v^ith chloroform. It is not difficult to maintain for hours v^ith ether an anaesthesia once completely effected b}'" chloroform, and this combined method has the great advantage that the ether need not be given in suffocating doses, since small doses and ordinary masks suffice. But for economical reasons it is always well to guard against the too rapid evaporation of the ether by covering the mask with impermeable tissue.
In disease of the heart muscle chloroform must never be given, but only ether.
For an anaesthesia of brief duration bromide of ethyl is an excellent drug : five drachms poured at once on an impermeable mask, and pressed on mouth and nose while air is excluded, will in from thirty to sixty seconds cause an anaesthesia which lasts from one to several minutes. But nothing more should be at- tempted with this drug, neither prolonged anaesthesia nor mus cular relaxation ; bromide of ethyl should not be poured on ^ second time because, owing to its quick effect, sinking of the blood pressure with consequent collapse may ensue with surpris- ing rapidity. Recent experience seems to show that bromide of ethyl anaesthesia may be effected with very small doses of from 80 to 100 minims if it is poured on drop by drop, and that the narcosis can then also be maintained for a longer time, fifteen to twenty minutes, without any danger.
Chloride of methylene is preferred to both chloroform and ether, as being much less dangerous, by such an authority as Spencer Wells. But as this drug is given by Spencer Wells, or by Junker von Langegg, the inventor of the Junker apparatus,
THE TREATMENT OF WOUNDS. 11
only by means of the latter, it is possible that the excellent re- sults obtained are due as much to their great experience in its administration as to its chemical composition. Our experi- ence with it has been unsatisfactory, probably owing to its inconstant chemical composition.
It is proper, and we have done so for nearly twenty years, to administer one-half hour prior to every anaesthesia a cup of tea with brandy or a glass of Marsala wine in order to strengthen the action of the heart and raise the blood pressure. We are able to prove by pulse tracings the influence exerted under an- aesthesia by these stimulants in this direction.
C. The Treatment of Wounds.
The second indication we have to meet during every opera- tion is asepsis. We must guard the patients both during and after the operation against the injury and danger of a wound infection.
It is not to be expected that an exhaustive treatment of this subject will be given within a couple of pages. In this place we mean only to explain the principles underlying this treat- ment of wounds, and how a rapid and undisturbed healing of every operative wound can be simply secured by excluding in- fection. When a wound is to be healed quickly it must be guarded against infection, that is to say, against the deposition and development of the agents of decomj)Osition. The truth of the fact may be considered as demonstrated that every wound, with proper care for favorable mechanical conditions, may be caused at once to adhere, provided micro-organisms and their products are kept from the tissues. Micro-organisms, however, adhere to all solid and liquid objects which come in contact with the wound and must be destroyed upon and within them.
Near the end of the sixth decade of this century. Lister dem- onstrated the decisive importance of atmospheric dust and all
12 OPERATIVE SURGERY.
objects touched by it, and he introduced the principle of the an- tiseptic treatment of wounds, based on Pasteur's proof of the origin and nature of the causes of decomposition in general. Lister first proved, that decomposition in wounds occurs only when particles of dust are brought in contact with them. Should these noxious particles be kept off, no decomposition occurs. The splendid results immediately obtained in surgery by having regard to this simple fact, both in the hands of Lister and particularly in those of German surgeons (Volkmann, Schede, Thiersch, and Socin), form the basis of the extraordinary im- portance of Lister's investigations and observations. The second step taken by Lister was his demonstration that these dust particles are of an organic nature, since they could be de- stroyed by such measures as destroy organic substances in gen- eral. Finally Lister proved that these substances are capable of development, that is to say, that they are organized.
Pasteur had furthermore found some definite germs for cer- tain decompositions outside of the human body. Billroth had published in a remarkable work the results of his investigation on the specific material of wound infection. But it was only toward the end of the seventh decade that Koch proved by means of greatly improved auxiliaries that in wounds as in fluids contained in glass flasks certain kinds of decomposition occur only through the influence of certain micro-organisms. Now the victory was gained upon the field on which the doctrine of the diseases of wound infection could be accurately established and on which even to the present day ever new advances are made in the treatment of surgical and medical diseases.
For the treatment of wounds, however, one preliminary standpoint has already become common property, namely, that we should strive to exclude all micro-organisms from wounds and that we possess the means to accomplish this object in prac- tice in a satisfactory manner.
Lister believed he could meet this indication in the main by
THE TREATMENT OF WOUNDS, 13
preventing atmospheric infection, and the spray introduced by him remained for a long time the fundamental point of the anti- septic treatment of wounds. The operator and the patient were enveloped in a dense fog of carbolic acid which was to penetrate the dust j)articles and render them innocuous.
The doctrine of atmospheric infection was based on experi- ments in which decomposition of an unstable fluid (urine) was positively prevented for years when the drawn-out neck of the vessel was bent downward; while decomposition ensued im- mediately when the neck of the bottle was broken. It has been recently shown that the spray is not only unnecessary but is even injurious because it agitates the dust particles and act- ually drags the germs of infection along upon the wound with- out harming them or arresting their development by the tem- porary contact with the carbolic spray. It appeared that in order to prevent atmospheric infection it was sufficient to re- move the dust particles by ventilation, mechanically by washing the walls and furniture, and finally by allowing the remaining dust to settle, if the operation is performed in appropriate locali- ties which can be shut off and have smooth, clean walls. Even Lister has proved by Tyndall's beautiful experiment that the air becomes perfectly freed from dust by allowing the heavy particles to settle : if a beam of sunlight is allowed to fall through an empty closed bottle it can be seen as a bright streak ; but when the bottle is left at rest the streak disappears because the dust particles which reflected the light have fallen to the bottom.
But the doctrine of the relative innoxiousness of atmospheric infection must not be carried ad absurclum by avowing that one would as readily operate in any by-place as in an operating-hall, provided instruments and dressings are properly disinfected. On the contrary, it must always be considered a matter of great safety when an operation can be performed in a room with clean, smooth walls, so that dust can neither fall nor be stirred up from
14 OPERATIVE SURGERY.
furniture, floor, or particularly from the ceiling or possibly a hanging lamj).
Of vastly greater importance indeed than an atmospheric infection is that form which at present is preferably designated, as contact infection. It is this upon which nowadays the great- est stress is laid in the treatment of wounds, even by Lister himself, and as a matter of fact we possess a true antisepsis only since this view has been accepted. This is the infection caused by touching wounds with larger or smaller objects of any kind — instruments, sponges, pledgets, the hands of the surgeon, and irrigating fluids.
It is at once clear how infectious materials introduced in this manner must adhere to the surface of the wound in quite a dif- ferent way from those coming from the air. When the tissues in the wound are grasped with hands or instruments the infectious matters are at the same time pressed into it, somewhat as in vac- cination. The term " infection by vaccination" would be more de- scriptive, inasmuch as air infection is really that of mere contact.
But it is still more important to separate another mode of infection, namely, that for which we have proposed the name "infection by implantation."
In this class belong in the first place infection by ligatures, and in the second place by other bibulous or porous foreign bodies. If infectious germs are introduced into a wound with a suture we infect not only by the momentary contact or vaccina- tion, but we transplant into the wound a permanent focus of incubation in which the germs at once find an appropriate place of development. Within such a foreign body (necrotic portions of tissue which have been infected act in a similar manner) are contained the most favorable conditions for a last- ing and spreading infection, which is by no means the case to a like degree in infection by vaccination. Hence infection by im- plantation is the worst of all, and disinfection must pay the greatest attention to this mode.
THE TREATMENT OF WOUNDS, 15
Do we at this time possess the means of positively disinfect- ing or sterilizing all those objects which come in contact with the wound or remain in it? This question is to be answered unhesitatingly in the affirmative as regards pledgets, dressings, sutures, and instruments, and a physician is no longer permitted to sin against the demands of absolute sterilization of the ob- jects named or to excuse defects in the antiseptic treatment of wounds by untoward external conditions.
What constitutes correct antisepsis? There is a whole series of drugs possessing disinfecting power. Foremost stand carbolic acid and the still more reliable corrosive sublimate. These two drugs, however, do not act instantaneously, but after some little time, so that the dressings must be exposed to their effect for some longer period. If the dressings are to be really sterile, that is to say, if all germs and spores are to be killed in them, we must adapt the duration of the influence of these antiseptics to the resistance of the most refractory spores. There are mi- cro-organisms which can resist even sublimate for two, three, or four hours, perhaps a whole day. ' We must leave our dressings in the respective solutions for several days, but this would injure many materials. Instruments cannot at all be placed in subli- mate, nor for days and weeks in the slowly acting carbolic acid. Chemical disinfection, therefore, finds application only with some materials, especially silk ligatures. These can be kept for a long time in sublimate without injury. One drawback of the chemi- cal method is that the dressings, when brought in contact with the body of the patient, manifest the poisonous effects of the drugs, both by their local influence and by absorption. The chemical mode of sterilization, therefore, is but a makeshift and applicable only to certain materials and under certain conditions.'
' Compare among others the investigations by Vicquerat and Zimmermann (under Tavel's direction), Berne Dissertation, 1889.
'^ With Tavel, we must make a distinction between disinfection and sterili- zation ; for the treatment of woiinds we may be satisfied with disinfection, and restrict sterilization to the pathogenic germs.
16 OPERATIVE SURGERY.
The dry preservation of dressings sterilized with solutions of carbolic acid and siablimate is to be entirely rejected. Steriliza- tion with these drugs lasts as long as the disinfectant remains present in active form. Positive demonstrations show that this is no longer the case with dry dressings. Corpora non agunt nisi liquida. We cannot be sure that during the preservation or at the moment of their use infectious germs did not adhere to such dressings. Chemical sterilization, therefore, is reliable only v/hen the materials are applied to the wound directly from the disinfecting fluids. Before applying, the materials taken from the solutions are expressed in a wringer and immediately placed upon the wound. All dry dressings, supplied ready pre- pared by the factories, should not be recognized as sterilized.
Ligatures have long been treated according to this view. These, when subjected to chemical sterilization, are wound upon spools which are preserved in the antiseptic fluid, from which they are transferred directly to the wound. This is admis- sible because we are dealing with a fine, thin substance and the small amount of adhering carbolic acid or sublimate is of no importance with reference to local or general poisonous effect ;' in the case of large dressings the drawback mentioned as to their direct application from the disinfecting fluid remains in force.
Our best sterilizing agent is heat. With a degree of heat of from 300 to 350° F. we secure satisfactory sterilization or disin- fection of all our dressings — gauze, binders, ligatures, and in- struments. Still more effective than this dry heat is moist heat. Its safest mode of employment, according to the most recent in- vestigations, is in the form of a current of steam under high pressure. This at 266° F. and above destroys all micro-organ- isms and their spores present in permeable objects, in the course
^ Taking the ligatures from the sublimate solutions during the operation has the advantage, on the contrary, that it guards at the same time against acci- dental infection at the moment of employment.
THE TREATMENT OF WOUNDS. 17
of a few minutes. At our clinic we use a steam boiler at 293° F. under pressure of three atmospheres.
But even this perfectly reliable method of sterilization is useless unless the objects can be directly transferred from the boiler to the wound. This is not possible in all cases, for extra- neous reasons, and instruments in particular suffer more from steam than from dry heat.
The best and simplest substitute for steam which we have used extensively for years is boiling of the instruments and dressings. The boiling must be continued for some time; but we may be sure of working with disinfected instruments when they have remained for half an hour in boiling water, or better, according to Schimmelbusch's method, in one-per-cent soda solu- tion, in which the instruments do not rust. Boiling has the great advantage that the necessary apparatus is everywhere ac- cessible and particularly can be so placed that instruments and dressings can be taken from the sterilizing apparatus directly by the hands of the operator. Quite recently Dr. Tavel has ex- perimented with solutions of table salt, and table salt with soda (we have used the former for a long time in place of plain water for wounds), and has found that they required less boiling for complete sterilization. Dr. TaveFs favorable report shows that a solution of 0.75^ of table salt and 0.25;^ of calcined soda is absolutely sterile after fifteen minutes' boiling (the spores of the anthrax and hay bacillus and of the bacillus mes. vulg. are killed) and keeps very long (a few mould fungi grow only after several weeks). Gauze compresses, pledgets, and silk are ab- solutely sterile after half an hour's boiling in the solution. Tavel subjected the salt-and-soda solution to a special examina- tion in order to use a solution containing the same amount of salt and alkali as the blood. As regards the salt solution our experience has long shown that it does not irritate the wounds at all. According to Tavel the salt-and-soda solution is also well borne in large doses by intravenous injection, nor does it
18 OPERATIVE SURGERY.
injure the peritoneum in any manner. A boiled solution of salt and soda (Tavel's 0.75^ of salt and 0.25^ of soda) also furnishes a perfectly sterile and unirritating fluid for rinsing and cleans- ing wounds. This does away with the objection against the flooding system raised by the advocates of the dry treatment of wounds. Warm compresses boiled in the salt-and-soda solution furnish the best dressing for immediate contact with the wound. We always use gauze, deprived of fat for dressings, pledgets of gauze in place of sponges for soaking up liquids, drainage tubes of glass, and silk ligatures.
Though we have arrived at absolute security in the disin- fection by relatively simple measures (steaming and boiling) of all inanimate objects, this is not true in like manner of our hands and the skin and tissues of the patient. Yet the cleans- ing of hands and skin is an indispensable condition of the anti- septic treatment of wounds. We cannot hold our hands in the steam nor can we boil or scald them. Hence we must resort to chemical measures which really should by rights, as we have shown, act for hours. As this is impossible, we must content ourselves with a preliminary thorough mechanical cleansing as we do in the prevention of atmospheric infection. Some days before the operation the skin of the patient is shaved over a large circumference, scrubbed with soap and hot water, protected against gross impurities by dressings, and immediately before the operation scrubbed with a 0.1^ sublimate solution and rinsed with an abundance of water. The operator's hands, fingers, and the nails particularly are washed with soap and brush for several minutes under a jet of warm water. Of course, by this means we do not effect sterilization, as ordinary water contains germs, but we make sterilization by simple measures possible, for a similar cleansing with a brush for one or two minutes is next effected with a 0.1 or better 0.2% acid sublimate solution. Bacteriological examination by Drs. Tavel and Vicquerat has proved that the hands, as a rule, are rendered sterile by this
THE TREATMENT OP WOUNDS. 19
means. If after such cleansing the hands are dipped in gelatin or we inoculate the detritus from under the nails, no bacteria develop. Of course, the antecedent occupation is not without influence. I have tested this on my own person in a case of osteomyelitis in which I opened a large abscess and purposely soiled myself. Despite the above-mentioned method of disinfec - tion, some colonies of staphylococci developed. After soiling with fatty material, washing with alcohol as recommended by Fiirbringer is excellent.
Under Tavel's direction Dr. Zimmermann made a number of experiments by instantaneously infecting small pieces of meat with definite micro-organisms and found that the sterilization of such particles of meat by placing them from one to five minutes in 0.1^ acid sublimate solution is not always successful, while it is easily effected in the case of infected strips of blotting-paper. Therefore we must have great care not to soil our hands, and those of all persons taking part in the operation, with infectious materials. By no means should we make a post-mortem ex- amination and still less dress infected wounds before an opera- tion, although competent surgeons have declared it to be ad- missible.
With hands previously cleansed, both bacteriological exami- nation and the healing of the wounds prove that disinfection can be secured by a thorough scrubbing of the nails, fingers, and hands with a brush, soap, and warm water, followed by a final scrubbing with a disinfected brush and a sterilized warm soda or salt solution, several times repeated in fresh liquid. Dr. Zim- mermann often showed that our hands and the epidermis scales from around and under the nails were absolutely free from germs. Of course such washing takes time, and every visible stain must be thoroughly removed by prolonged brushing under a warm-water jet. The brushing and washing in 0.1 or 0.2^ sublimate solution increases the certainty of sterilization and is doubly necessary in all cases where warm and sterilized
20 OPERATIVE SURGERY.
water is not plentiful, as well as when the hands have been previously soiled directly with pus or excrement. For even if this does not kill all the micro-organisms they are greatly weakened.
At all events it can he demonstrated that the disinfection of the hands and of the skin of the patient is not as reliable as the sterilization and the preparation of the instruments and dress- ings. If we remember in addition that accidental infections by inattention during an operation are never positively excluded, we shall do well to look, upon every operation wound, no matter how carefully made, as possibly slightly and superficially in- fected at the end of the operation. The more unfavorable the conditions the more certainly do pathogenic germs get upon the wound. Hence the question arises: Can the wound itself, can infected tissues be sterilized? And if this is not the case: How can we repair the damage of slight superficial and of grave in- fection ? As regards the sterilization of the wound a few words suffice. If according to the above-mentioned demonstration by Dr. Zimmermann it is impossible to destroy positively all the germs in a piece of meat infected by a momentary contact with micro-organisms, even when it had been left for five minutes in 0.1^ sublimate solution, there is no hope that it can be done with a wound. Still Zimmermann obtained by his disinfection quite an important difference in degree, since far less colonies developed and these did so more slowl}^ and at a later time, their virulence having been weakened. Therefore it need not surprise us to learn that Lister ' takes this stand as to the antisepsis of the wound and washes it with 0.2^ sublimate solution at the end of the operation. We have shown "" that the most excellent results are obtained by proceeding aseptically and using a 0.1^ solution of sublimate for a single washing of the wound.
We guard against excessive chemical injury of the tissues
' Paper read before the International Med. Congress at Berlin, August, 1890. ^ Correspondenzblatt f. Schweizer Aerzte, Jan. 1st, 1888.
THE TREATMENT OF WOUNDS. 21
and overabundant absorption of the sublimate by a final thor- ough washing of the wound with 0.75^ sterilized salt solution.
As to the opening of the large cavities of the body, proof has been furnished that excellent results can be obtained without any antiseptic irrigation; but the condition of the serous mem- branes and cavities is no guide for other injured tissues such as connective tissue and muscles. With reference to laparato- mies we have likewise restricted ourselves for many years to the antiseptic preparations previous to the operation, i.e., to what is now generally called the aseptic treatment of wounds. The wound cavity is merely rinsed with sterilized salt solution. But numerous experiments — for instance, with the peritoneum — prove that the serous membranes are very tolerant of infectious materials or digest them with relative facility and render them harmless, perhaps by the assistance of serous transudation, so long as the endothelium remains intact (experiments by Tavel and Walthard) ; but that the injured tissues in a wound are not in an equally favorable state. However, observations by Lanz show that micro-organisms develop much more frequently in the clot of drainage tubes when the wound runs a favorable course than in the bloody secretions from the depth of the wound. Hence we may hope that here too a small quantity of micro-organisms, especially when weakened, are exposed in the wound to similar influences which delay or arrest their develop- ment. Upon this disinfectant effect, especially of the transud- ing blood serum and the living tissues, we may rely for supple- menting our aseptic wound treatment, which thus far does not offer absolute security and in a concrete case probably never will.
Our last but by no means worst auxiliary for obtaining the aseptic healing of wounds is to render impossible a noxious de- velopment of the few infectious materials which may have reached the wound in spite of every precaution. In this respect we must bear in mind the following conditions:
Human tissues through which the circulating blood and
32 OPERATIVE SURGERY.
lymph pass form a poor nutrient for bacteria. But their devel- opment is favored by stagnant blood and stagnant serum in the wounds. Thence arises the indication to prevent the ac- cumulation of stagnant fluids between the raw surfaces. This is effected in two ways : (1) the exact coaptation of well-nour- ished wound margins. We avoid chemically injurious applica- tions (disinfection) and unnecessary mechanical influences (trac- tion, bruising, and pressure) ; we secure' good circulation by the proper selection of the incision and the position of the parts ; and bring the raw surfaces into close contact by suture and careful compression. (2) Where perfectly exact coaptation is impossi- ble, the wound secretions are conducted outward. The safest and the most excellent means for this is an open treatment of the wound. But the healing in that case would be slow.
For this reason we have re-introduced the method of the secondary suture, and Bergmann has employed it extensively. Spengler, Nussbaum, Helferich, and others have variously modi- fied it. It consists in leaving the wound open for twenty -four or forty -eight hours, rarely longer, and then closing it by sutures. This method unites the advantages of the open-wound treatment with that of the suture.
An easier but less reliable way is drainage of the wound. In conjunction with complete suture of the wound, it should always be effected through special small openings, by means of glass tubes with large perforations, which had been immersed in O.lfo sublimate solution. In twenty-four hours, more rarely after forty-eight hours, and exceptionally only after several days, the drainage tube will have carried off the fluids effused in consequence of the injury and should then be removed. Drainage tubes are allowed to remain longer only when it ap- pears that a wound has been gravely infected. Of course, in such a case an open-wound treatment, with or without an eventual secondary suture, is to be preferred after the use of re- peated disinfection.
THE TREATMENT OF WOUNDS. 23
The middle course, as it were, between the open treatment and drainage is held by Schede's treatment under the moist blood crust. When the immediate coaptation, of the wound margins is impossible it utilizes the blood effused into the wound to fill the cavity. The wound is allowed to fill with blood, the edges are but partially united by sutures, and the rest is covered with impermeable tissue. Where neither primary nor secondary suture is possible this method is much preferable to the simple open-wound treatment, with reference to the duration of the healing, by favoring the cicatrizing process.
When every facility is at hand for effecting perfect asepsis according to the above principles, i.e., for preventing before- hand any intense and lasting infection of the wound, the meas- ures here indicated will suffice. But when one must operate under unfavorable external conditions, i.e., when the ingress of larger quantities of micro-organisms cannot be prevented, or when a v/ound is exposed to subsequent infection, as in opera- tions on the mouth, pharynx, larynx, and rectum, or when operations must be jDerformed within the limits of foci of infec- tion, as in fistulse and ulcers, a single sterilization of the recent wound does not suffice, but we require a lasting effect of anti- septic measures, namely, continuous antisepsis.
This can be done in two ways: (1) By the repeated applica- tion of the above-enumerated antiseptic agents. This proce- dure presupposes an open wound. If the wound is left open through its entire extent, asepsis may be secured in a short time by the repeated direct application to the raw surfaces of carbolic acid or sublimate compresses, at first every few hours, then at longer intervals. But a corresponding absorption and poison- ous action of the drug is necessarily associated with it, and this serious incidental effect must be closely watched. Yet as we do not aim at a single powerful disinfection, but mainly at arrest- ing the development of micro-organisms, the desired object may be also attained by frequently changed warm antiseptic dress-
24 OPERATIVE SURGERY.
ings impregnated with a mild solution of carbolic acid (0.5 to 1%) and sublimate (0.01^ or with weaker antiseptics such as thymol {O.lfo) and sahcylic acid (0.15^). At first we use, as a rule, gauze slips dipped in freshly prepared 5fo carbolic acid solu- tion, which are changed every three hours ; later, moist warm compresses impregnated with 0.15^ salicylic acid solution. Far less reliable than compresses with antiseptics is irrigation through drainage tubes left in the wound.
(2) The other way of securing a prolonged effect consists in impregnating the raw surfaces with substances which render the tissues resistant against the influence of micro-organisms : with permanent antiseptics in the more restricted sense. This class includes caustics and iodoform. In the salts of mercury, silver, zinc, and bismuth we possess substances which combine with the albumin in the tissues and form albuminates which resist the decomposing effect of the bacteria — in fact, these me- tallic substances act as direct antiseptics upon the micro-organ- isms. For such purposes we employ a one-per-cent emulsion of subnitrate of bismuth or a similar preparation of zinc. The re- sults of our bismuth treatment are among the best obtained previous to the time of perfected antisepsis. But the drugs mentioned, bismuth in particular, are likewise decomposed by the processes occurring in the wound, a sulphate of bismuth being formed. These applications, therefore, exert their full effect only when employed before the decomposition of the tissues by the micro-organisms begins, i.e., upon fresh wounds. When necrosis of the tissues has set in through decomposition, more powerful antiseptics are required, such as tincture of iodine, pure powdered salicylic acid, or the thermo-cautery.
Iodoform belongs to a different class from the caustics. By the introduction of this drug Mosetig-Moorhof has opened the way for a new form of wound treatment. Iodoform manifests its effect only after the onset of decomposition processes. The lat- ter cause the iodoform to split up and thus the ptomaines and
THE SELECTION OF THE DIRECTION OF THE INCISION. 25
toxalbumins are fixed and incidentally the further development of the micro-organisms is arrested (De Ruyter). Therefore iodo- form has no place in the aseptic treatment of wounds. In wounds appropriate for the aseptic treatment its employment is senseless; on the contrary, the wound may be directly infected by its application. But it is the most active of all drugs for counteracting beginning and advanced decomposition, and hence is to be used on wounds where decomposition must be expected from insufficient asepsis. De Ruyter's investigations show that Bergmann's favorite mode of pouring into the wound a solution in ether and alcohol (iodoform, 10; ether, 20; alcohol, 80 parts) is to be preferred. Iodoform possesses the drawback that it produces marked poisonous effects in certain persons, especially on the central nervous system, so that it should be used with great care and in accurate doses.
Special mention should be made of the fact that wounds made when intense infection already exists, as in fistulge, etc., are to be united by sutures only in exceptional cases. As a rule, the open treatment, with or without secondary suture, will be necessary.
D. The Selection of the Direction of the Incision.
Before the period of anaesthesia and of asepsis in wounds it was a wise plan to make incisions where they could be done rapidly, where a small size sufficed, and where gravity insured free egress to the secretions.
The latter indication can nowadays be perfectly met by separate, very small incisions for the introduction of drainage tubes. On the other hand we still see some teachers, when instructing students in tying arteries, giving directions how to find an artery through the smallest possible incisions. Such practice is no longer justified. The true surgeon is recognized by his splitting the skin to an ample extent, yet proceeding
Fig. 5.
Fig. 2.
Fig. 0.
Temporal incision (trigeminus, III. ) Nasal incision
Upper neck incision (aditus I laryngis) f
Axillary incision (anterior half)
Hypochondrial I incision f
Hypogastric inci- sion (vermiform appendix)
Eyebrow incision (trigeminus, I.)
Upper maxillary incision (trigem. II.) Cheek incision (operations on tongue) ( Incision for the upper cervical trian- . 1 gle (external'carotid artery)
Lower neck incision (struma)
Incision for the lower cervical triangle (subclavian artery)
J Mammary gland j incision
Epigastric incision
Hypogastric inci- j sion (common ' iliac artery, sig- moid flexure)
Bladder incision
Knee incision
j Lower inguinal incision / (common femoral artery)
Upper inguinal incision
Scrotal incision
Fig. 7. — Normal Incisions.
THE SELECTION OF THE DIRECTION OP THE INCISION. 29
with the greatest care and conservatism in the depth of the wound. A large cutaneous incision forms no appreciable additional injury as compared with a smaller one, for an exact suture unites it as quickly, safely, and beautifully as the latter. Moreover, the extent of the cicatrix remaining is of no importance, provided it occupies a suitable direction. This brings us to the point which we have adhered to for years as decisive in placing the incision.
Langer's investigations into the directions in which the skin splits show that the tension of the skin varies greatly in two different directions. Two incisions vertical to each other ex- hibit a varying retraction of the wound margins: while one gapes widely, the edges of the other remain in contact even without artificial means. This fact has to be borne in mind in choosing the direction of the incision, unless other factors have a determining effect in a concrete case ; for the course of the vessels and especially of the larger and smaller nerve twigs is even more important for the direction of the incision. Thus in incisions in the face the first care will be as regards the course of the branches of the facial. Fortunately the course of the nerves and vessels largely coincides with the direction in which the skin shows the greater tension, so that a cutaneous incision adapted to the cleavage line corresponds also with the course of the important nerves and vessels.
For years we have noted our incisions which were not united by suture in a schematic diagram, according as to whether they appeared open or closed when the dressings were changed. For this purpose we made use of the drainage openings made close to the sutured cutaneous wounds. If the drainage tubes are removed after twenty -four and the sutures of the main wound in forty- eight hours, we are enabled to become posted as to the condition of cutaneous wounds not closed by sutures. We give below the results of this practice in juxtaposition with Langer's lines showing the cleavage lines of the human skin.
30
OPERATIVE SURGERY.
In Figs. 2, 3, 4, 6, and 6 the drainage openings which closed spontaneously after removal of the tubes are represented by a single line; those in which the openings remained patulous, by a spindle-shaped mark. Fig. 2 shows how largely well-directed incisions correspond with Langer's cleavage lines, as might have been expected a priori.
This having been ascertained, we gradually came to prefer the direction of the cleavage lines also for the longer incisions, and have convinced ourselves that the difference in cicatrization
after incisions with or against the cleavage lines is so important that it behooves us to indicate normal inci- sions for every region of the body. These show for that particular region the cleavage lines of the skin and at the same time are so placed as to avoid the course of important super- ficial nerves and vessels. We have convinced ourselves in the case of our frequent operations for struma that the cicatrices after such a normal in- cision become so faint in the course of time that they are hard to recognize, while cicatrices after incisions in different directions, especially on the neck, may often cause great deformity by contractions and folds.
We therefore have added diagrams containing our normal incisions (Figs. Y, 8, and 9). Of course, these refer mainly to the large incisions made on the head, neck, trunk, and the ar- ticular regions. For the remaining incisions, especially in the inter -articular portions of the extremities, we have retained the straight longitudinal direction in the case of shorter incisions (for ligatures and the exposure of nerves) for the sake of sim- plicity. One glance at the figures shows that a portion of these
Auricular incision (mastoid antrum)
Incision for the upper cervical triangle
Transverse cheek incision Temporal incision
Superior maxillary incision Fig. 8.
"Upper nuchal incision Coccipital I. nerve and artery; S
Shoulder incision (shoulder / resection)
Axillary incision (posterior half)
Resection of ribs
Lumbar incision l_
(nephrotomy) f
Elbow incision (re- I section of the elbow) \
Posterior pelvic incision (rectal resection)
Fig. 9.— Normal Incisions.
32 OPERATIVE SURGERY.
longitudinal incisions likewise coincides with the cleavage lines of the skin.
We need hardly say that we include among the normal in- cisions all the longitudinal incisions placed in the median line of the body, that is to say, all the incisions corresponding to a ver- tical line from the vertex to the symphysis, across the perineum to the anus, and returning behind to the vertex.
In the case of amputations, of course, a coaptation of seg- ments of skin naturally belonging together is out of the ques- tion. But even here it seems to be an advantage to keep to some extent to the cleavage lines of the skin, so as to have less retraction of the flaps.
How well the oblique incisions for amputations specially rec- ommended by us fit the cleavage lines of the skin is shown by a glance at the figures.
PART II.
SPECIAL OPERATIONS.
E. The Skull. a. Soft Parts.
The soft parts of the skull are distinguished by a profusion of vessels, but these are easily accessible for ligation, as they pass through the scalp whose cutis and corium are firmly united to the galea. The arteries lie quite loose in the scalp, the veins less so, and hence they do not retract like the arteries. In arte- rial hemorrhage pressure is made on the skin next to the edge of the wound and the vessel is seized with an artery forceps ; should this fail even with our arterial hook forceps, the needle is passed around it close to the wound.
The vessels which carry the blood to the dome of the head come from the forehead, the temples, and the occiput. If in profuse hemorrhages the flow is to be arrested from the centre, attention should be directed to these three points.
1. Temporal Artery and Vein. — Auriculo- Temporal Nerve {Trigeminus III.). (See Figs. 10 and 11.) — One centimetre in front of the ear the finger feels at the upper edge of the zygomatic arch the pulsation of the temporal artery ; in hemor- rhage of one of its branches pressure- with one finger can here control it and it may be ligated at the same point. Incision is made in a vertical direction, one centimetre in front of the an- terior end of the helix. After dividing the skin the fascia ap- pears, namely, the superficial layer of the galea aponeurotica. Here the artery passes over the zygomatic arch and appears subfascially at its upper edge.
34
OPERATIVE SURGERY.
The position of the temporal vein is not constant ; usually it lies parallel with the artery and behind it.
Of more importance is the nerve here situated which fur- nishes the sensory supply to the ear and the temporal region, the auriculo-temporal nerve (see Figs. 10 and 11) from the third branch of the trigeminus. It encircles the artery from behind
j Temporal artery
I Auriculo-temporal nerve
Superior thyroid artery
Vertebral artery )
Inferior thyroid artery V
CEsophagotomy )
( External and internal caro- j tid artery
Hypoglossal uerve
Lingual nerve
Fig. 10.
forward to above backward and passes upward parallel to its posterior side. If the nerve is to be stretched or exposed in the case of neuralgia, the artery is located and the nerve found nearer toward the ear. Higher up the branches of the nerve and the artery pass into the scalp.
2. Supra- Orbital Artery . — Supra- Orbital, Frontal, andEth- moidal Nerves (Figs. 12 and 13). — The main artery of the fore- head is the supra-orbital. It is smaller than the temporal artery.
THE SKULL.
35
As guiding-point for its ligation we have the paljjable supra- orbital foramen ; here the artery emerges in a sagittal direction from the orbit ; it passes through the fibres of the orbicularis vertically upward under the galea. After shaving the eyebrow the incision is made transversely at the supra-orbital margin and carried deeper.
Hypoglossal nerve Occipital artery
Ext'nal maxillary artery Common facial vem Submaxillary gland
Lingual artery-
Scalenus anticus muscle
Thyroid gland
Inferior thyroid art( ry
Recurrent laryngeal nerve
Descending branch of the hypoglossal
Zygomatic arch
— Temporal artery
Auriculo-temp"l nerve Temporal vein
Internal jugular vein Sterno-mastoid muscle
\ Descending branch of the
i hypoglossal Internal carotid artery External carotid artery
Omo hyoid muscle
-— Stemo-mastoid muscle
Common carotid artery
Phrenic nerve
Longus colli muscle ""
Sterno-hyoid muscle
Fig. 11.
At the same orbital neuralgia guiding-point for through the skin, mediately on the without injuring the eyebrow has the facial. The
point is the supra-orbital nerve. In supra-
the supra-orbital foramen is likewise the best
the incision because it can be positively located
The nerve lies deeper than the artery, im-
periosteum ; it is not easy to sever the nerve the artery at the same time. The incision in the advantage that it avoids the branches of orbicularis and the frontalis muscles are sup-
36
OPERATIVE SURGERY.
plied by the facial ; the corresponding nerve twigs enter them from a lateral direction and therefore are not touched by the transverse incision recommended.
3. The frontal nerve lies about two centimetres toward the median line from a vertical above the inner canthus ; it is much thinner and more superficial in the fibres of the orbicularis, ris-
( Supra-orbital artery < Supra-orbital nerve ( Frontal nerve
j Frontal sinus 1 Ethmoidal sinus
( Infra-orbital nerve 1 Supramaxillary nerve
ing almost vertically. In order to expose it we use the inner half of the eyebrow incision.
4. The ethmoidal nerve (Fig., 12) passes at the inner and upper circumference of the orbit into the cranial cavity and leaves it again through the cribriform bone, spreading over the nasal septum and supplying with its terminal branch the tip of the nose. It can be well seen and ligated with an aneurism
THE SKULL.
37
needle, about 2 cm. behind the median end of the supra-orbital margin. The eyebrow incision is somewhat prolonged down- ward over the root of the nose (the branches of the angular artery and vein being ligated), the periosteum is divided, and at the inner and upper circumference of the orbit it (the peri-
Froutal sinus
Frontal nerve
Supra-orbital nerve
Supra-orbital artery
Supra-orbital margin
Orbicularis muscle
Orbicularis muscle — r-
Zygoma — ^1 Infra-orbital nerve Masseter muscle
orbita) is slowly stripped off backward until the transversely stretched cord running to the anterior ethmoidal foramen is seen to separate from the roof of the orbit. The ethmoidal ar- tery (from the naso-frontalis artery) is torn in this manipula- tion and the hemorrhage is arrested by tampons.
5. Occipital Artery. — Major and Minor Occipital Nerves (Figs. 14 and 15). — The occipital is the thickest artery of the
38
OPERATIVE SURGERY.
head. Midway between the occipital spine and the highest point of the mastoid process the artery emerges from under the me- dian edge of the splenius muscle and piercing the fascia it rises toward the occiput, where it lies under the galea. The vessel is ligated at the point where it pierces the thick fascia. The inci- sion for its ligation runs transversely in the line uniting the
Occipital artery ) Major occipital nerve >■ Minor occipital nerve )
Major occipital nerve
Fig. 14.
abovementioned points along the semicircular line from the pos- terior lower circumference of the mastoid process to the level of the belly of the trapezius. The skin here is very thick. Divid- ing the fascia, the posterior edge of the sterno-cleido-mastoid muscle is exposed, avoiding the minor occipital nerve (from the third cervical) which rises to the occiput along this edge (Figs. 14 and 15). Under the sterno-cleido-mastoid muscle ap-
THE SKULL.
39
pears the splenius capitis, whose fibres ascend obliquely forward ; at its anterior edge is tbe longissimus capitis muscle. The splenius is divided in the direction of the cutaneous incision ; the artery appears beneath it, first resting on the obliquus capitis superior, then on the semispinalis capitis muscle.
The artery can be ligated at the median edge of the splenius muscle, where it rises subfascially in the angle between the
Trephining of the ) transverse sinus (
Trapezius muscle ^
Major occipital nerve
Occipital artery.
Splenius capitis muscle
Minor occipital nerve
Semispinalis muscle J!
Sterno-mastoid muscle Splenius capitis muscle
Trapezius muscle
Semispinalis capitis I
muscle j
Trapezius muscle
Splenms capitis — / muscle
Major occipital nerve j Obhqiuis capitis in- / ferioi muscle Splenius capitis muscle
Fig. 15.
posterior edge of the sterno-cleido-mastoid and the anterior edge of the trapezius muscle to the skin of the occiput. At this point it is met by the major occipital nerve which comes from the median direction.
At its origin the occipital artery can be ligated through the same incision as the external carotid artery (which see). At that point it passes under the digastric and stylo-hyoid mus-
40 OPERATIVE SURGERY.
cles. The occipital vein is beside the artery, but its position is not constant.
6. The major occipital nerve (posterior branch of the second cervical (Figs. 14 and 15), after piercing the semispinalis capitis muscle, comes to the surface at the lateral margin of the trape- zius muscle. On ligating the artery the nerve is usually found near its median side, the two approaching each other.
If a more central point of the nerve is sought for stretching, as in neuralgias, the incision must be made deeper (Figs. 14 and 15). Incision transversely at the height of the strongly projecting spur of the epistropheus, laterally from the median line. The comparatively thin trapezius is cut, beneath it the thick splenius capitis with its oblique fibres running upward and outward, and then the vertical stout semispinalis are divided, until the obliquus capitis inferior muscle appears, which runs outward and slightly upward. The thick nerve is seen upon it ; it rises over the lower lateral edge of the muscle and runs trans- versely medially and upward. At this point the nerve, which is mainly sensory, contributes some motor branches to the nuchal muscles.
The minor occipital nerve (Figs. 14 and 15), from the third cervical nerve. After reaching the posterior margin of the sterno-cleido-mastoid muscle, it passes subfascially upward par- allel to this margin to the occiput, giving off branches laterally from the field supplied by the major occipital nerve. (For its exposure see Occipital artery.)
h. The Relations of the Cerebral Convolutions to the Skull.
Since physiological experiments and complementary experi- ences of surgeons on the living patient have positively demon- strated that certain cortical regions of the brain represent foci ' for definite functions of a motor, sensory, and tactile variety,
' We prefer this term to the word " centres" used by Horsley.
THE SKULL. 41
the surgeon is called upon to find strictly circumscribed portions of the brain cortex in paralytic and irritative conditions.
Different methods have been resorted to in order to obtain guiding points as to the relations of the cortex of the brain to the cranium or to points on the surface of the head accessible to palpation and inspection. These can be of service only in so far as they may be promptly applicable to different shapes and sizes of heads.
The method of percentage measurements introduced by Dr. Miiller is one of the most reliable for striking again and again the same points. It consists in drav/ing connecting lines from two main lines which are subdivided in a definite manner. The relations of the points thus obtained to the regions of the brain lying beneath them are ascertained from a larger number of observations. Our procedure is an analogous one : Dr. Schenk, of Berne, has constructed for us an instrument consisting of two spring steel strips, which can be adapted and applied without difficulty to any skull by means of an elastic band running across the forehead, occiput, and temples. Being divided into centi- metres and millimetres, the various lines can be adjusted to a relative percentage. By means of the elastic band the instru- ment is placed transversely around the skull (equatorial lines) so that its upper margin (point A) strikes in front the crista gla- bellse (this is the name we propose for this ridge) which unites the arcus superciliares across the root of the nose, in width about equal to the thumb; behind it strikes the lowest point of the occipital protuberance (point B). The band passes directly over the upper attachment of the auricle. In a sagittal direction an elastic strip runs from the glabella to the occipital protuberance (sagittal meridian). On this meridian a second elastic strip bearing a graduated circle is movable and can be fixed at any desired point of the sagittal meridian and at any angle.
From the point midway (Figs. 16 and 17) between the crista glabella? and the occipital protuberance (the upper pole of the
42
OPERATIVE SURGERY.
sagittal meridian = point C) we draw two oblique meridians, each at an angle of 60°, running forward and backward respectively (anterior [line CGHJ] and posterior [line CSTV] oblique meridi-
> IB
Fig. 16.
an). A third line is more complicated. For its construction the sagittal meridian is divided into three parts (anterior [point D] and posterior [point E] third point of the sagittal meridian) . The posterior half of the sagittal meridian is divided into two equal parts (posterior fourth point [point F]). From the centre (point
THE SKULL.
43
X) between the posterior fourth point and the posterior third point extends an oblique line XYZi^J, the movable spring strip being applied from here to the surface of the head. At the tem- ple it intersects the equatorial line about 1 cm. behind the oblique
Fig. ir.
anterior meridian. The two oblique meridians and the oblique line are divided into three equal parts and thus we obtain a sufficient number of definite points for localization on the surface of the brain.
We have demonstrated on a large number of brains those points of the cerebral cortex which correspond to the above-men-
44
OPERATIVE SURGERY.
tioned points on the surface of the head and have convinced our- selves that we are thus put in possession of the main points whose function is known and whose location comes in question on the living patient. Instead of long explanations we have had the
Fig. 18.
artist designate the points determined by the various observations (Figs. 18 and 19) precisely as we had marked them, after per- foration of the skull at the respective points, by the injection of a minute drop of aniline solution with a hypodermic syringe. The following remarks remain to be added regarding the
THE SKULL,
45
drawings. The equatorial line corresponds to the greatest hori- zontal circumference of the brain; in front at A it coincides with the anterior pole of the frontal brain, behind at B it lies nearly 1 cm. below the posterior pole of the occipital brain, and laterally it passes over the temporal lobe. The intersection
(J) of the anterior oblique meridian with the equatorial line is situated on the skull at the pterion (the junction of the fron- tal, sphenoidal, temporal, and parietal bones), and on the brain at the anterior end of the fissure of Sylvius, where the horizon- tal ramus of this sulcus passes into the anterior ascending one.
46 OPERATIVE SURGERY.
Hence it designates the depression between the frontal and tem- poral brain.
The intersection of the posterior oblique meridian with the equatorial line (V) marks the limit between the temporal lobe and the occipital brain. This point lies 1 cm. below the margin which divides the external and inferior surfaces of the brain. The upper pole of the sagittal meridian (C) lies at the highest point of the anterior central convolution in front of the fissure of Rolando.
The upper third point of the anterior oblique meridian (G) is the point where the anterior central convolution joins the first and second frontal convolutions.
The lower third point of the anterior oblique meridian (H) marks the place where the second and third frontal convolutions join the anterior central convolution.
On the posterior oblique meridian the upper third point (S) lies over the interparietal sulcus in the upper parietal lobe, ex- actly above the supramarginal gyrus.
The lower third point (T) of the posterior oblique meridian marks the posterior end of the first temporal fissure and hence lies under the angular-gyras.
The oblique line at the intersection with the sagittal me- ridian (X) corresponds about to the tip of the lambdoidal su- ture on the skull and the parieto-occipital fissure of the brain.
The upper third point of the oblique line (Y) lies in the an- gular gyrus, the lower third point of the oblique line (Z) in the posterior end of the horizontal portion of the fissure of Sylvius. The intersection of the oblique line with the equatorial line (^) strikes the anterior end of the first temporal fissure.
It is at once evident that by these points we have sufficiently marked all the motor and sensory centres thus far known. On the skull the bregma (the point where the sagittal and the coronal sutures join) can be found by dividing the sagittal meridian into three parts. The anterior third point (D) corresponds to it and
THE SKULL. 47
marks the limit between the first frontal convolution and the anterior parts.
7. Centres of the Brain Cortex. — Basing on Horsley's classi- cal investigations on the centres in the cerebral cortex of the monkey, we give a synopsis of the known centres of the human brain or the points where the skull must be opened in lesions of separate centres. In compliance with our request Professor Horsley was kind enough to send us autograph drawings which we here reproduce (Figs. 20 and 21) . Comparison with the draw- ings shows that the known centres of the cerebral cortex are . grouped in a simple manner around the points which our method of measurement enables us to determine.
The crown of the trephine is to be ai3plied directly to the side of C for the low^er extremity, or close to the middle line for its peripheral parts (hallux), and farther away, behind G, for its central portions (hip) . According to the localizations drawn from certain monkey brains, the focus for the hip would lie half a trephine opening farther forward, and the same distance far- ther backward for the toes, especially the great toe.
The centres for the upper extremity are found by applying the trephine immediately behind G as far as H, at the upper portion for the shoulder and elbow, at the lower portion for the wrist, fingers, and thumb. According to other experiments, the opening for both fingers and thumb should be made half a trephine circle farther back.
Slightly downward behind the line GH, somewhat above the latter point and over the entire breadth of the two central con- volutions, the trephine opening strikes the focus for the ocular portion of the facial, that is to say, for the contralateral clos- ure of the lid. Behind the line HJ in the upper third lies the focus for the contralateral lifting of the angle of the mouth ; in the middle third that for retraction of the angle of the mouth, and finally in the lower third above and behind J the centres for the larynx and pharynx, those for deglutition and mastication
48
OPERATIVE SURGERY.
and the opening of the mouth in an oblique backward and up- ward direction, the latter centre lying vertically a good finger's bread above ^.
Up and down before H lies the focus for moving the head (as well as the eyes, according to our own clinical observations) to the opposite side. In front of the middle of the line HJ lies the point whose lesion is followed by motor aphasia (Horsley has failed to mark this point) , Below the posterior half of the
Fig. 20 A. -
line Zi2 lies the focus for auditory aphasia; below the point T that for visual aphasia, and above BV the point for psychical vision or psychical blindness.
Exposure and possibly excision might also be effected for the centres lying immediately adjoining the median line on the me- dian surface of the brain — those for the trunk muscles behind the point D or in the anterior half of the line CD ; the centre for central vision (or hemianopsia) in front of the upper half of the line XB.
Finally let us indicate the point where in our opinion punc- ture of the lateral ventricles of the brain can be performed in
THE SKULL.
49
the most certain and least harmful manner. This may be done from above, from in front, and from the side. From the pos- terior half of the first temporal fissure we need only perforate 1
I'IG. ~M.
cm. of brain substance (counting from the depth of the fissure) in order to reach the posterior horn. In one of our cases of tu- bercular meningitis in which the trephine was aj^plied behind and
above the ear, in front of the posterior end of the crista temporalis
4
50 OPERATIVE SURGERY.
(see Fig. 23), the point below Z was exposed, and the lateral ventricle opened exactly at the bottom behind the posterior end of the caudate nucleus. But despite the exact location, after one thorough evacuation drainage failed — a fact we explained by collapse of the walls of the ventricles after evacuation, owing to the pressure of the brain substance from above.
In another analogous case direct drainage from above suc- ceeded well and had a very good effect. Hence it is preferable to reach the ventricle from above rather than from below, al- though four or five centimetres of brain substance must be per- forated. However, as puncture directly from above injures the centres for the lower extremity, it would be better to effect the object from without the motor region, namely, from above for- ward, laterally from the point D and forward of the point Gr. If puncture is made here, about 2^ to 3 cm. from the median line and 3 cm. forward of the precentral fissure, preferably in the fissure between the upper and middle frontal convolution, as shown in the figure, the ventricle is easily reached backward and downward, without the risk of a grave lesion of the cortex. At present we have under treatment a case of tumor of the brain, in which a drainage tube introduced in this manner car- ries off an ample amount of cerebro-spinal fluid. For this opera- tion the crown of the trephine should measure at least 4 cm. in diameter, since according to Horsley the opening must be rather large.
8. As a guide we first make a puncture with a hypodermic syringe whose needle should be at least 6 cm. long ; the dura is divided very slightly so that the drainage tube may be held rather firmly in the opening, and then we introduce one of our arterial hook forceps, by the opening of which we make room for the passage of the tube. As in all our cases, we employ a glass drainage tube, 6 cm. in length, which passes through a special small cutaneous opening, so that the main wound can be sutured throughout its entire extent and in order that the
THE SKULL. 51
opening in the skin may aid in keeping the tube in a definite direction. The escajDing cerebro-spinal fluid is at first bloody but soon becomes quite clear, and as it often is abundant the dressings should be frequently changed early after the operation.
c. Trephining.
Having become posted as to the manner in which after in- cisions of the skull the right points can be found in the depth, and how and where certain nerves and vessels may be avoided or the latter ligated after injury, the incision for trephining should be made as a rule in the meridian, i.e., rising vertically toward the vertex, because both nerves and arteries run from below upward. When a longitudinal incision does not suffice a flap is formed with the base below and a broad point above. The cross cut which is largely used does great damage. The incisions are made with a resection knife and carried vigorously down to the bone, the periosteum is divided and folded back with the flap, which is easily effected by the aid of an elevator ; only at the sutures the periosteum adheres so flrmly that it must l3e loosened with the knife. The bone is divided with the crown of the trephine, of the hand or bow pattern, or in recent times with small circular saws. Instead of the trephine the use of a sharp chisel and a hammer would be simpler, provided there is no ground for fearing the concussion connected with it. The chisel marks out the limit of the opening and the piece of bone thus loosened is lifted out with the elevator as soon as it proves movable; the edges are smoothed with Liiers' paring forceps. Particular care should be taken not to injure the superficial dural vessels.
Wagner's temporary resection of the skull with an omega- incision and chiselling out of the bone in connection with the soft parts for subsequent replacement appears indicated when very large openings are made and in diagnostic trephining.
52
OPERATIVE SURGERY.
The attempt to lift out the entire plate of bone with the loosely adhering periosteum does not always succeed.
9 , Trephining of the Longitudinal and Transverse Sinuses. — Trephining over the sinuses of the dura mater is done only when this is the part to be exposed or opened.
Total resection of the upper maxilla
Incision into the mu- cous membrane for the mental nerve
Transverse incision of the cheek
Inferior lateral pharyngotomy
Orbital nerve Auricular incis'n Mastoid antrum Lateral ventricle Transverse sinus
Trephining of the cerebellum
Facial nerve Buccinator nerve
Fig. 22.
The superior longitudinal sinus lies to the right of the sagit- tal median line.
A much more important point is that of the
10. Transverse Sinus (see Figs. 22 and 23). — Here thrombo- sis and suppuration from extension of inflammations from the middle ear are of the most frequent occurrence. To locate the spot for trephining search is made for the most prominent point at the base of the mastoid process which appears posterior to the edge of the auricle. A finger's breadth higher lies the tem-
THE SKULL.
53
poral ridge which rises obliquely backward. Between this ridge and the former eminence on the inner side lies the transverse sinus which can be followed downward for some distance along the mastoid process. The incision is made along the posterior edge of the auricle (auricular incision, Fig. 22) and the posterior
Temporal ridge
( Trephine opening for puncture of < the lateral ventricle and for otitic I cerebral abscess / Trephin'g of the mastoid antrum ' ' Spina supra meatum
I Trephining of the transverse I sinus
Trephining of the cerebellum
Resection of the lower maxilla
Fig. 23.
margin of the wound is drawn slightly backward. After chisel- ling through the skull the wall of the sinus is exposed. More frequently we are called upon to avoid the sinus in operations at this point, especially in opening the mastoid cells (which see).
1 1 . Trephining for Ligature of th e Middle Meningeal Artery (see Figs. 24 and 25). — The middle meningeal artery supplies the cerebral meninges with blood. For ligating it a point is usually selected (Vogt) two fingers' breadth above the zygo- matic arch and a thumb's breadth behind the zygomatic process
54
OPERATIVE SURGERY.
of the frontal bone. But this point strikes only a part of the artery, ' namely, its anterior branch. If the posterior branch is to be found at the same time, the trephine opening must be made immediately over the middle of the zygomatic arch (below our points i2 and I) . At this point, however, not only must the
Lateral pharyngotomy (
Lingual artei-..-
Hypoglossal nerve
Superior laryng'l nerve
Common carotid
["Temporal incision Third branch of trigeminus -j nerve
I Middle meningeal artery [ Internal maxillary artery
I Accessory nerve J Auricularis magnus nerve J Internal jugular vein ( External jugular vein
Masseter muscle External maxillary artery External maxillary vein
— Supraclavicular nerves Trapezius muscle
Platysma
Scalenus medius muscle
Stemo-mastoid muscle External jugular vein
Transversa colli artery Brachial plexus Transverse scapular artery Subclavian artery Subclavian vein Scalenus anticus muscle
Fig. 24.
scalp and periosteum be divided, but the temporal muscle with its vertical fibres must be taken into account. But as an in- cision at this point must not extend below the zygomatic arch, owing to the branches of the facial nerve, a longitudinal divi- sion is not admissible, and our temporal incision must be used (see Fig. 25). This runs obliquely from the junction of the
' See Merkel's Anatomy, p. 65.
THE SKULL.
55
frontal bone and the zygoma ' to the posterior end of the zygo- matic arch, thence backward and upward ; it divides the skin and the tense temporal fascia, and after ligature of the superficial temporal artery at the posterior edge of the temporal muscle strikes the bone from which the muscle and periosteum are turned forward. In this way we avoid hemorrhage from the
Sutomaxill'ry gland Lingual artery
Hyoglossus muscle
Superior laryngeal nerve
Common cai otid artery
Platysma — Omohyoid muscle
Temporal fascia
Temporal muscle Temporal artery
Zygomatic arch
Masseter muscle
Digastric muscle
Auricularis magnus nerve External jugular vein Sterno-mastoid muscle Accessory nerve Internal jugular vein Common facial vein Hyoglossal nerve Major cornu of the hyoid bone
3 Descending branch of the — 1 hypoglossal nerve Vagus nerve
Common jugular vein Sterno-mastoid muscle
deeper temporal vessels and most certainly strike the spot on the squamous portion of the temporal bone under which the artery lies. The bone here is very thin.
There are two more points on the skull which we may either avoid in trephining or oftener purposely expose, namely, the
^ In Fig. 25 the anterior incision is drawn somewhat too low in its anterior
half.
56
OPERATIVE SURGERY.
frontal sinus and the antrum with the mastoid cells. Accumu- lations of pus in these cavities form the most frequent indica- tions for their opening.
12. Trephining of the Frontal Sinus (Figs. 26 and 27). — • After shaving, the incision is carried in a curve through the eyebrow down to the bone as far as the median line. The upper
( Supra-orbital artery ■< Supra-orbital nerve ( Frontal nerve
j Frontal sinus ( Ethmoidal sinus
( Infra -orbital nerve ( Supramaxillary nerve
Fig. 26.
edge of the wound together with the detached periosteum is vigorously drawn upward. The incision divides the frontal and supra-orbital nerves and the artery of the same name ; but, what is much more important, it avoids the branches of the facial extending to the frontal muscles, the corrugator, and the orbic- ularis. Earely an additional vertical incision is required ; this is carried obliquely upward alongside the median line. At the
THE SKULL.
57
inner end of the superciliary arch, after hfting the flap of skin and periosteum with tlie elevator, the sinus is opened with the chisel. The anterior wall contains diploe ; hence some hemor- rhage should be expected from its abundant vessels. The pos- terior wall is formed by the vitreous layer alone. Under the an-
Frontal sinus
Frontal nerve
Supra-orbital nerve
Supra-orbital artery
Supra-orbital margin
Orbicularis muscle
Orbicularis muscle •y,'"i^ Zygoma — qfr Infra-orbital nerve Masseter muscle
Fig. ir.
terior bony wall is the thin mucous membrane, w^hich may be much thickened in the case of suppuration. After it is de- tached a probe can be carried backward and downward from the sinus into the nasal cavity beneath the anterior end of the mid- dle turbinated bone, and after forcible dilatation v/ithout cutting, a permanent drainage tube may be carried to the same point. 13. Trephininfj of the Mastoid Process (Figs. 28 and 20). —
58
OPERATIVE SURGERY.
The surgeon is frequently called upon to open the hony cavities of the mastoid process.
As the drum cavity communicates with the mastoid antrum and the mastoid cells, infectious materials are apt to be carried there ; stagnation favors their development, they attack the thin
Total resection of I ■ the upper maxilla )
Incision into the mu- 1 cous membrane for V the mental nerve )
Transverse incision of the cheek
Inferior lateral pharyngotomy
Fig. 28.
Orbital nerve Auricular incis'n Mastoid antrum Lateral ventricle Transverse sinus
J Trephining of the 1 cerebellum
Facial nerve Buccinator nerve
bony walls, and extend to the exernal and internal periosteum. Starting from the external periosteum a phlegmon forms behind the auricle. The internal periosteum is the dura mater and periostitis here is identical with pachymeningitis. This leads to the formation of cerebral abscesses in the temporal lobe or the cerebellum, to basilar meningitis, or to phlebitis of the trans- verse sinus, according to the point where the otitis passed into mastoid osteitis.
In opening the mastoid process we aim first at the mastoid
THE SKULL.
59
antrum as the cavity which is earliest involved from the drum cavity in accordance with the direct communication. While egress may be given to pus from the drum cavity by an in- cision into the membrana tympani, an artificial passage outward must be made for the mastoid antrum, whose anterior opening
Temporal ridpo
(Trephine openin;? for puncture of < the lateral ventricle and for otitic ( cerebral aliscess
Trephin'e: of the mastoid antrum
Spina supra nieatuni
Trephining of the transverse sinus
Trephining of the cerebellum
Eesection of the lower maxilla
Fig. 23.
lies higher than the base of the cavity. This is still more nec- essary for the more deeply situated mastoid cells.
In exposing the cavities of the mastoid process, any unnec- essary opening of the skull cavity is to be avoided, especially lesion of the transverse sinus and the facial canal or nerve.
In order to reach the mastoid antrum surely by the most direct road without incidental injuries it is necessary to expose the entire process by a large incision. The latter is made par- allel to the posterior margin of the auricle, the jDeribsteum is
60 OPERATIVE SURGERY.
pushed away as far as needed forward and backward, so as to expose the bony process. The spina supra meatum behind and above the bony auditory meatus serves as a guiding-point for the application of the chisel which niust penetrate vertically, i.e., in a median direction. At a depth of about li cm. the mastoid antrum is opened. Downward and somewhat back- ward of this we strike the mastoid cells by chiselling away the superficial layers of bone as far as the point of the process. In this way all the mastoid cells can be exposed. By deviating forward from the direction indicated, or by penetrating deeper into the bony auditory canal, we strike the facial canal. By deviating backward we strike the transverse sinus, and higher up we open the cavity of the skull (Figs. 28 and 29), and above the base of the pyramid of the petrous bone we come to the pos- terior part of the temporal lobe of the brain through which the lateral ventricle may be opened at its lowest point. When suppuration has extended in any of these three directions this course is purposely followed.
14. Trephining of the Cerebellum (Fig. 29). — This is per- formed below the superior linea nuchse behind the mastoid pro- cess, by means of a transverse incision down to the bone along that line. The muscles here attached (posterior end of the sterno-cleido-mastoid, splenius, longus capitis) are turned down with the periosteum, and the crown of the trephine is applied back of the mastoid process. The minor occipital nerve is di- vided, the major occipital nerve and the occipital artery are lifted and turned down with the soft parts.
F. The Face.
The condition of the skin of the face differs from that of the skull in being looser, but it is likewise exceedingly vascular. Hence we must be prepared for spurting arteries even in the cutaneous incision. Most of the vessels lie beneath the cutis.
As to the direction of the incisions the same rules apply as
THE FACE. 61
were given for placing normal incisions in general. The first care in operations on the face should be to avoid the facial nerve ; incisions must be chosen which run parallel to the branches of this nerve, for every injury to it means deformity.
It matters very much less when an arterial twig is severed than when ever so small a nerve is cut. Accordingly the in- cisions will be so placed as to radiate from the point of entry of the facial nerve into the parotid as a centre. In this w^ay we guard against disturbances of facial expression. Of course a portion of the vessels will thus be cut across. On the other hand the normal incisions coincide with the direction of Steno's duct to w^hich they are parallel. The muscles must be divided in part. In general, however, division of muscles is avoided and the direction of their interstices is j)referred, because wounds of muscles heal badly after infection. The latter factor no longer enters into the question under asepsis; with it we may obtain a rapid cicatrization of the muscle with complete restoration of its function, provided the afferent nerve twigs have been left intact.
In our operative surgery we always come back to this point : rather divide even a strong muscle (as for instance the rectus abdominis) and produce an artificial inscriptio tendinea than injure the afferent nerves, and thus cause paralysis and atrophy of the muscle. The chief artery of the face is the external maxillary,
15. Ligature of the External Maxillary Artery. — The point of ligature of this artery can be exactly determined : it passes up over the edge of the jaw, precisely at the anterior margin of the masseter muscle, accompanied by the anterior facial vein, whose course is not quite constant. An incision is made through the skin and platysma at the anterior edge of the masseter, parallel to the margin of the maxilla, and the artery is dissected out with careful avoidance of the marginal branch of the facial nerve which passes along the border of the maxilla.
62 . OPERATIVE SURGERY.
16. Operations on the Nose and the Nasal Cavities. — Pene- tration into the nasal cavities through the nostrils finds no ap- plication in serious nasal affections such as the deep inflamma- tions or malignant neoplasms. In such diseases the interior of the nose must be made directly accessible to palpation and in- spection.
A simple method for this purpose is furnished by the split- ting of the nasal septum recommended by us. The blades of a strong pair of scissors are passed into both nostrils as far as pos- sible and the cartilaginous septum is divided; this causes the small arteries of the septum to spurt. Then the finger can be easily introduced into the nose and the walls palpated. In ozgena this manipulation suffices to render further procedures clear, especially to find circumscribed disease of the bones and to remove affected pieces of bone. Two sutures suffice to effect so exact a coaptation that no sign of the operation remains.
17. But if a view into the nose is desired further access must be gained. This is obtained by a division of the nose by means of a median section (see Nasal incision, Fig. 7). But the division should not be made exactly in the middle, because the nasal cartilage shows a depression at its most prominent part and the cicatricial retraction after exact median division marks the above-named depression externally, thus leading to no in- considerable deformity. Therefore the cartilage and nasal bones are divided slightly to one side of the median line, thus securing a cicatrix which later is hardly visible. When, after the ante- rior division, the frontal process of the upper maxilla and the base of the nasal bone are chiselled through past the lachrymal sac and upward from the pyriform aperture, one-half of the nose can be turned over and a good view is obtained throughout the entire cavity in question.
Another method is the lateral division of the nose (see Fig. 28). When the disease is situated laterally and extends to the upper maxilla, the incision is carried only around the ala nasi
THE FACE. G3
and upward in its groove, either merely along the osseous pyri- form aperture, when the loosened half of the nose is turned over toward the centre, or the incision is carried, higher, the chisel being used to split the frontal process of the maxilla upward and the nasal bones transversely. This procedure gives free access to the anterior portion of the nose. By this means tubercular ulcerations may be subjected to a very exact local treatment. Of course, the method has the disadvantage that it destroys the function of some muscular fibres, namely, the nasal muscle which springs from the alveolar margin of the upper maxilla and goes to the dorsum and ala nasi, and the levator alse nasi. Yet as the divided muscles may be made to heal by first inten- tion and the afferent nerve fibres remain partly intact, no mate- rial disturbance of the expression results. When correctly su- tured, the cicatrix becomes in a short time invisible. Of the vessels, the alar branches of the angular artery are divided ; the latter artery is to be preserved in the upper portion of the in- cision. If a deeper view into the nasal passages is desired than can be gained by the above method, a partial osteoplastic resec- tion of the upper maxilla may be made (see Fig. 28), and the inner, anterior, and a portion of the upper wall of the maxillary sinus turned outward, when inspection can be carried to the choanse. Further details will be found among the methods of resection of the upper maxilla.
Another way of obtaining free access to the posterior portion of the nasal cavity consists in division of the hard and soft jDal- ate by a median incision. The mucous and periosteal tissues are detached toward both sides and the horizontal plate of the l^alate with a portion of the vomer is chiselled out (Gussen- bauer). By this means we expose the most posterior part of the nasal cavity as far as the upper pharynx, and tumors of the base of the skull (fibromas and fibro-sarcomas) can be removed under thorough control. In a case recently operated on for re- lapsing sarcoma of the base of the skull and the posterior roof of
64 OPERATIVE SURGERY.
the nose, we gained a very full view of the field of operation by splitting of the upper lip, transverse separation of both alveolar processes from the upper jaw, and median division of the hard and soft palate, while the subsequent disfigurement was trifling. '
18. For opening the cavities of the sphenoid bone the above- mentioned method of Gussenbauer is the most appropriate. The sphenoid cavities open into those of the nose at the posterior margin of the upper turbinated bodies. They can be opened at the upper circumference of the choana between the posterior margin of the middle turbinated body and the ala of the vomer, by perforating the roof of the nose with a narrow sharp spoon.
Through the opened nasal cavity, under the anterior end of the lower turbinated body, 1^ cm. behind the margin of the pyriform aperture, we reach the naso-lachrymal canal beneath the middle turbinated body; 2|- cm. behind the same margin in a lateral direction we strike the antrum of Highmore; above this opening, beneath the same turbinated body, a probe can be carried into the efferent duct of the frontal sinus. The direction of this latter canal, as well as that of the nasal duct, is about parallel to the lateral margin of the pyriform aperture.
Another operation for exposing the nasal cavities without injuring the facial nerve is an incision from the sublabial mu- cous membrane. Without touching the face, the mucous mem- brane is detached at the junction of the gums with the upper lip, the attachment of the cartilaginous nose to the pyriform aperture is divided, and the whole of the soft parts (nose and cheek) is turned up to the eyes (Rouge) ; if the septum is di- vided in addition, the entire nasal cavity is accessible from in front. This operation has the advantage of leaving absolutely no deformity, but it causes profuse hemorrhage.
19. Free Exposure of the Antrum of Highmore {Maxillary Sinus). — One method of reaching the antrum we have learned
^ Dr. Lanz will furnish a more minute description of this method of opera- tion.
OPERATIONS ON THE NERVES OF THE FACE. 65
in connection with exposure of the nasal cavity. Even when ample exposure is desired it is customary to avoid an external incision and to proceed through the mucous membrane, either from the mouth or from the nose. The antrum frequently con- tains jjurulent foci after prolonged inflammations, and therefore we are often called ujDon to open the maxillary sinus perma- nently. The point from which access is most readily gained for the purpose of free exposure and careful examination is the canine fossa. We lift the upper lip, divide the mucous mem- brane and periosteum at the point of flexion above the root of the three anterior molars, lift the periosteum upward and out- ward with the elevator to below the infra-orbital foramen, and cut through the thin bony wall with the hollow chisel. The two strong bony ridges beside the canine fossa, namely, the frontal process and the edge of the zygoma, are left intact.
A second mode is an upward opening with a perforator through the alveola of a missing or drawn tooth, preferably the third or fourth molar.
20. A third method of opening the antrum without a cuta- neous incision is from the nose. The thin median wall of the sinus is perforated exactly below the middle of the lower tur- binated body from the lower nasal fossa, with a curved-pointed instrument (Mikulicz). This method has the advantage that the pus does not escajDe into the mouth, but into the nose. Its drawback is that it does not open the lowest part of the antrum as do the operations through the mouth. The two last-men- tioned methods do not permit direct inspection, or palpation of the antrum with the finger. But this is possible in opening- through the canine fossa.
Operations on the Nerves of the Face.
21. The Facial Nerve (see Fig. 22). — The surgeon is called upon to expose the facial nerve in order to protect it during operations in the retro -maxillary fossa, as in excision of swollen
66 OPERATIVE SURGERY.
lymphatic glands and tumors of the parotid. Besides, the facial is occasionally exposed in order to stretch it in cases of spasm of the facial muscles. The guiding points for the incision are the anterior margin of the mastoid process and the posterior margin of the maxilla (Hiiter, Lobker, Kauf mann) . The lobe of the ear is divided at its anterior edge as far as the auricle along the point of attachment ; this incision is prolonged down- ward to behind the angle of the jaw; the point where the facial nerve comes forward corresponds about to the middle between the angle of the jaw and the zygomatic arch. The skin and the parotid-masseteric fascia are divided, the parotid is exposed at its posterior margin and completely drawn forward. The ten- dinous fibres of the attachment of the sterno-mastoid muscle are then visible and along them the incision is carried deeper at the anterior circumference of the mastoid process. The facial nerve is seen 1 cm. deeper, where it emerges from the stylomastoid foramen toward the surface.
The Trigeminus Nerve. — The main indications for exposure of the fifth cranial nerve are neuralgias. For finding its first branch see "Ligature of the Supra -Orbital and. Frontal Artery," pp. 34 and 35, Figs. 26 and 27.
22. The Second Branch of the Trigeminus (see Figs. 30 and 31). — The main branch of this nerve, which is most frequently attacked by neuralgia, is the infra -orbital. In order to stretch it the mucous membrane at the point of transition of the upper lip may be divided from the mouth as far as the canine fossa. Having reached the periosteum, this is lifted upward to the infra-orbital foramen. One-half centimetre below the middle of the infra -orbital margin the nerve can be exposed and stretched with an aneurism needle and vigorously drawn for- ward with the finger.
A very good method, though it requires an external incision, is the following : Incision in the course of our normal upper maxillary incision (Figs. 12 and 13), beginning 0.5 cm. below
OPERATIONS ON THE NERVES OF THE FACE.
67
the median end of the infra-orbital margin, extending some- what obliquely downward and outward to the most prominent part of the zygoma so as to strike the zygomatic muscle at its origin, and spare the branches of the facial supplying the mus- cles below and the orbicularis oculi. The incision goes down to
Masseter muscle Zygomatic muscle
' Quadratus labi; superioris muscle
Infra-orbital nerve.
Fig. 30.
the bone and divides the attachment of the quadratus labii superioris muscle. The periosteum is turned down as far as the point of emergence of the nerve from the infra-orbital canal, where it is to be isolated from the infra-orbital artery and an aneurism needle passed around it. Above, the perios- teum is turned back over the infra-orbital margin and from the floor of the orbit until the beginning of the infra-orbital canal
68 OPERATIVE SURGERY.
is felt or seen (Wagner) ; then the thick upper wall of the canal is chiselled out with two blows of the instrument. In this way the nerve can be exposed, stretched, or resected for a consider- able distance. If the antrum of Highmore has not been opened, the wound will certainly heal by first intention, without result- ing deformity ; this is, however, the rule even after opening the antrum.
If, however, a permanent result is to be obtained in opera- tions for neuralgia, the second branch of the trigeminus must be resected at the foramen rotundum. For the infra-orbital nerve subdivides into the orbital and the superior posterior alveo- lar before it enters the orbit, and the trunk of the second branch of the trigeminus, the supra-maxillary, gives off in the spheno- palatine fossa, besides the infra-orbital, the spheno -palatine nerve which passes downward to the nasal ganglion. The latter branch is not to be found isolated, but some of the twigs of the infra- orbital can be.
23. Resection of the Orbital (Zygomatic) Nerve (Fig. 30). — Incision 1 cm. long at the outer margin of the orbit, running obliquely outward and downward, beginning near the outer canthus and extending to the bone. The periosteum is detached from the lateral wall of the orbit, and with it the nerve is torn from its point of entry into the orbital surface of the zygoma.
The superior alveolar nerves have been isolated in the fol- lowing manner (von Langenbeck). After lifting the lips a large incision is made over the teeth down to the bone, and the saw or chisel divides the lateral wall of the antrum with the mucous membrane from the nasal cavity to the pterygoid process.
24. In proportion as operations for neuralgia are limited to the division of peripheral branches the prospects for perma- nent recovery become less. When, however, the supra-maxillary nerve is exposed at the foramen rotundum (Figs. 12, 13, 30, and 31), the only branch missed is the recurrent supra-maxillary
OPERATIONS ON THE NERVES OF THE FACE.
69
passing to the dura mater. On the other hand, this central operation has the drawback of causing paralysis of the motor branches of the facial for the palatal muscles, which enter the nasal ganglion and join the palatal nerve through the Vidian. The foramen rotundum is reached with difficulty. Von
Roof of the antrum {
of Highmore (
Floor of the orbit
Attaching fibres of /
niasseter muscle (
Posterior surface )
of the zygoma \
Intra-orbital nerve
Antrum
Orbicularis muscle j Supra-maxillary / nerve
Orbital fat
Fig. 31.
Langenbeck inserts a tenotome at the external orbital margin under the external palpebral ligament. This method has been abandoned because it does not guard against incidental injuries and wounds the infra-orbital artery. For this reason resection of the zygoma is now generally practised (Liicke, Lossen, Braun). On the principle that all incisions are incorrect which run across the branches of the facial, we proceed in the follow- ing manner. Incision as for exposing the infra-orbital nerve
70 OPERATIVE SURGERY.
(see Figs. 12 and 13), but longer, i.e., beginning 1 cm, in a median direction from the palpable infra-orbital foramen, run- ning somewhat obliquely downward, but mainly horizontally outward over the lower part of the zygoma to the anterior edge of the masseter muscle. At the inner end of the incision the angular artery and at the lateral end the transverse artery of the face are drawn down or ligated; Steno's duct remains below. At the median end the incision passes down to the bone between the lower margin of the orbicularis oculi muscle and the origin of the quadra tus labii superioris ; the former muscle is lifted off with the periosteum as far as the orbit, the latter is detached under the periosteum until the infra-orbital nerve is exposed, where it emerges from the canal of the same name and can be grasped with an artery tenaculum.
The lateral portion of the incision passes above the attach- ment of the zygomatic muscles to the anterior edge of the mas- seter. The former are divided at their origin, and the foremost portion of the attachment of the masseter to the lower and inner surface of the zygoma is detached.
The body of the zygoma is freed inward and outward in a vertical direction by means of an elevator (Fig. 27) so as to be chiselled through. The zygomatic process of the upper maxilla is freed at its anterior surface to the infra-orbital foramen, at its posterior surface to the inferior orbital fissure so that the upper wall of the infra-orbital canal can be lifted with it, and the infra -orbital nerve drawn with a hook in a median direction through its entire length. Then the upper maxilla is chiselled through so that the orbital plate and the lateral wall of the antrum together with its posterior angle remain in connection with the zygoma and can be lifted with it.
In order to effect luxation of the zygoma, the connection of the frontal bone with the zygoma is exposed by a small incision (see Fig. 30), and the chisel carried through to the posterior part of the inferior orbital fissure so that it is possible to remove
OPERATIONS ON THE NERVES OF THE FACE. 71
simultaneously also its upper border, namely, the crista zygomat- ica and orbitalis of the sphenoid bone. The zygoma is luxated ujDward and outward from the large wound by means of a strong, sharp hook, the orbital fat is carefully lifted with a blunt hook, and then it is easy to follow the tense infra-orbital nerve across the gaping Highmorian cavity to the foramen rotundum, and to introduce a small hook, behind the spheno-palatine nerve which runs vertically downward, around the main trunk and to divide it, or tear it as Thiersch does. The infra-orbital artery is torn when the zygoma is detached and luxated ; the hemor- rhage is arrested by tampons. At the end of the operation the zygoma is replaced. No bone sutures are needed for its fixa- tion. Then the cutaneous wound is closed. The cicatrix causes absolutely no disfigurement.
The third branch of the trigeminus (Figs. 32 and 33) at the foramen ovale contains both portions, namely, the motor (pos- tero-externally) and the sensory, so closely intertwined that they cannot be separated. Hence a central division of the nerve has the drawback of an incidental injury which is not intended, namely, unilateral paralysis and atrophy of the muscles of mas- tication. Fortunately experience (our own included) shows that this unilateral paralysis per se does not seriously limit the func- tion of the maxilla ; it merely lessens the force of the closure of the jaw and the amplitude of the lateral motions. Still the above drawback connected with the division of the trunk at the foramen ovale would justify the attempt to stretch or divide only single branches in neuralgia, despite the uncertainty of the result.
Particularly the lingual and the alveolar nerves are fre- quently the seat of neuralgias, especially the latter in its course through the infra-maxillary canal, from which it again emerges as the mental nerve. Besides we occasionally meet with neur- algias in the auriculo-temporal and the buccinator nerves which supply the region of the angle of the mouth.
72 OPERATIVE SURGERY.
The inferior alveolar nerve (Fig. 28) can be rendered acces- sible at different points.
25, If the terminal branch alone, the mental nerve (Fig. 28), is sought, the lower lip is vigorously pulled away from the maxilla, the mucous membrane is incised vertically at its turn- ing-point under the interstices of the first and second premolar teeth of the lower jaw, the periosteum is divided, and the nerve is seen to emerge from the mental foramen. Usually, however, the seat of the neuralgia is higher up in the region of the teeth. Hence the nerve must be exposed before it enters the infra- maxillary canal. To reach it there two methods have been chiefly employed.
26. Inferior Alveolar Nerve (Fig. 29). — a. Trephining of the ascending ramus by an incision at the margin of the angle of the jaw. But at this very point run the branches of the facial which supply the muscles of the chin and lower lip. Hence the angle of the jaw must be approached by a curved incision, the marginal branch being withdrawn and the facial carefully dissected out (compare the posterior part of our nor- mal incision for the upper cervical triangle, Fig. 29). Then the fibres of the masseter are partly detached upward from the maxilla by means of the elevator without cutting, the muscle together with the upper margin of the wound is held up with a blunt hook, and a piece of bone is chiselled out exactly in the middle of the ascending ramus (Velpeau, Linhardt), Thus we reach at the inner surface of the maxilla the point of entry of the nerve. This method is very exact and we are sure of strik- ing the nerve. If healing ensues by first intention, the func- tion of the maxilla remains unimpaired.
h. Paravicini's method. The mouth being opened wide (White's speculum), we palpate at the anterior margin of the ascending ramus of the jawbone its sharp inner edge upon which we divide the mucous membrane and periosteum down to the bone. The inner margin is sufficiently detached subperi-
OPERATIONS ON THE NERVES OF THE FACE. 73
osteally with a blunt instrument from the inner surface of the ascending ramus until the lingula is felt as a pointed projection at the inner circumference of the infra-maxillary canal. Be- hind this the nerve is sure to be found. The operation is ex- ceedingly simple and far less serious than that from without; but it has the drawback of necessitating a wound in the mouth which possibly may be infected, while in operations from with- out infection can be positively prevented. The slower- heal- ing of an infected wound, and the fact that the internal liga- ment is attached at the lingula, may have the consequence that the opening of the mouth is for some time interfered with.
27. The lingual nerve can be exposed after Paravicini's in- trabuccal method. The following procedure is simpler. At the point where the nerve passes forward between the anterior pala- tine arch and the base of the tongue it is situated very super- ficially under the mucous membrane. Therefore only a small longitudinal incision is needed to expose it with certainty. The opening should not be too near the tongue. The transverse division of the cheek after Roser is not a necessary preliminary. The operation has the disadvantage that a wound is made inside the oral cavity.
In order to avoid this, the attempt has been made to expose the nerve from without and below at the point where it passes above the submaxillary gland. The incision (part of our nor- mal incision for the upper cervical triangle) at the neck simply exposes the submaxillary gland at its lower margin. The gland is turned upward and the nerve is grasped at the j)oint where it is in connection with the submaxillary gland through the lingual ganglion. The operation is far more difficult than the former, but it has the advantage that healing by first intention is certain to be obtained. Thirdly, the nerve can be found, like the inferior alveolar nerve, by trephining of the ascending ramus of the maxilla.
74
OPERATIVE SURGERY.
28. The auriculo -temporal nerve (see Figs. 10 and 11) is exposed at the posterior surface of the temporal vessels under which it passes upward. A longitudinal incision from the root of the zygomatic arch upward through skin and fascia renders the thin nerve trunk accessible.
29. The buccinator nerve is the sensory nerve for the region
Fat
aporal muscle jomatic arch
ttachment of the masseter
Fig. 32.
of the angle of the mouth. It lies at the inner side of the cor- onoid process of the lower maxilla. The nerve can be grasped at the anterior margin of the process, both in operating from without and from within. The operation from within is more simple. After opening the mouth wide, the edge at the an- terior margin of the process named is felt without difficulty ; we cut down upon it, dividing the mucous membrane and the fibres of the buccinator muscle. The nerve passes transversely for- ward upon the process.
The operation from without (Zuckerkandl) is effected by an
OPERATIONS ON THE NERVES OF THE FACE.
75
incision below the zygomatic arch and bone, extending forward from the anterior margin of the masseter in a horizontal direc- tion above Steno's duct, the transverse facial artery being left intact (Fig. 22) ; at the anterior margin of the masseter we strike the mass of fat of the cheek ; after this is pushed aside or removed, we reach the anterior margin of the coronoid process
i External surface of the I sphenoid bone
i External surface of the ' temporal bone
Crista iufra-temporalis Infra-maxillary nerve
Cut surface of I
the zygoma C
Temporal muscle
( Attachment to the zy- -. g-omaJc arch of the ( massetfr Zygoma drawn down
Fig. 33.
on the inner side of which the nerve passes forward upon the fibres of the buccinator muscle.
30. Infra- Maxillary Nerve. — All operations on the branches of the third trunk of the trigeminus are so often followed by relapses that nothing is left but to look for the third trunk of the trigeminus at the foramen ovale (Figs. 24, 25, 32, 33). This operation is most certain in its results if the zygomatic arch is resected (Lilcke, Braun, Lossen, Kronlein).
We adhere to the rule that here, too, only those incisions must be made which avoid injury of the branches of the facial nerve.
76 OPERATIVE SURGERY.
The incision begins behind the frontal process of the zygoma and is carried obhquely downward as far as the posterior end of the zygomatic arch. From the posterior end of this incision another one is carried down to the bone at a right angle, rising obliquely backward in front of the ear (ligature of the temporal artery and vein). We divide the skin, some fibres of the orbi- cularis, and the tense temporal fascia, which is drawn down, together with the branches of the facial nerve supplying the eye and forehead. Immediately behind the ascending frontal pro- cess of the zygoma the latter is now exposed in a vertical line within and without, and chiselled through. At the posterior end of the zj^gomatic arch its root is likewise divided close to its origin, and the arch drawn down with a strong hook.
The outer surface of the temporal muscle, covered with fat, is now laid bare. This muscle is lifted from the skull by its posterior margin and drawn vigorously forward with a blunt hook. Only if the access gained is insufficient is the attach- ment of the muscle at the coronoid process divided, or else the point of this process is severed with cutting forceps when prop- erly isolated (Kronlein). It is not a matter of special impor- tance that the muscle be spared ; but detachment diminishes the injury as compared with cutting, and gives a clearer field of operation. Then the periosteum - along the crista infra-tem- poralis is divided from the anterior edge of the origin of the zygomatic arch at the temporal bone and all the soft parts to- gether are lifted subperiosteally from the lower surface of the skull in a median direction. Thus we reach without further injury the outer surface of the base of the pterygoid process, and behind its sharp posterior edge the foramen ovale is dis- tinctly palpable, about 3 cm. deeper than the temporal origin of the zygomatic arch. Occasionally there are two openings from which the nerve emerges. The large arteries, branches of the internal maxillary, remain in the soft parts which have been turned down, with the exception of the middle meningeal which
OPERATIONS ON THE NERVES OF THE FACE. 77
lies posteriorly. The zygomatic arch is replaced and fastened, and the resulting cicatrix is almost invisible. It is unnecessary to resect the zygoma, in addition, at its orbital plate or as far as its junction with the upper maxilla, for no more room is gained thereby for the isolation of the nerve.
31. Resection of the Upper Maxilla (see Figs. 22 and 23). — If the surgeon is to have courage enough to perform pnv- tial or total resection of the upper maxilla with the necessary thoroughness in the early beginning of malignant new-forma- tions, that is to say, to expose the diseased i3art so perfectly that all suspicious tissues can be removed, he requires to be ac- quainted with operations which are not followed by serious dis- figurement. Especially facial expression should not be injured unnecessarily. The aim, therefore, is not only to secure small cicatrices, but the facial muscles and particularly their motor nerves must be kept intact. In order to attain this, the follow- ing procedure is to be recommended. A median incision is made (see Fig. 22) which passes upward beside the filtrum from the slight depression in the upper lip into the nostril, from the nostril close around the ala nasi, along the jDyriform aperture obliquely upward and in a median direction to the junction of the nasal bone with the upper maxilla as far as the height of the inner canthus or to the root of the nose. In this way only the levator alse nasi is divided, which is of no consequence in facial expression.
Should the incision described prove insufficient to permit a good view, it may be enlarged as follows. Entering between the upper and the lower fields supplied by the facial nerve, a transverse incision is added which runs laterally and slightly downward, from the lower margin of the orbicularis oculi mus- cle across the attachments of the quadratus labii superioris and the zygomatic muscles (our normal upper maxillary incision below the infra-orbital margin. Fig. 22). The entire flap to gether with all the healthy soft parts and nerve twigs is turned
78 OPERATIVE SURGERY.
outward and the bone or the tumor laid bare. By grasping the base of the turned flap sufficient compression can be exerted and the vessels easily and safely ligated (angular, labial, and infra- orbital artery, possibly the transverse facial) . Immediate, thor- ough arrest of hemorrhage is an eminently important factor in operating correctly. For this reason and the loss of blood in general, a preliminary ligation of the external carotid artery is to be highly recommended in resection of the upper maxilla and renders the operation much cleaner and easier.
The upper maxilla is then freed from its attachments. With the chisel or cutting forceps we divide, in extensive disease, the frontal process of the upper maxilla together with the nasal iDone from the upper part of the pyriform aperture backward, passing through the lachrymal and ethmoid bones to the pos- terior end of the inferior orbital fissure, in the course of which no serious injuries are inflicted. For the connection of the upper maxilla with the zygoma we make the division, according to the indications, either at the point just named, or else the zygoma is removed altogether with a vigorous blow of the chisel, after dividing the zygomatic arch and the frontal process of that bone through a separate small incision. During this step the wound margins must be drawn vigorously aside with sharp hooks. There remains the third connection with the upper maxilla of the opposite side. The chisel is applied medi- ally between the incisors, and the plate of the palate throughout its entire length is cut, after the mucous membrane and perios- teum of the palate at the limit of the disease has been divided down to the bone and the soft palate, too, separated transversely from its attachments, with the knife or, better, the thermo- cautery.
Lastly we have the connection with the pterygoid process. If the flap is vigorously drawn back, the soft parts can be divided from without as far as this process, with the necessary control of the hemorrhage, i.e., mucous membrane, buccinator,
OPERATIONS ON THE NERVES OF THE FACE. 79
external and internal pterygoid muscles; then the bony process is cut from without with the chisel, the flap containing the soft parts being drawn out of the way. Where this bone is not to be removed its connection with the maxilla is broken by draw- ing the latter strongly downward ; this should be done quickly so that the bleeding may be arrested. For during this act the large terminal branches of the internal maxillary artery are torn (the spheno-palatine, pterygo-palatine, and infra -orbital arteries).
32. Less radical is the osteoplastic total resection of the upper maxilla, during which the jaw is bent out and again replaced. This operation is indicated in tumors of the base of the skull (os basilare and its neighborhood), especially in retro- maxillary tumors, when sufficient room cannot be gained by Gussenbauer's method of dividing the soft palate and chiselling out the hard palate. The difference between this and the pre- ceding operation consists in the fact that after the cutaneous incisions the soft parts are not detached from the bone; but, the bony connections having been severed, the maxilla is bent over laterally together with the soft parts. The frontal process of the zygoma must be severed through a special oblique inci- sion, in like manner as in the above -described method of resec- tion of the supra-maxillary nerve at the foramen rotundura (see Fig. 30).
For exposing the retro-maxillary fossa use is made of the method of resection of the zygoma described in connection with the division of the second trunk of the trigeminus.
When only the nasal cavity, alone or with the antrum of Highmore, is to be rendered accessible, a partial osteoplastic resection of the upper maxilla (Fig. 23) suffices and is performed as follows. Cutaneous incision as for resection of the upper maxilla, except that the upper lip is not split (Fig. 28), that is to say, from the nostril around the ala nasi up to near the inner canthus and beneath the infra-orbital margin across to the .zygoma.
80 OPERATIVE SURGERY.
Starting from the upper end of the pyriform aperture the parts are severed in the following order: First the connection of the nasal bone, laterally the junction of the latter and of the frontal process of the upper maxilla and that of the lachrymal bone with the frontal bone, then obliquely backward and down- ward the orbital plate of the cribriform bone as far as the infe- rior orbital fissure, by means of the bone forceps or a fine chisel. From the lowest portion of the pyriform aperture the chisel divides the median and anterior wall of the antrum to the infra- orbital canal ; finally backward along the latter the orbital plate of the upper maxilla, from the horizontal cutaneous incision. Then the bones with the soft parts can be turned outward, thus exposing as a single space the nasal cavity and that of the antrum of Highmore.
We have stated in connection with the nasal operations (p. 63) how by a simple cut through the upper lip and a median incision through the hard and soft palate, the two halves of the upper maxilla can be opened and the base of the skull rendered accessible.
33. Eesection of the Lower Maxilla. — This operation is a simple one, but even here unnecessary disfigurement due to lesion of the oral branch of the facial, especially its marginal ramus, should be avoided.
As the simplest may be recommended the median incision (Fig. 23), v/hich divides the lower lip and eventually extends to the middle of the hyoid bone. This incision alone gives ample room in disease of the middle portion and a large part of the horizontal rami of the lower maxilla. In disease affecting the region of the angle of the jaw and the ascending ramus, and when it is necessary to expose and clear the submandibular fossa of malignant new-formations, a lateral incision is added. This should not be placed, as is often done, at the margin of the maxilla, on account of the branches of the facial passing there ; but it should be carried from the hyoid bone, extending back-
OPERATIONS ON THE NERVES OF THE FACE. 81
ward and upward in the fold between the floor of the mouth and the neck, the width of the thumb behind and below the angle of the jaw, if necessary as far as the tip of the mastoid process (compare our normal incision for the upper cervical triangle. Fig. 29). The flap limited by these incisions is turned up and fastened to the skin of the face with sutures. Withal the surgeon must keep as close as possible to the bone, and detach the muscles with the flap (anteriorly the mental, trian- gulai'is and quadrangularis mentis muscles, posteriorly the buccinator and masseter). On the inner surface of the maxilla the muscles detached are, anteriorly the digastric, genio-hyoid, mylo-hyoid, and genio-glossus, posteriorly the internal ptery- goid.
Before the muscles are detached it is proper to saw through the maxilla in front so that it can be vigorously drawn forward and the soft parts rendered tense. After the muscles and the mucosa are divided the maxilla is drawn down so that the cor- onoid process may be seen and felt. Its point is removed with cutting forceps and thus the attachment of the temporal muscle severed. The head and neck of the maxilla are not freed with sharp instruments, lest the internal maxillary artery be injured ;; but after all the other connections have been divided the head is simply twisted out and the joint capsule and the external pterygoid muscle are torn by torsion. The external maxillary artery has been severed and tied during the turning over of the flap composed of soft parts. When the horizontal portion of the maxilla is sawn through, the inferior alveolar artery is lacer- ated in the infra-maxillary canal and tamponed with a plug of wax; should one-half of the maxilla be totally removed, the artery is ligated in the posterior upper angle of the wound, either before or after the maxilla is twisted off or while the internal pterygoid is detached.
The inferior alveolar nerve is torn or else it is divided when
the internal pterygoid muscle is detached. 6
82 OPERATIVE SURGERY.
In this operation, as in resection of the upper maxilla, it is advisable, as soon as the cutaneous incision has been made, to ligate the external carotid artery above the superior thyroid or possibly above the point where the lingual artery branches off.
34. Osteoplastic resection of the lower maxilla is an impor- tant preliminary operation for exposing the floor of the mouth, the root of the tongue, the isthmus of the fauces, and the tis- sues in the lower pharynx. Satisfactory access is gained to the tissues situated in front of the isthmus of the fauces by the median division of the lip and the lower maxilla. This opera- tion has the great advantage that, if exactly sutured with iron wire, the movements of the lower jaw are not even temporarily hampered to any notable extent, and the fragments knit readily if well coaptated.
For cases requiring division of the maxilla in disease around the isthmus of the fauces and in the pharyngeal tissues situated behind it, the normal procedure is division of the maxilla in front of the ascending ramus. The incision is like that for resection of the lower maxilla, in a line from the mastoid process toward the hyoid bone, the length being adapted to the requirements. After ligature of the internal maxillary artery at the anterior circumference of the masseter the lower margin of the maxilla is exposed, the periosteum is detached forward and backward, the mucous membrane is torn with the elevator, and the bone is divided with the fret-saw behind the molars.
Before this last step it is proper to make one or two drill openings for the subsequent suture with iron wire. The saw should move obliquely so that the external lower side is farther forward than the inner and upper, for the posterior end of the maxilla tends to be displaced medially and upward. The as- cending ramus is now turned upward with a sharp hook, and the anterior portion of the maxilla is drawn forward.
35. The oral and pharyngeal organs can also be made acces- sible without osteoplastic resection of the lower maxilla. An
OPERATIONS ON THE NERVES OF THE FACE. 83
excellent method is the transverse incision of the cheek recom- mended by Roser for exposure of the lingual nerve (see Fig. 22). This incision extends from the angle of the mouth transversely backward, parallel to the branches of the facial nerve, as far as the prominence of the masseter, all the soft parts being divided (skin, orbicularis oris and buccinator muscles, and mucous membrane). Of course this incision leaves a cicatrix with sub- sequent retraction, but the resulting disfigurement is unimpor- tant, since the expression is in no way restricted, thanks to the preservation of all the branches of the facial. Steno's duct and the transverse facial artery remain above the incision, but the external maxillary artery is cut and requires double ligature,
36. Incisions in the Tongue and the Floor of the Mouth. — These should not be made except after thorough opening of the mouth with proper specula (White's), the tongue being drawn forward with a loop of thread intro'duced deeply through its sagit- tal median line. Thorough opening of the mouth presupposes profound anaesthesia, especially if the motion of the jaw is re- stricted by inflammation or other painful infiltration of the soft parts between the upper and lower maxilla or in the region of the latter. Incisions can be made on the dorsum of the tongue without fear of injuring the larger vessels and nerve trunks. The median line is to be preferred, as here the damage is least.
Laterally and on the floor of the mouth are large vessels (the lingual and sublingual arteries and veins), nerve trunks (hypoglossus, lingual, and behind the glosso-pharyngeus), and the efferent ducts of the salivary glands (Wharton's and Eiv- inus'). The closer the incision is kept to the maxilla the more certainly are these structures avoided. Near the lateral margin of the tongue, under the prominence of the lingual muscle and on the outer side of the genio-glossus muscle, the lingual artery and nerve can be exposed. Posteriorly the artery is covered by the fibres of the hyo-glossus muscle. Toward the tip of the tongue the vessels approach the lower surface. Where profuse
84 OPERATIVE SURGERY.
hemorrhage is to be feared from incisions about the tongue a prophylactic ligature of the lingual artery is to be recommended.
G. The Upper Lateral Cervical Triangle.'
The Normal Incision for the Upper Cervical Triangle.
In accordance with our principle to place cutaneous incisions in the direction in which the skin splits naturally, we recom- mend for the exposure of the organs in the infra- and retro- mandibular fossa an incision (Fig. 29) already indicated for resection of the maxilla; namely, passing from the anterior end of the tip of the mastoid process to the middle of the hyoid bone, extending a finger's breadth below and behind the angle of the jaw, and intersecting at this point the anterior margin of the sterno-cleido-mastoid muscle. This incision has the great advantage that it lies on the border line where the muscles coming from above and below meet or end, in so far as they concern the organs within the neck : above, the digastric, stylo- hyoid, genio-hyoid, and mylo-hyoid; below, the sterno-hyoid, thyreo-hyoid, and omo-hyoid. The muscles crossing this border line are either unimportant as the platysma, or they remain at the side or behind as the sterno-cleido-mastoid and the muscles of the vertebral column.
Moreover, this incision enables us to avoid the important nerves in so far as their main trunks lie either above or behind or can be drawn aside, while their branches running up and down radiate from the direction of the incision. Thus the vagus and sympathetic lie posteriorly with the sterno-cleido- mastoid muscle, together with the spinal accessory and the de- scending ramus of the hypoglossal. The inferior branch of the facial, the hypoglossal, the lingual, and the glosso-pharyngeus
' For practical reasons we limit it above by the margin of the lower maxilla, inward by the median line as far as the upper margin of the thyroid cartilage, and backward by the anterior margin of the sterno-cleido-mastoid muscle.
THE UPPER LATERAL CERVICAL TRIANGLE. 85
are above ; the superior laryngeal branch of the vagus is drawn down.
In the third place the incision strikes the points where the branching of the large vessels of the neck begins and, in the main, terminates. At the level of the upper margin of the thyroid cartilage the common carotid divides and immediately above are given off the branches of the external carotid in close proximity. At the same level the anterior and posterior facial veins join the common facial vein, and the latter the common jugular vein. Hence from the normal incision the great num- ber of branches and even the trunks of the larger vessels of the neck can be ligated.
For this reason we designate this incision the normal one for the upper cervical triangle, and all the longer and shorter incisions here required coincide with it.
37. External and Internal Carotids (Figs. 10 and 11). — The point of our normal incision at which we feel the pulsation of the artery and ligate it lies at the anterior margin of the sterno- cleido- mastoid muscle. The margin of this m^^scle ascends much more vertically than it is usually represented ; the fascia draws it forward toward the angle of the jaw. The point for our ligature, therefore, lies a finger's breadth vertically under the angle of the jaw. Here the artery ascends vertically from below. For its exposure we employ a corresponding portion of our normal incision, forward and backward of the point men- tioned. After the skin the platysma is divided, which often forms quite an extensive muscular layer. Its fibres pass up- ward and forward over the margin of the maxilla. In the pos- terior portion of the incision the external jugular vein which passes up exactly over the sterno-cleido-mastoid muscle is not divided but drawn back with the large auricular nerve that runs behind it. By dividing the fascia the anterior margin of the sterno-cleido-mastoid muscle is exposed, and then appears the common facial vein as far as its termination in the common
86
OPERATIVE SURGERY.
jugular vein. The former descends over the digastric muscle. These veins have to be drawn forward and downward; their smaller branches must be ligated. We now strike the external and internal carotid arteries, the latter lying at its origin pos- teriorly and somewhat more superficially, which fact is apt to lead to error. The internal carotid gives off no branches, while
j Temporal artery
( Auriculo-temporal nerve
{ External and internal caro- J tld artery ' J Hypoglossal nerve ( Lingual nerve
Superior thyroid artery —
Vertebral artery 1 Inferior thyroid artery V _ CEsophagotomy )
'^m
Fiox. 34 A.
the external is characterized by a branch, the superior thyroid artery, immediately above its origin. Hence the vessels cannot be mistaken for each other. Moreover, the external carotid, at the point where the external maxillary artery is given off, is surrounded from behind and without by the hypoglossal nerve. The small cleido-mastoid artery bends backward over the nerve. Ligature of the external carotid is not easy, since its guiding- points consist only of soft parts (anterior margin of the sterno-
THE UPPER LATERAL CERVICAL TRIANGLE.
87
cleido-mastoid) which may be displaced with every incision. In exposing the artery we must preserve the descending hypo- glossal branch which supplies the muscles of the sternum and larynx.
Through the same incision we can ligate a large number of the branches of the external carotid at their origin, as the
Hypoglossal nerve Occipital artery
Ext" nal maxillary artery — , Common facial vein — " Submaxillary gland
Lingual artery
Scalenus anticus muscle
Thvroid gland
Inferior thj roid artery
Becurrent laryngeal nerve
Descending branch of the hypoglossal
Zygomatic arch
Temporal artery
Auriculo-temp'l nerve Temporal vein
Internal jugular vein Sterno-mastoid muscle
' j Descending branch of the
hypoglossal
, — Internal carotid artery External carotid artery
Omo h J Old muscle
Sttrnb-mastoid muscle — Common carotid artery — Phrenic nerve
Longus colli muscle
Sterno-hyoid muscle
Fig. 34 B.
superior thyroid, the lingual, the external maxillary, and the occipital artery. The course of these four main branches is sufficiently characterized by their direction, downward, forward, upward, and backward, respectively. For the perijDheral liga- ture of these vessels there are more accessible and more reliable points.
38. Superior Thyroid Artery (Fig. 10) — The ligature of the superior thyroid arter}^ is effected at the tip of the upper cornu
88 OPERATIVE SURGERY.
of the thyroid gland. The incision chosen is thp.t portion of our normal incision which passes from the anterior margin of the sterno-cleido- mastoid muscle to the body of the hyoid bone. The lower edge of the skin wound is drawn vigorously down- ward. Where the superior cornu of the thyroid gland does not rise so high, it is better to make the transverse incision 3 cm. deeper, corresponding to the upper margin of the thyroid carti- lage. The anterior branch of the su^rior thyroid artery, in cases of enlargement of the gland for which alone this ligature comes in question, can always be felt on the median anterior side of the superior cornu, passing downward along the larynx. By following this branch beyond the tip of the upper cornu the trunk of the artery is sure to be found.
39. Lingual Artery (Fig. 35) . — Ligature of the lingual artery is of importance because it supplies a more deeply seated organ in which the arrest of hemorrhage is not always easy. Hence prophylactic ligature is often desirable. The course of the lin- gual artery is well marked, for it passes toward the hyoid bone, with the posterior end of whose large cornu it comes in close proximity.
This point is best for ligation because in most persons the end of the large cornu of the hyoid bone can be felt through the skin and thus furnishes a definite, guiding-point for incisions. We open in the direction of our normal incision from the mar- gin of the sterno-cleido-mastoid muscle along the large cornu of the hyoid bone as far as the body of this bone. The incision divides the skin, platysma, and fascia as if the large cornu of the hyoid bone alone were to be laid bare. When this is done the cornu is seized with a hook and the bone drawn upward ; thereby we secure the great advantage that the entire field of operation is made more superficial. At the thickened posterior end of the cornu the fibres of the hyo-glossus muscle ascend vertically in a characteristic manner. Care is required so that close above the club-shaped end of the cornu no more and no
THE UPPER LATERAL CERVICAL TRIANGLE.
89
less is divided than these muscuh^r fibres. Then the artery ap- pears immediately above that extremity. This mode of Hga- ture we beheve to be the most reliable.
A second method recommended for this ligature is that over the digastric muscle. The incision is made parallel to the large cornu of the hyoid bone; extends through skin, platysma, and
Temporal fascia
Temporal muscle Temporal artery
Zygomatic arch
Masseter muscle
Digastric muscle
SubmaxiU'ry gland Lingual artery
Hyoglossus muscle
Superior laryngeal nerve
Common carotid artery
Platysma
Omohyoid muscle
Auricularis magnus nerve External jugular vein Sterno-mastoid muscle Accessory nerve Internal jugular vein Common facial vein Hyoglossal nerve Major cornu of the hyoid bone
Descending branch of the hypoglossal nerve Vagus nerve
Common jugiilar vein — Stemo-niastoid muscle
•'•-'//</:
Fia. 35.
fascia ; and the lower margin of the submaxillary salivary gland with the anterior facial vein is drawn forward. In the angle formed by the upper margin of the digastric and the stylo-hyoid muscles with the posterior margin of the mylo-hyoid, the artery lies under the ascending fibres of the hyo-glossas muscle. On the external surface of this latter muscle lies the hypoglossal nerve and often one of the lingual veins.
90 OPEKATIVE SURGERY.
All hemorrhages about the head, excepting those which are intracranial and within the orbit, can be arrested by ligation of the external carotid, which is a reliable and safe operation. The common carotid should never be ligated in place of the ex- ternal, because it is impossible to foresee whether a permanent disturbance of the cerebral circulation (especially in persons of advanced age) will not ensue in consequence thereof.
40. In the case of intracranial hemorrhages ligation of the internal carotid (Fig. 11) is to be preferred to that of the com- mon carotid because the collateral circulation from the angular artery into the branches of the ophthalmic artery is preserved. The ligation equals that of the external carotid, but upward between both vessels pass the stylo-glossus and stylo -pharyngeus, and the deep fascia with the stylo -maxillary ligament.
During pharyngeal operations in which profuse hemorrhages may suddenly occur, and occasionally even during tonsilloto- mies, it is important to be certain as to whether a hemorrhage comes from the internal carotid or from branches of the exter- nal carotid (pharyngeal and tonsillary artery). In tonsillotomy injury to the internal carotid is not the one to be most feared, although the artery is felt pulsating behind the gland ; for in the region of the tonsil the artery is separated from the pharyn- geal wall by the stylo-glossus and stylo -pharyngeal muscles. But injury may be inflicted on the pharyngeal artery and the ascending palatine with its tonsillary branch (Zuckerkandl) .
41. The exposure of the hypoglossal nerve coincides with that of the external carotid artery which it surrounds from without, and in its anterior portion it coincides with that of the lingual artery. But the nerve lies on the external surface of the hyo-glossus muscle, the artery on its internal surface.
42. If the submaxillary salivary gland is turned out, the posterior fibres of the mylo-hyoid muscle are incised, and we work upward along the outer surface of the hyo-glossus muscle toward the mucosa of the floor of the mouth, it is possible to
THE UPPER LATERAL CERVICAL TRIANGLE. 91
expose the lingual nerve, though it lies very deep, from the neck through our normal incision (Fig. 10).
43. Superior Larymjeal Nerve (Fig. 35). — This branch of the vagus, which furnishes the main sensory supply of the larynx, is rendered visible at the lower edge of the skin when the hyoid portion of our normal incision is drawn down. It passes forward in the depth behind the external carotid (where the external maxillary artery is given off), parallel to the large cornu of the hyoid bone, above the pharyngo-laryngeal muscle oil the outer surface of the hyo-thyroid membrane, and disap- pears under the posterior margin of the thyro-hyoid muscle. It is exceedingly important to bear the course of this nerve in. mind, for its injury causes insensibility of the larynx, and where this follows operations on the pharynx and mouth the patients are very liable to die of foreign-body pneumonia.
rttt. Ligation of the Internal and Connnon Jugular Vein (Figs. 11 and 35). — This operation is the same as that for liga- tion of the external and common carotid. The vessel lies on the outer side of the internal carotid. Aside from hemorrhages, the ligation is of special importance in infectious thrombosis in the afferent region of the vein. For instance, when an otitis media and mastoidea extends to the bone, thrombi may form in the transverse sinus. When such thrombi break up, embolic pyaemia ensues. Ligation of the internal or common jugular vein is to prevent this.
45. The spinal accessory nerve (Figs. 10 and 35) jDasses down- ward dorsad of the large vessels, giving off branches to the sterno- cleido-mastoid and trapezius muscles. In spasm of these mus- cles stretching of this nerve is indicated. Its preservation in operations about the uj^per end of the sterno-cleido-mastoid is still more important, especially during the excision . of glands frequently performed at this point. For exposing the nerve we use the mastoid portion of our normal incision, and after the external jugular vein and the large auricular nerve have been
92 OPEEATIVE SURGERY.
lifted off, the muscle is drawn back. The course of the nerve is well marked: from the distinctly palpable anterior circum- ference of the transverse process of the atlas it runs obliquely downward and backward under the anterior margin of the sterno-cleido-mastoid muscle. The occipital artery passes back- ward over it. Above, the nerve is covered by the digastric muscle. In front the sterno-cleido-mastoid artery (from the external carotid) runs parallel to the nerve.
46. Lateral Pharyngotomy . — The above-described normal incision forms the foundation for all operations intended to lay bare from without the lateral pharyngeal region with the tonsil and the base of the tongue.
The incision for the lateral opening of the pharynx, which permits full inspection of the lateral margin of the tongue as far as the epiglottis, and the lateral pharyngeal wall with the entire retro-pharyngeal space, corresponds to our complete nor- mal incision for the upper cervical triangle (Fig. 24). The large auricular nerve and the external jugular vein must occa- sionally be severed if the posterior portion of the incision is to be made fully accessible.
After dividing the skin, platysma, and fascia the infra- mandibular region is exposed ; but further progress toward the floor of the mouth and the pharyngeal wall is interfered with by the vessels which pass from below toward the outer surface of the maxilla. These hindrances are : the anterior facial vein on the external surface of the posterior belly of the digastric, the external maxillary artery under the maxillary gland, and finally the latter gland itself. The vessels named must be doubly ligated and cut ; the submaxillary gland is lifted out and turned upward or extirpated. It may be useful to ligate also the lingual, pharyngeal, and palatine arteries at their origin, or else to ligate the external carotid. This will make it possible to draw the large cervical vessels with the vagus and spinal acces- sory nerves backward, and the arch of the hypoglossal nerve up-
THE UPPER LATERAL CERVICAL TRIANGLE. 03
ward. The superior laryngeal nerve and the superior thyroid artery remain under the lower wound margin. We must save all we can of the presenting muscles in the interest of the mechanism of deglutition, and therefore proceed along the in- ternal surface of the maxilla and the internal pterygoid muscle toward the mucous membrane. If adhesions or the limitation of the field force us to divide the muscles, we must do so in a way to preserve the innervation of the intact muscles. For in- stance, the posterior belly of the digastric and stylo-hyoid are severed as close as possible to the hyoid bone, being supplied from behind (through the facial nerve) ; the stylo-glossus, for the same reason, is cut near the tongue so as to preserve the lingual and glosso- pharyngeal nerves which adjoin it. The stylo-pharyngeus is divided near its attachment to the pharynx; the hyo-glossus and myo-hyoid (supplied from above through the hypoglossal nerve), at their attachment to the hyoid bone, so far as may be necessary. Now the pharyngeal wall is ex- posed, limited above by the cephalo -pharyngeal, below by the laryngo- pharyngeal muscle. Of course, adhesions would neces- sitate cutting the lingual and glosso-pharyngeal nerves.
The upper part of the pharynx, however, can only be ren- dered completely accessible to the eye by adding the above- mentioned osteoplastic resection of the lower maxilla; or, to express it more correctly, the oblique division of the maxilla in a direction from behind inward and above, to in front outward and below, at the anterior margin of the masseter muscle ; after which the ascending ramus of the jaw is vigorously drawn upward and the horizontal ramus forward.
Should the new -formation in the tongue and pharynx have extended to the transition fold between the upper and lower maxilla, it will be best to saw through the jawbone at the above-named point, if necessarj'" detach the soft parts (the mas- seter externally, the internal pterygoid internally) from the bone by twisting the joint capsule and the external pterygoid
94 OPERATIVE SURGERY.
muscle, and to exarticulate and remove the ascending ramus of the maxilla. This will most certainly prevent subsequent anky- losis of the jaw. In this operation as in the above-described resection the inferior alveolar nerve and artery are cut and the latter ligated.
If the lowest part of the pharynx behind the larynx is to be exposed, the muscles of the tongue and pharynx with their nerves remain intact, as well as the branches of the external carotid. The pharynx is opened below the superior laryngeal nerve, between the latter and the superior thyroid artery (which may have to be cut), the incision reaching from the larynx upward to the point where the descending ramus of the hypoglossal nerve is given off, at the anterior margin of the carotid. In order to expose the lowest part of the pharynx it is often necessary to add to the normal incision (which is then to be shortened behind correspondingly) a longitudinal incision downward along the anterior margin of the sterno-cleido- mastoid muscle (Fig. 22).
47. Median or Subhyoid Pharyngotomy (Fig. 36). — To ex- pose the entrance of the larynx when disease is limited to this region it is best to proceed from in front. Transverse incision upon the body of the hyoid bone and the anterior portion of the large cornu of this bone, extending from one side to the other through the skin and muscular fibres of the platysma, thus exposing the hyoid bone. Vertical connections of the subcuta- neous veins are ligated. The hyoid artery and vein run upon the bone of the same name and must likewise be ligated. The incision divides the attachments of the muscles to the hyoid bone as far as necessary, at first the sterno-hyoid and omo-hyoid and laterally the thyro-hyoids. It is desirable to preserve some of the fibres of these muscles. The hyo-thyroid membrane is now laid bare. After dividing it we work up under the hyoid bone in order to open the mucous membrane between the base of the tongue and the epiglottis. We object to making the
THE UPPER LATERAL CERVICAL TRIANGLE.
95
/!t^'
Sfubhyoid pliai-yngotoiiiy
Pectoralis major muscle Clavicle Sul)cla\ lan veiu , | Anterior thoi acic iifrv i^-, i ' :Mib.jla\ian .u ttrv C.-pli.ilii veia Thoracicoacroinml .11 ter> I Deltoid mu-cl Pectoralis iiiinoi- aiuscle
Hyoid bone Stemo-hyoid muscle
Thyro-hyoid muscle Epiglottis Tfiyroifl cartilage TI\o thjioid iiiftubrane bterno thjroid muscle Steino hjoid muscle Median jugulai veiu Innominate ai leiy End of the clavicle Left innominate vein
Infisura stHrni vein ^otch of tilt bteriium %?j ^3>^ \ bteino 'l m'stoidm.
Pectoralis major m
Exfl intercostal m .^ <Ligament. coruscaus) Inti intercosral lu — • Pleura — : External obliquus i -" , abdominis muscle i ~^^^0 Rib -^-' /' Periosteum -^? '^- Exfl intercostal m r^'f ^/'
Aponeurosis of the
external oblique \ ^ Rectus aljJorniuis m -- Intereos. nerve & \ essels ^-' Internal obliquus ab i dominis muscle i Gall blidder External ol)liquu.-> ab dominis umscle
Ascending col n Small intestii .
■Circjmflexa il arter\
.JW
Ti ans^ ei ^us abdominis ./jj I muscle with fascia ,# Peritoneum -=a^i- Liver — Omentum
\ Fascia of the ob- I liquus externusm. 1 P'a^cia of the inter- I nal oblique muscle Rectus abdominis m.
Ti ansversalis fascia J Inferior epigastric I artery
96 OPERATIVE SURGERY.
division away from the hyoid bone, owing to the course of the superior laryngeal nerve which, piercing the thyro-hyoid mem- brane, enters the larynx. If its branches are cut the larynx is rendered insensitive and this gives rise to the entrance of food particles, mucus, and wound secretions into the larynx. Such substances are not removed by reflex cough and dangerous foreign-body pneumonia is the result.
The epiglottis can now be seized with a sharp hook and drawn forward, thus affording a very good view of the entrance of the larynx, especially the region of the arytenoid cartilages which is subject to many diseases (tuberculosis, cancer). In order to permit undisturbed operation we must, as in laryng- otomies, reduce the irritability of the mucous membrane by painting it with a ten-per-cent cocaine solution.
The described operation, which was introduced by von Lan- genbeck, is to be highly recommended for the entrance of the larynx and especially the septum between the latter and the pharynx, since it is not followed by incidental functional dis- turbances.
In the after-treatment of the wound made by pharyngotomy we must bear in mind that we have to deal with tissues infected ab initio, for the pharynx cannot be completely disinfected. For this reason it is advisable, in -the case of ulcerations and ulcerated tumors, to make the resection in two steps : first the dissection as far as the pharynx, then the wound is allowed to granulate by filling it with aseptic gauze and keeping it well open. Not until three or four days later is the pharynx opened and the tumor or ulcer removed, best with the thermo-cautery. Where operation in two steps is not feasible and the whole must be performed in one sitting, the main thing is an open antiseptic wound treatment, i.e., the wound is filled with carbolic gauze, each time freshly prepared bj^ immersion in five-per-cent car- bolic solution and expression. The gauze is changed every two hours, when necrotic points are painted with tincture of iodine,
THE ANTERIOR CERVICAL TRIANGLE. 97
or powdered iodoform or bismuth is rubbed into them. Should the effect of the carboHc acid be too strong, thymol gauze tam- pons are substituted. These must likewise be each time freshly prepared by immersion in 0.1-per-cent thymol solution and ex- pression.
It is self-evident that under favorable conditions — that is, when the wound is small and an exact suture can be applied — the attempt at healing by first intention may occasionally be justified in pharyngotomy, the wound surface in the pharynx having been thoroughly dusted with iodoform. Every tam- ponade of the pharynx and the entrance of the larynx presup- poses a tracheotomy which is indicated even for the sake of securing a quiet operation ; it had best precede the main opera- tion by several days.
H. The Anterior Cervical Triangle.'
If w^e are to enter deeply between the contents of the neck and the sterno-cleido-mastoid muscle, transverse incisions cor- resj)onding to the cleavage lines of the skin do not always suffice, and we are often forced to make longitudinal incisions, either median or lateral along the sterno-cleido-mastoid muscle.
48. Common Carotid Artery (Figs. 2-i and 25). — The com- mon carotid ascends vertically in the shortest direction from the chest to the head. The incision exposing it, therefore, lies ver- tically and crosses the anterior margin of the sterno-cleido- mastoid muscle or the line corresponding to it from the angle of the jaw to the sterno-clavicular articulation. The artery can also be exposed very readily by a transverse incision, whose centre corresponds to the anterior margin of the sterno-cleido- mastoid, made at the height of the cricoid cartilage. This in- cision, corresponding to the cleavage line of the skin, leaves
' The limits of this triangle are the vi]iper margin of the thyroid cartilage and the anterior margins of the sterno cleido-mastoid muscles as far as the jugulum.
7
98 OPERATIVE SURGERY.
a better cicatrix. The artery can be felt throughout the entire neck alongside of the trachea and oesophagus and may be com- pressed with certainty against the vertebral column, best at the height of the cricoid cartilage. By its side we feel the markedly projecting transverse process of the sixth cervical vertebra, the so-called tuberculum caroticum. Now and then compression of the carotid will incidentally cause pressure symptoms on the part of the vagus nerve, slowing of the pulse, and dyspnoea to a feeling of syncope. The preferred point for ligating the artery is like- wise at the height of the cricoid cartilage. This cartilage can nearly always be distinctly felt. After dividing the skin and platysma, the transverse subcutaneous colli nerve appears, pass- ing forward over the sterno-cleido-mastoid muscle from its poste- rior margin. It is cut (preserved in the transverse incision) and the fascia divided so that the body of the sterno-cleido muscle is laid bare. Its anterior margin is drawn outward with a blunt hook. Under this margin the omo-hyoid muscle is seen passing upward and somewhat medially. The artery is ap- proached through the angle, open above, between the two mus- cles named. The vessel is still covered by the second fascia which forms its sheath at the same time. After this is divided the artery is exposed. The descending branch of the hypo- glossal, the motor nerve for the muscles rising to the larynx, passes down on the sheath of the vessel. The nerve is carefully drawn to the median side. The greatest caution is required lest the vagus nerve, which lies close to the posterior surface of the artery, be included in the ligature. The common jugular vein lies outward and the sympathetic backward of the artery.
49. Ligation of the Common Jugular Vein (Figs. S-i and 25). — At the same point the common jugular vein can be ligated. It lies on the antero-lateral side of the common carotid artery. The ligation is indicated, aside from hemorrhages, when throm- boses have formed in the afferent field, especially in the trans- verse sinus by extension of infectious inflammations from the
THE ANTERIOR CERVICAL TRIANGLE. 99
ear. The vein is very frequently ligated when it is adherent to tumors such as mahgnant struma, carcinoma and sarcoma of lymphatic glands.
50. At the same point and for the last-named reasons resec- tion of the vagus nerve (Fig. 25) may become necessary. Uni- lateral division of this nerve can be performed without danger to life, even without any disturbance of the patient.
51. Ligation of the Inferior Thyroid and the Vertebral Ar- tery (see Figs. 37 and 38). — Ligation of these two large branches of the subclavian artery is properly performed from the same ver- tical incision which was described for the common carotid, lat- erally from the cervical structures in the anterior cervical triangle, crossing the margin of the sterno-cleido muscle, but prolonged as far as the clavicle.
We have often ligated the thyroid artery for struma vascu- losa in recent years, since Wolfler has recommended the opera- tion for struma in general. A well-marked point for exposing the vessel is where it changes its upward direction to a median, toward the posterior surface of the thyroid gland. Here the horizontal artery lies on the median side of the common carotid, resting on the spinal column or the longus colli muscle. The operation resembles that for exposing the common carotid at the lower part of the neck. The skin and platysmaare divided, the anterior margin of the sterno-cleido-mastoid muscle is laid bare and drawn vigorously outward ; if more room is needed it is incised. The common jugular vein and the carotid with the vagus are drawn outward. At the inner side of the bundle of vessels, between this and the margin of the thyroid gland or the muscles covering it, the sterno-hyoid and sterno-thyroid, we proceed toward the spinal column. Here the pulsation of the artery is felt. The thyroid gland must be drawn in a median direction and lifted up. The artery is characterized by a curve whose convexity is upward and outward, for the ascending Tessel turns in a median direction to the point where the thyroid
100
OPERATIVE SURGERY,
gland and trachea join. The thyreo-cervical artery gives off, besides the thyroid artery, the ascending cervical and the super- ficial cervical. The operation must be performed under careful control and thorough arrest of hemorrhage, so as to enable us, on the one hand, to preserve the inferior laryngeal nerve where it crosses the artery ; for that nerve furnishes the chief motor
Hypoglossal nerve Occipital artery
Ext'nal maxillary artery Common facial vein Submaxillary gland
Lingual artery
Scalenus anticus muscle
Thyroid gland
Inferior thyroid artery
Recurrent laryngeal nerve
rc-i
Descending branch of the hypoglossal
Zygomatic arch
Temporal artery
Auriculo-temp''l nerve Temporal vein
Internal jugular vein Sterno-mastoid muscle J DescendiDg branch of the ( hypoglossal Internal carotid artery External carotid artery
i-hyoid muscle
Sterno-mastoid muscle Common carotid artery Phrenic nerve
Loagus colli muscle
Sterno-hyoid muscle
Fig. 37.
supply of the larynx. On the other hand we must guard against lesion of the cardiac branches of the sympathetic or division of the trunk of the 'sympathetic which occasionally sur- rounds the artery with an anterior and posterior branch. When the thyroid gland is enlarged the capsule must be divided and the gland drawn in a median direction with a blunt hook. At the same time the inferior accessory thyroid vein should be doubly ligated and cut.
THE ANTERIOR CERVICAL TRIANGLE. 101
52. Vertebral Artery (Fig. 38.) — Ligation is effected in an analogous manner to that for the inferior thyroid ; it is more difficult because the artery lies still deeper. Its course is not only upon but within the deep cervical muscles, under the pre- vertebral fascia. The main guiding point for the artery is the so-called tuberculum caroticum at the transverse process of the sixth cervical vertebra, the most promi- nent portion of the antero-lateral sur- face of the cervical spinal column. This tubercle is also used in ligation of the carotid, whence the name. It is not of much importance in ligation of the ca- rotid, but is undoubtedly so for ligation ^^^ ^ ^ of the vertebral artery which here enters
the transverse foramen. It would be more appropriate, there- fore, to name this prominence the vertebral tubercle. The artery ascends toward the lower surface of this tubercle. After the sterno-cleido muscle with the large cervical vessels has been drawn outward, and the sterno-hyoid and sterno-thyroid in- ward, the prevertebral fascia is divided above the curve of the inferior thyroid artery; then the vertically ascending artery, which disappears above under the vertebral tubercle, is felt upon and partly within the fibres of the longus colli muscle. In a lateral direction lies the scalenus anticus muscle and upon it the phrenic nerve. The latter passes from the outer margin of the muscle over its anterior surface and enters the upper thoracic aperture.
53. (Esophagotomy (Fig. 10). — The oesophagus is opened in the anterior cervical triangle from the left side, where it pro- jects beyond the trachea. If it is to be exposed on account of a new-formation or a foreign bod}'', the incision is made exactly like that for ligation of the common carotid and the inferior
' This figure represents the incision for the inferior thyi'oid artery shown in Fig. 37, but on a larger scale.
102 OPERATIVE SURGERY.
thyroid artery, but it should be longer. After withdrawal of the sterno-cleido muscle and the large cervical vessels the inferior thyroid artery must be doubly ligated, and the thyroid gland lifted in a median direction together with the sterno-hyoid and sterno- thyroid muscles covering it. The capsule of the gland, forming a part of the deep fascia which adheres laterally to the sheath of the large cervical vessels, must be divided. The oesophagus becomes accessible only after dividing the deep fascia. Great care is to be taken to preserve the recurrent laryngeal nerve which runs upward in a groove between the trachea and oeso- phagus; for this reason the oesophagus must be opened quite laterally or latero-posteriorly. Its opening is more difficult when the tube is collapsed, hence the oesophagus is first dilated by the introduction of a sound or olive-tipped bougie.
54. Retro-CBSophageal Space. — The same operation gives ac- cess to retro-pharyngeal and retro-oesophageal abscesses. These abscesses, which are largely due to tubercular disease of the vertebral column and the glands, ma}^ endanger life not only by closing the entrance of the larynx, but by their rupture causing sudden suffocation. Opening them from without instead of from within has the advantage that no communication is estab- lished with the lumen of the pharynx and oesophagus, thus per- mitting a relatively aseptic course. -
Laryngotomy and Tracheotomy. — Median incisions in the anterior cervical triangle are among the most frequent opera- tions the surgeon is called upon to perform for the opening of the larnyx and trachea.
55. Tracheotomy (Fig. 39.) — In the great majority of cases in which we are forced to perform this operation very rapidly, crico-tracheotomy is the safest and least bloody.
The upper tracheal rings are covered by the isthmus of the thyroid gland, which is often rather thick. At its upper and lower margin the communicating veins run as stout transverse branches between the thyroid veins. Twigs are given off by
THE ANTERIOR CERVICAL TRIANGLE.
103
them and the anterior branch of the superior thyroid artery to the pyramidal process when present, so that even arterial vessels may cross the middle line at the upper end of the isthmus. At the posterior surface of the isthmus runs an inferior laryngeal branch from the inferior thyroid artery below, and beneath the isthmus we constantly find the thick inferior venae thyreoidese
Cricoid cartilage Sterno-hyoid muscle
f/1
Thyroid isthmus Sterno-thyroid muscle Pretracheal fascia
Fig. 39.— Tracheotomy, Bose's Method.
rising vertically on both sides of the median line; occasionally there is also an inferior arteria thyi-eoidea. All these vessels can be spared in performing crico-tracheotomy. The skin and superficial fascia are divided, and the margin of the sterno- thyroid muscle is drawn uj)ward with blunt hooks. At first the incision is directed only against the anterior circumference of the cricoid cartilage which can always be felt, and the cartilage
104 OPERATIVE SUBGERY.
is entireh^ exposed. The cricoid artery on the crico-thyroid hgament is preserved. After the cartilage is laid bare the deep fascia which fastens the thyroid gland to the anterior surface of the cricoid cartilage is detached from the inferior edge of the latter. By entering w^ith a blunt instrument the upper tracheal rings can all be laid bare without cutting, by lifting the fascia with the thyroid isthmus and all the vessels in its region down- ward from the bared trachea (Fig. 39).
If crico-tracheotomy does not afford sufficient room or it is desired to make the tracheal wound farther from the larynx, the cutaneous incision must be prolonged downward and the fascia between the sternal muscles below the isthmus divided exactly in the median line. The inferior venae thyreoidesB always remain to the right and left, as they pass vertically downward. The deep fascia having been divided without cutting, we come upon the trachea and may open it below the isthmus (inferior tracheotomy), or else we may introduce an aneurism needle be- tween the trachea and the isthmus which latter has been bluntly detached from above and below. Then the isthmus is firmly ligated with strong thread to the right and left of the median line and divided. This mode is preferable where the trachea is to be adequately exposed.
Where such an operation is to precede a subsequent laryn- gotomy or laryngectomy, inferior tracheotomy is to be preferred, as it leaves the field free for the second operation. Wherever possible such preliminary tracheotomies should precede the main operation a number of days.
56. Laryngotomy and Laryngectomy. — There is an absolute indication for opening the larynx in the case of intra-laryngeal malignant tumors ; the operation may become necessary in rela- tively benign tumors such as papilloma of the larynx, ulcers, infectious diseases, and tuberculosis of the larynx. Median ex- posure of the larynx is comparatively a simple operation. The incision passes downward in the median line from the hyoid
THE ANTERIOR CERVICAL TRIANGLE. 105
bone to the upper part of the trachea. This causes injury of some vessels: the hyoid artery (branch of the lingual) at the hyoid bone; the crico-thyroid artery (branch of the superior thyroid) on the crico-thyroid membrane; a transverse branch of the superior thyroid passing to the pyramidal process of the thyroid gland ; also numerous veins and transverse connections of the venae median£e colli and deeper veins. All these vessels must be ligated. After dividing the skin and fascia, the mus- cles passing from the sternum to the larynx and hyoid bone are drawn aside. The median hyo-thyroid membrane is divided above the thyroid notch, and the perichondrium of the carti- laginous plates of the thyroid inferiorly. Now a hollow sound can be passed beneath the anterior edge of the thyroid cartilage and sever it, or it may be freely divided from without and the plates drawn asunder with sharp double tenacula before the mucous membrane is cut.
It must be laid down as a rule that several days before this operation it should be preceded by an inferior tracheotomy, so as to secure perfectly free respiration during and after the oper- ation and in order that the entry of blood and mucus into the air passages may be positively prevented by the insertion from above of soft little sponges. Instead of tamponing simply through the laryngotomy wound above the tracheal canula, the tamponade can also be effected from the tracheotomy wound by tying a flat soft sponge like a diaphragm to the lower end of the tracheotomy canula. To obtain an unobstructed view into the interior of the larynx we require complete anaesthesia during which the cough reflex is inhibited. It is best to use besides chloroform a local application of a ten-per-cent cocaine solution. By this means malignant neoplasms can be thoroughly inspected and extirpated. Should more room be needed the epiglottis can be divided above. For exact coaptation of the plates of the thyroid cartilage the cricoid cartilage forms a good support, pro- vided it can be spared.
106 OPERATIVE SURGERY.
57. Laryngectomy. — Where the entire larynx is diseased, a transverse incision along the hyoid bone is added to the longi- tudinal incision for the purpose of laryngectomy. This addi- tional incision is like that for subhyoid pharyngotomy. A tra- cheotomy a number of days before this operation is particularly indicated. Through the longitudinal incision the anterior sur- face of the larynx is laid bare and the sterno-hyoid and thyro- hyoid muscles are severed close to the hyoid bone. Then the hyo-thyroid membrane which is attached under the hyoid bone, especially its strong median ligament, is divided along with the mucosa beneath, and the epiglottis is drawn out with a stout hook. The latter organ is divided close to the diseased point ; then the morbid portion is circumscribed above with the knife. Generally the thyroid cartilage is now divided, eventually also the cricoid cartilage and a portion of the trachea, so as to fur- nish a clear insight into the extent of the disease ; but this in- formation can be gained also by introducing the finger. When a neoplasm completely fills the larynx the mucous membrane at its limit toward the pharynx is divided, and likewise forward toward the epiglottis. If we have operated in the median line, the mucous membrane will also be exactly divided along the lower limit in the larynx and in the trachea. Not until then is the outer surface of the larynx laid bare. As far as possible the muscles are preserved which cover the lateral and anterior surface of the larynx (the sterno-thyroid and hyo-thyroid). If the muscles are diseased they are removed. The cartilages are exposed and as far as they adjoin the neoplasm directly they are removed, in total disease over the entire chxumference. On the posterior surface of the cricoid cartilage the oesophageal mucosa is preserved if it is healthy and movable. Thus we reach the lower limit of the disease and make a transverse division in healthy tissue, whether it be the trachea or the cricoid cartilage.
The anterior pharyngeal and oesophageal wall is sutured up-
THE ANTERIOR CERVICAL TRIANfJLE. 107
ward as far as possible in order to restore the septum between the air and food passages.
The after-treatment is the same as in pharyngotomy.
58. The Lntoininate Artery (Fig. oG). — This artery is the one nearest the heart, which is accessible to ligation ; it is al- ways a grave operation, in view of secondary hemorrhages. As a rule, therefore, we ligate at the same time the main branches which carry the blood back. These are the common carotid and the vertebral artery. The pulsation of the artery may be felt in the jugulum. For the purpose of ligating it we make an oblique incision at the anterior margin of the right sterno- mastoid muscle, extending from its middle third to the anterior surface of the manubrium of the sternum. Skin and fascia are divided and the attachment of the sternal portion of the sterno- mastoid muscle is separated from the sternum. Two veins are to he preserved : the transverse connection of the two venae me- dianae colli in the notch of the sternum and the transverse vein behind the attachment of the muscle. Thus we reach behind the sterno-clavicular articulation the common carotid artery. The right inferior vena thyreoidea is to be ligated and cut. The lateral margin of the sterno-hyoid and sterno-thyroid muscles is incised transversely and these muscles are drawn in a median direction together with the branches of the descending hypo- glossal nerve, and finally the deep fascia is severed. Between the sterno-mastoid and the other muscles we follow the carotid down to its junction with the subclavian under which the trunk of the innominate is ligated ; the pleura lying postero- externally must be protected. The left innominate vein, coming from the left, lies in front of the artery. The vagus aiid the loop of the recurrent laryngeal remain laterally and so does the j)hrenic nerve.
59. Excision of the Diseased Thyroid Gland. — The descrip- tion here given for this operation is based on a case of moderate severity. For slighter cases, i.e. , movable circumscribed nodules
108 OPERATIVE SURGERY.
of struma, it is best to use the method which we designate as enucleating resection. Very difficult cases can be undertaken only by a surgeon who has gathered experience in less com- plicated excisions.
The best cicatrices result from the transverse curved incision (collar incision, Fig. 7) along the cutaneous folds, but this gives less ready access and is therefore to be reserved for the slighter cases. Amply sufficient room for all cases is furnished by the angular incision. This begins at the height of the thyroid car- tilage on the prominence of the sterno-mastoid muscle, passes transversely in the direction of the cutaneous fold as far as the median line, and then down along this to the jugulum. In more deeply seated struma it is prolonged to the manubrium sterni. In the transverse portion we divide the skin and platysma, and toward the median line the thick mediana colli vein which is doubly ligated. The external jugular vein is preserved. After the superficial fascia is sufficiently divided the muscles are laid bare. The sterno-mastoid is drawn outward. At its anterior margin, as a rule, a vein must be ligated (the connecting branch between the external and median jugular veins) . In the median line the fascia is divided which unites the sterno-laryngeal muscles ; above the sternal notch a trans- verse vein is often ligated. The medial margin of the last- named muscles is freed and the finger is inserted beneath them so that their upper end may be incised but not severed, the vessels belonging to the upper stump being ligated. Then these muscles likewise are drawn aside with hooks.
The connective-tissue layer, which is usually thin, is then lifted above the goitre, whose capsule is raised and divided until the brownish -red or bluish surface of the goitre with its thick veins is exposed. The finger is passed carefully around the goitre so as to make sure that no larger veins run anteriorly or laterally from the capsule to the surface of the struma. Should this not be the case, the struma is lifted and displaced forward
THE ANTERIOR CERVICAL TRIANGLE. 109
over the withdrawn muscles. This is especially desirable in cases associated with marked symptoms of pressure and stenosis, because this step suddenly relieves the trachea and respiration becomes easy. But it should be done only when no large veins are torn thereby. Accessory veins often pass from without to the surface of the goitre and must be doubly ligated before the luxation.
Where the goitre can be turned sufficiently, we see and feel behind it the inferior thyroid artery and associated vein ; these pass in a curve from without toward the attachment of the tumor to the trachea and can be ligated. This should be done, however, only after careful isolation, because the vessels are crossed by the recurrent nerve ; for the same reason the artery is not severed but merely tied.
We now turn to the upper or lower pole of the tumor, which- ever is more readily isolated. When the struma is not deep, i.e., when the lower cornu does not extend into the thorax, we isolate at the lower pole the inferior thyroid vein, which is usually very thick and near the goitre divides into several branches. These vessels become tense when the tumor is lifted and can be doubly ligated and cut without fear of incidental injury.
The external capsule being properly separated as far as the upper pole, we seize the superior cornu at its upper end and thus isolate the upper pedicle with the superior thyroid artery and vein, which are included in a common double ligature (very firmly tied) and divided.
At the upper and lower margin of the thyroid isthmus we find respectively a communicating superior and inferior vein, and now and then an artery of the pyramidal process above. If possible they are ligated separately. Then a struma sound can be passed between the trachea and isthmus and the latter surrounded with a strong ligature and divided under traction.
Usually more or less of the thyroid-gland tissue remains
110 OPERATIVE SURGERY.
normal and may be preserved. To this end, after the goitre has "been freed as far as the isthmus, it may be rested on the fingers of the left haod, thus lifted out and stretched, and the incision carried through the tissue parallel to the trachea at some dis- tance from the isthmus as far as the nodule. The bleeding ves- sels are ligated while the median circumference of the nodule is enucleated without cutting, until the healthy glandular sub- stance at the posterior surface is reached, when this . portion, too, is divided at some distance from the trachea. By this enu- cleating resection we also avoid injuring the recurrent nerve at the median circumference of the tumor. A semi-lateral ex- cision should never be made until we have assured ourselves of the presence of a lobe on the other side.
J. The Lcwer Lateral Triangle of the Neck,
The supra-clavicular triangle is limited by the clavicle, the sterno-mastoid muscle, and the trapezius muscle. The surgery of this region is simpler than that of the upper lateral triangle of the neck. Here the large vessels and nerves run to the arm, and here, too, we strike the branches of the subclavian artery and vein. The background of the triangle is formed by the first rib and the first intercostal space, together with the lateral neck muscles, especially the scaleni.'
The normal incision (Fig. 25) for this region, which corre- sponds to the cleavage line of the skin, lies almost trans- versely, from the attachment of the sterno-mastoid muscle at the clavicle, rising somewhat obliquely to the margin of the trapezius. The incision is used for the ligation of the sub- clavian artery, under which head it is described.
60. Subclavian Artery (Figs. 24 and 25) . — This vessel springs from behind the manubrium sterni, passes over the pleura of the apex of the lung, over the first rib between the scalenus anticus and medius muscles, then it reaches the outer surface of the thorax under the middle of the clavicle between the sub-
THE LOWER LATERAL TRIANGLE OF THE NECK. Ill
clavius and serratus muscles. It can be with certainty com- pressed at the outer margin of the scalenus anticus muscle.
In order to ligate the vessel a transverse incision is made, beginning a finger's breadth above the clavicle on the clavicular portion of the sterno mastoid muscle and extending to the anterior margin of the trapezius muscle, slightly ascending in a lateral direction. After dividing the skin we strike the platysma and the sensory supra-clavicular nerves from the upper cervical plexus, which suppl}^ the upper portion of the thorax and the shoulder. These are divided transversely. Then the fascia is severed. At the lateral margin of the sterno-cleido-mastoid muscle the external jugular vein must be preserved ; it bends down over the posterior margin of the muscle toward the com- mon j Ligular vein . Lesion of this vein is dangerous because the fascia through which it passes keeps it tense and hence air may be aspirated. If it cannot be drawn inward it must be doubly ligated before being cut. After the fascia is divided, there ap- pears in the inner angle of the wound the omo-hyoid muscle, rising obliquely inward in the adipose tissue of the triangle with imbedded glands. In this adipose tissue lie the transverse scap- ular artery behind the clavicle, the superficial cervical artery ascending posteriorly, above the latter but under the deejD fascia the rathe]' thick transversa colli artery which passes backward upon or through the nerve plexus.
After removing the adij)ose tissue, the thin deep fascia covers the brachial plexus, now becoming visible, whose thick nerve trunks emerge between the scaleni muscles and descend steeply under the clavicle. The relation of the artery to the nerve plexus is very characteristic. If we pass down toward the first rib along the anterior surface of the nerve plexus we find the attachment of the scalenus anticus muscle at the rib marked by a prominence — the tubercle of Lisfranc ; behind this the artery passes covered by the nerves. In a median direction from the scalenus anticus muscle lies the bulb of the common
112
OPERATIVE SURGERY.
jugular vein ; in front of the muscle and upon the first rib, the subclavian vein, hence apart from the artery. On the anterior surface of the scalenus anticus muscle the phrenic nerve passes into the thoracic cavity. Alongside of the scalenus muscle the thoracic duct passes from the thorax into the neck and termi-
Lateral pharyngotomy ]
Lingual artery Hypoglossal ner^e r Superior laryng 1 nerve \
Common carotid
["Temporal incision Thn-d branch of trigeminus ■j nerve
I Middle meningeal artery L Internal maxillary artery
Accessory nerve 4.uricularis magnus nerve Internal jugular vein External jugular vein
Mas^eter muscle External maxillary artery External maxillary vein
— Supraclavicular nerves Trapezius muscle
Platysma
j Scalenus medius I muscle
Sterno-mastoid muscle External jugular vein
Phrenic
Transversa colli artery Brachial plexus Transverse scapular artery I Subclavian artery Subclavian vein Scalenus anticus muscle
Fig. 40.
nates in the angle between the subclavian and common jugular veins.
The branches of the subclavian artery, three of which we have already mentioned, spring from the main trunk in a cen- tral direction from the scaleni muscles, excepting the trans- versa colli. The guiding points for finding the vertebral and the inferior thyroid artery have been given above.
THE LOWER LATERAL TRIANGLE OF THE NECK. 113
The ligation of the internal mammary artery will be dis- cussed below.
61. The external branch of the spinal accessory nerve (Fig. 10) becomes visible in the lower cervical triangle beneath the middle of the sterno-mastoid muscle immediately under the first fascia, that is, quite superficially ; its course is obliquely backward to the trapezius muscle. When the nerve is to be stretched or divided in spasmodic conditions it is exposed by a transverse incision which intersects the posterior margin of the sterno- mastoid muscle at its centre. At the same point the
62. Subcutaneous colli nerve and the
63. Auricularis magnus nerve surround the posterior margin of the muscle.
6tl:. Through the normal incision for the lower cervical tri- angle may be exposed, besides the large nerve trunks of the axillary plexus, also all its shorter branches. They spread in a conoidal form over the thorax, posteriorly, exteriorly, and an- teriorly. Posteriorly we have the dorsal scapular nerve passing to the levator scapulae and the rhomboid muscles, through the scalenus medius ; exteriorly, the suprascapular nerve passing to the incisura scapulae to supply the supra-spinatus and infra- spinatus muscles; the axillary nerve, passing along the lateral wall of the axilla between the teres major and minor on the one hand and the anconseus longus and humerus on the other hand to the lower surface of the deltoid to supply the latter, the teres minor, and by a sensory branch the dorsal side of the arm ; the subscapular nerves which pass at the posterior wall of the axilla to the teres major, subscapularis, and latissimus dorsi ; the thoracic posticus (longus) nerve which extends from the medial wall of the axilla to the serratus anticus major; anteriorly, the anterior thoracic nerves which surround the sub- clavian artery and pass between the pectoralis major and minor to supply these two muscles.
114 OPERATIVE SURGERY.
K. The Nuchal Region.
The surgery of the upper nuchal region has been discussed with the occiput (which see for the occipital artery and the major and minor occipital nerves).
There are no large vessels and nerve trunks in the lower nuchal region. Incisions are very often made at the nucha in inflammations, especially furuncles and carbuncles. Deep in- cisions can be made without the fear of wounding important structures.
For opening the spinal canal see the dorsal spine.
L. The Thorax.
The main indications for incisions on the thorax are fur- nished by diseases of the pleura and the ribs, less often by dis- ease of the lungs, and most rarely by affections of the pericar- dium. Among the larger vessels to be ligated are the internal mammary artery and the intercostal arteries, but above all the subclavian artery and its branches.
65. Internal Mammary Artery (Fig. 36). — This supplies the inner surface of the anterior thoracic wall and its branches pass through the latter to the skin. With its concomitant vein it lies upon the pleura from which it is separated by a very thin layer of fascia and below by the anterior thoracic muscle. In front the artery adjoins the costal cartilages and the intercostal muscles.
It is ligated through a transverse incision in the intercostal spaces where the sternum is narrowest, hence by preference in the second. The incision is carried from the middle of the sternum transversely outward between the costal cartilages, and divides the skin, fascia, and the pectoralis major muscle. Now appear the obliquely inward descending fibres of the fascia of the external intercostal muscle (ligamentum corn scans) ; this
THE THORAX. 115
fascia is often very thin and beneath it the obliquely outward descending fibres of the internal intercostal muscle become visi- ble. As soon as these are divided the artery is seen passing down on the pleura, about 0.5 to 1 cm. from the edge of the sternum. The vein lies more medial.
GQ. Intercostal Artery (Fig. 30). — The main branch of this artery passes between the two intercostal muscles to the lower edge of the rib, while a smaller branch runs along the upper edge. Its ligation is not easy because the artery is hidden under the overhanging antero-inferior edge of the rib.
The external intercostal muscle which descends obliquely in- ward is divided, the artery is surrounded from behind with a ligature, very carefully lest the pleura be injured, or for safety's sake a subperiosteal resection of a portion of the covering rib may be made.
67. The intercostal nerve passes below the artery and must be drawn aside. It can be exposed like the artery in order to be stretched in neuralgias.
68. Thoracotomy . — The best method for the free opening of the pleural cavity is that preceded by resection of the ribs. For mere puncture we enter between the ribs, nearer to their upper than their lower edge, on account of the nerves and the larger vessels. The skin is pressed as deeply as possible into the intercostal space, and the trocar vigorously pushed in beside the finger above the upper edge of the rib. For large trocars a small cutaneous incision is made first.
69. For resection of the ribs (Fig. 36) the incision is made over their largest curvature, parallel to both margins. In cut- ting directly upon the bone no larger vessel or nerve is injured, only the covering skin and muscle. After the periosteum is divided it is very carefully detached with an elevator, above, below, and behind the rib, and a piece cut out of the latter, thus laid bare, with strong bone forceps.
Behind the rib, covered besides the periosteum with a very
116
OPERATIVE SURGERY.
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thin fascia (the endothoracic) , Hes the pleura, which can then at once be incised in the direction of the exsected rib, the presence of the exudation having been determined, in doubtful cases, by puncture.
Very often the resection of a single rib does not suffice. In such a case the upper rib is cut in like manner (Fig. 41) through
the same cutaneous incision, the skin being drawn strongl}^ up- ward; a piece is resected also from this rib and the underlying pleura opened likewise longitu- dinally as with the first rib. An aneurism needle is now passed at the lateral and medial end of the two pleural incisions under the intervening tissues of the intercostal space, the vessels are ligated together with the pleura and muscles, and after this is done the two pleural incisions are connected in the centre by a vertical cut ; thus we obtain a gaping opening in the form of a recumbent H (I) .
If permanent drainage is to be provided for, the opening must be made in the lowest part of the cavity. In the line of the nipple we still strike the pleural cavity after removal of the car- tilage of the sixth rib. In the lateral region the pleura is struck on the right after removal of the ninth rib and on the left even of the tenth rib ; behind in both scapular lines after removal of the twelfth rib. But there is a contra-indication to the incon- siderate opening of the pleura at these lowest limits, especially with pointed instruments, because the diaphragm of the anterior chest wall might immediately adjoin it; it is advisable, there- fore, to open the pleural cavity at first at the point where fluid
Fig. 41.— Free Opening of the Thorax, with Resection of two Ribs.
THE THORAX. 117
is sure to be met, i.e., where its presence has been determined by aspiration. Only after free access has been gained here a sound is introduced to the