vEolumbta Untufrsttg in tl|F Olttij 0f Nfm fork JFrom ll^f iCtbrarg jif (EijurrljiU (Carmalt, iW. 1. ^«0rntpJi bg ti\e iExtfrttf (Elub of Npu» Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/operativesurgeryOOkoch !'f; IV' i 1 1 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 •'•-'// 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 .^ 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. ^^' y 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 lowest part of the cavity, or else this is ascertained by the finger from within. A second opening is then made in the same way by costal resection at the latter point and through-drainage thus provided for. 70. Resection of Larger Portions of the Chest Wall. — Ex- tensive excisions of the chest wall are apt to be called for in pleural disease with retraction of the lung, where a closure of the pus cavity is mechanically impossible through rigidity of the wall : in neoplasms, especially chondromata and sarcomata of the ribs which have involved the pleura. The operation bears Estlander's name, although isolated extensive resections were performed and reported before his time (De Cerenville). Through every large incision running parallel to the ribs a number of ribs can easily be resected. But if larger portions of the chest wall must be removed in one piece, flap incisions are required. For these two directions are to be recommended : in- cision beginning at the anterior axillary fold, running obliquely backward and downward over the lateral surface of the thorax between the attachments of the serratus anticus major and the latissimus dorsi posteriorly and the external oblique of the abdo- men anteriorly. To this is added an oblique incision along one of the ribs at the desired height. The second direction of the incision runs vertically along the margin of the extensors of the back to the posterior angles of the ribs, dividing the tendi- nous portion of the latissimus and partly of the trapezius and serratus posticus inferior. To this incision, which runs from above downward and strikes the border line of the large mus- cular regions and their nerve twigs, is likewise added a second incision parallel to the course of the ribs, according to re- quirements. Yl. Operations on the Lungs. — At any desired point where abscesses, cavities, or, exceptionally, new-formations in the puU 118 OPERATIVE SURGERY. monary tissue call for interference, the lung may be exposed in the same manner as the pleural cavity is opened ; with this dif- ference, however, that we must be sure, either by adhesions artificially induced (cauterization) or by direct fixation previous to free opening, that the portion of the lung in question is kept in contact with the chest wall, unless adhesions have been caused by the disease. For the opening of cavities at their most frequent seat, namely, the apex, the operation is performed as follows : Incision through skin, fascia, and pectoralis major muscle along the first intercostal space, parallel to the clavicle, and in a lateral direction from its sternal end. Division of both inter- costal muscles, medially only the internal. At this point the internal mammary artery should not be injured, nor the sub- clavian vein at the lateral end- of the incision. At the lower edge of the first rib the periosteum on its anterior surface is divided and carefully displaced forward and backward ; then the lower two-thirds of the rib are resected, leaving a bridge above, lest any of the large vessels resting upon the rib be injured. Aspiration with a hypodermic syringe is now resorted to in order to determinp the position of the cavity, a small incision is made through the pleura, and en- larged with a pair of arterial forceps. M. Opening of the Spinal Canal. Horsley by his brilliant operations has shown the excellent results to be obtained by relieving the pressure on the cord caused by tumors, even in very advanced cases, and other sur- geons have reached equally satisfactory effects by relieving the pressure due to fracture and luxations of the vertebrae or by opening abscesses. 72. The operation is performed in the following manner: Long median incision down to the spinous processes, detach- LUMBAR REGION. ] 10 ment of the muscles on both sides with the knife, close to the bone (especially the transverso-spinalis muscle), if necessary by the aid of transverse nicking of the thick covering fascia. The exposed spinal processes are removed at their base with bone forceps, together with the interspinal ligaments. The posterior arches are removed by making a transverse incision through the stout intercrural (flava) ligaments along the upper and lower margin of the arches close to the bone. The arches are severed on both sides and lifted out, one after the other, until the cord is sufficiently exposed. Adipose tissue and large vessels (circuli venosi) are divided with the knife and ligated if necessary, then the dura is opened in the median line. Of course, v/hen the pressure is due merely to a displaced or broken vertebra, or an extradural tumor or abscess, the dura is not opened. Even when the dura has been opened, a complete suture is to be applied after drainage, and thus healing by first intention may be secured in the course of forty-eight hours. N. Lumbar Region. 73. Nephrotomy and Nephrectomy (Fig. 42). — The incisions for exposing the kidney best illustrate the normal incision for the lumbar region. Nephrotomy is performed for wandering kidney so as to fasten the organ to the skin and fascia, for opening the pelvis and the calyces of the kidney in hydrone- phrosis, pyonephrosis, nephrolithiasis, and neoplasms. Neph- rectomy is performed for the total removal of the kidney in the case of tumors and extensive disease by lithiasis, inflamma- tions, and tuberculosis. The same incision exposes the ureter. The correct direction is a transverse incision beginning on the prominence of the sacro -lumbar muscle and passing under the twelfth rib to the anterior axillary line. It divides the skin, subcutaneous tissue, the thick lumbo-dorsal fascia with its cor- 120 OPEKATIVE SURGERY. responding muscles, the latissimus dorsi and beneath it the ser- ratus posticus inferior. The most lateral serration of the former muscle appears as a flat, thick muscular bundle. The remaining part of the muscle is cut laterally from the sacro-lumbar mar- gin, as are the thin fibres of the serratus posticus inferior which ascend obliquely outward and are not always recognized as a separate layer. The sacro-lumbalis is slightly nicked at its margin or vigorously drawn in a median direction with a blunt hook. In the case of longer incisions the external oblique ab- dominal muscle with its descending fibres is transversely divided for a short distance, and at its posterior margin and beneath it the obliquely ascending fibres of the internal oblique are treated in the same way. At the margin of the sacro-lumbalis and between the divided ends of the above-mentioned two abdominal muscles appears the tense, glistening lumbo-costal fascia, from which spring the fibres of the transversus abdominis muscle. After this fascia is divided, the margin of the quadratus lumborum muscle becomes visible, running almost vertically and parallel to the margin of the sacro-lumbalis; beneath it appears the twelfth intercostal nerve with its concomitant thick vessels, passing antero-inferiorly. The first lumbar (ilio-hypo- gastric) nerve descends more deeply than the twelfth intercostal, at the margin of the quadratus muscle. Anteriorly the nerves perforate the transversus and pass between it and the obliquus internus muscle. They are drawn upward and downward, and the vessels, if necessary, are ligated and cut. At the lateral margin of the quadratus muscle, which ac- cording to requirements may be nicked or withdrawn, under the thin transverse fascia lies the abundant retro-renal loose adipose tissue, with vessels. A finger is inserted, carefully separates these tissues (capsula adiposa), and reaches the kidney without meeting with resistance. For nephroraphy the thin fibrous capsula propria which covers the kidney tensely is nicked and detached from the organ without cutting. LUMBAR REGION. 121 Lumbo-dorsal fascia Sacro-lumbalis rausscle Serratus posticus mfe rior muscle Latissimus dorsi muscle Lumbo-costal fascia Glutasus maxim us m. Glutseus medius m. Super' r gluteal artery Pyriformis muscle Tip of the great I trochanter f Base of the great ) trochanter ( Latissimus dorsi muscle Tw elf th mtercostal nerve Quadratus lumboiiim m. First lumbar nerve Transverse abdominal m. Ext 1 abdoni'l oblique m. Int 1 abdom'l oblique m. Posterior super" r spine of the ilium 3 Postenoi infer'r spine ( of the ilium J Glutseus maximus 1 muscle Int'l pudendal artery Int'l pudendal nerve Pyriformis muscle Sciatic artery Sciatic nerve Posterior cutaneus femoris nerve j Obturator internus m. (withgemeUi) Fig. 4-Z. — Nephrotom.y. Gluteal and sciatic arteries. 122 OPERATIVE SURGERY. If the kidney is to be luxated in toto for examination, inci- sion, or excision, the detachment of the fibrous capsula propria is. omitted. The renal pelvis can be palpated from behind by passing^ the finger toward the hilus, the ureter lying behind the vessels. The renal pelvis is incised directly from behind if it is dilated j in other cases it is better to make a short longitudinal incision from the convexity of the kidney and insinuate the finger in the direction of the hilus as far as the pelvis of the kidney. Where the parenchyma of the kidney has been injured it is ad- visable to adopt the open wound treatment or secondary suture, not only on account of the discharge of the urine, but because, according to our experience, gained by the aid of Dr. Tavel, in- juries to the kidney are apt to infect the neighborhood. The kidney usually contains (by excretion?) micro-organisms which give rise to inflammation. For this reason it is a good plan to prepare such patients for the operation by the administration of salol, 45 grains pro die. As regards nephrectomy we have in recent years invariably adhered to the practice of lengthening the transverse incision so far forward as to strike the transition fold of the peritoneum adjoining the colon, which comes within the region of the axil- lary line, and to open the peritoneum first at this point. From here we always succeed in insinuating the hand far enough into the abdominal cavity to palpate the other kidney, ascertain its size and consistence, and feel the renal artery. After deter- mining the presence of a well-developed kidney on the opposite side, the peritoneum was sutured and the operation performed in the above-described manner. Y4. Ureter. — The ureter can be exposed at various points: a. At its lowest point ; see Exposure of the seminal vesicles and vasa deferentia from the perineum, in surgery of the peri- neal region, and from the posterior pelvic incision. h. On the internal iliac fossa ; see Ligation of the common iliac artery. ABDOMEN, 123 c. In the neighborhood of the kidney by the same incision as for nephrotomy ; or, in case it must be followed for some dis- tance downward, by a longitudinal incision along the margin of the sacro -lumbar muscle. 75. In an analogous manner to the kidney the spleen can be exposed on the left side, the incision being lengthened forward. We abstain from giving a detailed description because the method of operation depends too largely on the individual rela- tions of the case, especially the size and nature of the tumors. O. Abdomen. Normal Incisions. — Access to the contents of the abdomen is obtained with the least amount of incidental injury by a ver- tical incision in the anterior median line. No large vessels are met with, aside perhaps from an unobliterated umbilical vein and a few veins in the subserous adipose tissue. The incision divides the skin, superficial fascia, and the linea alba, i.e., the union of the aponeuroses of the recti abdominis muscles. Beneath this lies the transverse fascia and under this the peritoneum, covered with more or less subserous fat. Above and below the peritoneum can be displaced on the linea alba ; in the region of the umbilicus it adheres firmly. For the deeper organs lying more laterally the median inci- sion does not always suffice, i.e.., it inflicts an unnecessary in- jury because the intestines present ; especially organs near the hypogastrium and hypochondrium are too far for a median in- cision. The rather common lateral longitudinal incisions along the margin of the rectus abdominis muscle should be rejected because they divide the nerves supplying the latter muscle. In the case of long incisions this drawback should not be under- valued, especially in the upper part of the abdomen. Paralysis of the muscle favors the development of abdominal hernias. Aside from the median incision the onlv rational ones with 124 OPERATIVE SURGERY, reference to the course of the nerves are transverse incisions (Fig. 36) or transverse oblique incisions placed parallel to the nerve trunks. It is true these transverse incisions divide the three broad abdominal muscles, but the nerves lying between the several layers, especially the internal oblique and the trans- versus, can be pushed out of the way. Even the rectus abdo- minis is less injured by a transverse incision than by a longi- tudinal one made laterally, because the motor nerves remain intact and merely an artificial inscriptio tendinea is superadded so that the muscle contracts as before. Still in transverse incisions the superior and inferior epigastric artery must be cut and ligated. Hypochondrium. Y6. Cholecystotomy (Fig. 36), — The following is the proce- dure for opening and eventually removing the gall bladder. Oblique transverse incision 4 to 6 cm, below the free border of the ribs, 10 to 15 cm. in length. It begins three fingers' breadth from the median line on the prominence of the rectus abdominis, divides the skin, superficial fascia, and the fascia of the internal oblique ; in front of the rectus the two fascias are united. Un- derneath appears the rectus, whose lateral half is divided ; the superior epigastric artery under its lateral margin being ligated. In the lateral portion the external abdominal oblique muscle is cut, and still farther away the internal oblique and the trans- versus. Beneath these the terminal branches of the intercostal nerves pass obliquely inward toward the rectus. Smaller per- forating twigs of these nerves are met with in the first fascia. Beneath the muscles appears the transverse fascia, quite thick at this point, with its transverse fibres, and after it is divided the peritoneum is reached. When the latter is opened the gall bladder can be seen and removed if it is lengthened and enlarged. For cholecystectomy the visceral peritoneum must be divided ABDOMEN. 125 parallel to the border of the liver, at the apex of the fundus of the bladder, and the gall bladder detached subperitoneally, with- out cutting, as far as the cystic duct ; the artery vesicae felleae being ligated. The duct is doubly ligated and divided. Since micro-organisms may migrate from the intestine into the bile ducts, the peritoneum must be protected with sterilized pledgets, and after the duct is cut the stumps must be disinfected by means of sublimated cotton or the thermo -cautery. Hypogastrium . As a type of the operations in the region of the lateral hypo- gastria we may instance the ligation of the common and the external iliac artery. In the case of the former we enter the peritoneum by an incision two fingers' breadth above Poupart's liagment. In the case of the latter the peritoneum is avoided by keeping close to Poupart's ligament and dividing only the transverse fascia which is attached to it ; while the peritoneum forms a reduplication on the internal iliac fascia, about 0.5 cm. above (for both these ligations see below) . In an analogous manner abscesses of the internal iliac fossa can be opened extra-peritoneally by proceeding upon or beneath the internal iliac fascia ; or else we may proceed after opening the peritoneum if the vermiform appendix is to be resected, tumors of the caecum are to be removed, or if on the left side the sigmoid flexure is to be drawn out for the formation of an artificial anus or for removal in the case of neoplasm. A trans- verse incision from one side to the other, from the right anterior inguinal ring to the one on the opposite side, is indicated when the bladder is to be opened (compare Fig. T). The inguinal canal is opened directly in its course when the spermatic cord is to be exposed in castration, or the round liga- ment is to be sought, or finally if the neck of a hernial sac situ- ated in the canal is to be reached (herniotomy). 126 OPERATIVE SURGERY. Exposure of the Inguinal Canal (for herniotomy, castra- tion, varicocele operation, and Alexander's prolapsus operation). YT. Castration. Excision of the Tunica Vaginalis (Fig. Y) . — Transverse incision along the inguinal canal one finger's breadth above Poupart's ligament, running in a median direc- tion downward parallel to the median third of the ligament. The incision corresponds exactly to the cleavage line of the skin and therefore adheres very readily. In the subcutaneous tissue and superficial fascia a thick vein descending from above is to be ligated without and within. The superficial epigastric artery, ascending from the femoral artery across the abdominal wall, is severed with the external vein if the incision is lengthened laterally. Then follows division of the thin external fascia of Cooper, which incloses the spermatic cord, and is a delicate con- tinuation of the fascia of the external abdominal oblique muscle ; of the muscular fibres of the cremaster (from the internal oblique) laterally from the last-named fascia ; and of the thick infundibuliform fascia (a continuation of the transverse fascia). This contains the spermatic cord, or, respectively, the round ligament and possibly diverticula of the peritoneum in the shape of hernial sacs. In the case of castration it is easy to turn the testicle upward, unless it is adherent to the scrotum or greatly enlarged, and remove it, or to replace it if no more is intended than the division and excision of the tunica vaginalis in hydro- cele vaginalis and funiculi. When the testicle is adherent or the seat of larger tumors the castration is performed by means of a transverse incision in a frontal direction at the lower end of the scrotum. After the skin and dartos tunic (Fig. 7) are divided between the visible larger scrotal vessels, the testicle with its envelopes is turned out. As the incision is parallel to the scrotal vessels (external scrotal arteries) , so it is also on the surface of the vaginal tunics parallel to the branches of the vessels of the spermatic cord passing to the lower pole. ABDOMEN. 127 Y8. Inguinal Herniotoiny. — The incision for this operation is -exactly like that for the exposure of the spermatic cord descriljed above. After sufficient division of the cremaster and especially of the infundibuliform fascia, the neck of the hernial sac can generally be readily isolated, without cutting, from the struc- tures belonging to the spermatic cord and lifted by traction from the scrotum as far as its rounded lower end. The limits of a thin hernial sac can also be rendered apparent by stretching the tissues of the spermatic cord and holding them to the light. For the radical operation uj^vvard the hernial sac is carefully isolated and vigorously drawn down, until the portion lying in the posterior inguinal ring can be seized, stitched with silk thread, and strongly ligated in two directions. After being cut off below, the ligated portion is entirely withdrawn into the abdomen. Then a series of deep sutures are placed through the fascia of the external oblique and the muscular fibres under- neath so as to narrow the entire length of the inguinal canal. 79. Isolation of the Round Ligament (Fig. 43). — The round ligament in the female sex is isolated in an analogous manner to the spermatic cord. But the operation is much easier because of the absence of the cremaster and of a distinct infundibuliform fascia. The placing of the incision depends upon the way the ligament is to be stitched, in retroversion, retroflexion, and pro- lapsus uteri. We have obtained very good results from the following modification of Alexander's operation : The entire length of the incision is carried the breadth of the little finger above Poupart's ligament through the skin, the superficial fascia, and above the inner half, ?'.e., above the in- guinal canal, through the fascia of the external abdominal oblique. The superficial hypogastric artery in the superficial fascia together with the vein, and a vein ascending vertically at the inner angle of the wound, are ligated. The round ligament with the accompanying thin vessel can now at once be isolated out of the groove of Poupart's ligament without resort to the 128 OPERATIVE SURGERY. knife. The round ligament is freed from its peripheral attach- ments toward the symphysis and vigorously drawn out in the direction toward the anterior superior iliac spine. We can readily convince ourselves on the cadaver that by this means the uterus is drawn up, bent forward, and, if the operation is Round ligament turned outward Cone of peritoneum withdrawn Point to which the continuous / suture extends ) Fascia of the external oblique, divided- Anterior inguinal ring, divided Fig. 43. done bilaterally, held so tensely on both sides as to remain fixed in its new position. But the round ligament carries with it a cone of parietal peritoneum about 3 cm. long. As, soon as we have convinced ourselves that no intestines have come forward with this cone, the ligament is stitched with a continuous silk suture to the fascia of the external oblique. The suture includes also the per- itoneal cone, begins at the anterior superior iliac spine, and extends to the posterior inguinal ring. Then the inguinal canal is again closed with deep sutures (compare No. Y8). 80. Resection of the Vermiform Appendix. — The method of operation can here be only outlined for cases in which the ap- pendix is resected in the intervals between relapsing inflamma- tions, and in the absence of perityphlitic or paratyphlitic exu- dations and abscess. ABDOMEN. 120 The incision (see Fig. 7) is like that for the ligation of the common iliac artery but shorter, two fingers' breadth above the right anterior superior iliac spine, along the external half of Poupart's ligament and extending beyond its middle. The dif- ferent layers are divided as in the ligation of the above-named artery, but the peritoneum is likewise opened in the line of the incision. If possible the caecum is drawn out, otherwise the appendix, whose situation varies, is sought, freed from adhe- sions, and withdrawn. Its mesentery is cut between two liga- tures. One centimetre from the attachment of the appendix to the csecum the serous and muscular coats are cut around and dissected off ; finally the mucosa is surrounded with silk thread as close as jjossible to the csecum and severed, and the stump is touched wi^h the thermo -cautery so as to disinfect it. Then it is turned in and stitched over it with a continuous silk suture. 81. Formation of a Fecal Fistula (Fig. 44). — In every case in which the intestinal gases cannot be expelled and thus give rise to respiratory and nutritive disturbances, the temporary formation of a fecal fistula may be indicated, especially in ileus in the more restricted sense and in peritonitis. By gaining time many a life can be saved. The operation, when correctly per- formed, is absolutely free from danger and therefore should not be postponed too long. The abdominal wall is incised at various points, preferably, where choice is possible, two to three fingers' breadth above the middle of Poupart's ligament, and parallel to it, for a distance of 6 cm. After dividing the abdominal wall down to the peri- toneum, the latter is nicked to a less extent, say 2 to 2.5 cm. As a rule a tense loop of intestine at once presents in the wound and is so arranged as to fill the whole width of the wound witL- out being drawn out in any way. Then a button suture is in- serted in each of the four directions, to include the intestinal and the parietal serosa with the fascia, but away from the peri- toneal wound (Fig. 44), so as to fasten the intestine to the 130 OPERATIVE SURGERY. abdomiaal wall. After this follows, corresponding to the edge of the peritoneal opening, an uninterrupted fine silk suture which kermetically presses the parietal and the intestinal serosa together. In the centre of the opening thus made a quick short insdsion is made with a small knife and a sound is introduced to Parietal peritoneum Fascia of the external abdominal oblique Transverse fascia Surface of intestine Fig. 44.— Formation of a Fecal Fistula. make sure that the lumen of the intestine has been reached. The wound is powdered with iodoform oraristol, and warm 0.1^ salicylated water compresses are applied and frequently changed. 82. Formation of an Artificial Anus (Fig. 45). — A small fecal fistula always suffices for the temporary evacuation of the intestine in tympanites. An artificial anus, therefore, is formed only in cases where a permanent-discharge and protection of the inferior intestine from the contents are intended. The opera- tion is performed in the following manner : Incision two fingers' breadth above Poupart's ligament, extending laterally from its middle. After opening the abdominal wall as for fecal fistula by dividing the three muscular layers and fascia, and the peri- toneum to a less extent, the intestine — for instance, the sigmoid flexure in impassable rectal cancer — is drawn into the wound until a complete loop is present. This is stitched to the parietal peritoneum with a continuous silk suture so that the afferent portion of the intestine has ample room, while the efferent por- tion is compressed by the former. Then a triangular piece is ABDOMEN. 131 resected from the convexity of the loop as far as the attach- ment of the mesentery. Unless opening is urgent it should be jjostponed until good adhesions have formed (two days) . 83. Resection and Suture of the Intestine (Figs. 46 and 47), — If gangrenous hernise, constrictions, or new -formations call Skin Abdominal wall Parietal peritoneum Fig. 45.— Formation of an Artificial Anus. ' for the removal of a portion of the intestine, the first care should be, not only that the resection be made in healthy tissue, but also at the points where a free mesenteric blood supply is assured. The intestine is not divided quite transversely, but in a somewhat oblique line, so that a little more is removed from the convexity so as to make sure of the circulation on that side of the intestinal wall which is farthest from the mesentery. The latter is never unnecessarily extirpated, even where it lies in thick folds, but always divided as close to the gut as possible, along its attachment. For the suture the extremities of the gut must be placed in a handy position outside the abdominal cavity if at all possible, then the mesenteric portions of the two intestinal lumina are first brought in contact by a silk button suture, whose ends are left long. Next a second button suture is placed at the convexity through both intestinal lumina. The intestinal wall being: now ' The figure represents the operation on the right instead of the left side and therefore should be reversed for the flexure. 132 OPERATIVE SURGERY. turned in toward the lumen until broad surfaces of the serous covering are in contact (Lembert), a continuous and reliable silk suture is placed, which must include the muscular and^' serous tissues and be drawn very tight. Over this first suture is placed a second (after Czerny and Kocher) uninterrupted fine silk suture through the serosa only, the first end of the thread being tied to the last. A thorough cleansing with 0. ^% table - salt solution at 98.6° F. is followed by another with 0.1% sublimate solution, and every trace of this fluid is again removed with warm salt water. If Fig. 46. Fig. 47. — Intestinal Resection and Circular Intestinal Suture. Longitudinal section. 84. High Supra-Pubic Cystotomy (Fig. Y). — The bladder in- cision above the symphysis is at present the normal procedure for opening the bladder for very different indications, as, con- trary to the perineal operation, it enables us to secure healing by first intention. The normal incision runs transversely in the fold above the symphysis through the fat, skin, and fascia so as to expose the recti. In the Trendelenburg position with its high elevation of the pelvis this permits a very good view upon ABDOMEN, 133 and into the bladder. Some vertical veins are to be severed and ligated. In order to gain sufficient room without exposing the peritoneum to danger, the soft parts above the symphysis are freely divided, and the incision is carried in a curve from the region above one inguinal canal to the same point on the oppo- site side. The attachments of the recti muscles to the symphysis are partly severed with the pyramidal muscles. In the depth a longitudinal division of the median line through the linea alba (united fascia of the abdominal recti) is added. The finger is introduced behind the symphysis and draws up the thin fascia, the subserous fat, and with it the reduj)lication of the perito- neum which can be seen or felt as a transverse fold or promi- nence. This manipulation in conjunction with' the high position of the pelvis renders unnecessary the elevation of the bladder by filling it or the rectum. The latter measures are not without danger from rupture or injury of these organs when diseased. It is desirable to draw a firm loop of thread through the entire thickness of the muscular layer at the lowest point of the bladder which can be readily reached. In the same way a second loop is passed through the muscular tissue of the vertex of the bladder at the peritoneal fold. The introduction of such loops materially facilitates the subsequent suture after the blad- der has been evacuated. Between the two loops the muscular tissue is divided in a vertical direction until the mucosa projects as a bluish vesicle. Hemorrhages are at once arrested. On puncturing this protru- sion the urine (or the aseptic solution introduced into the bladder) spurts out and the incision can be extended according to re- quirements for the extraction of a stone, excision of a neojDlasm, or mere inspection and digital exploration of the bladder. The mucosa does not need as large an opening as the muscular coat, being very elastic. The bladder is closed with a two-tiered suture, the first extending to the mucosa, the superficial one 134 OPERATIVE SURGERY. (uninterrupted) including the covering cellular tissue with the muscular coat. Then follows the closure of the external wound. Before the operation the bladder has been thoroughly irri- gated and filled with 150 to 200 ccm. of boiled 4:% boric acid solution at 98.6° F. For the after-treatment a Nelaton catheter is introduced through the urethra to which it is fastened by a silk thread car- ried through the frenulum, and the urine is permanently con- ducted through a rubber tube into a bottle filled with 5^ car- bolic acid (or 0.1^ sublimate) solution, placed close to the bed. The catheter remains in place from one to two weeks until the healing of the bladder wound is assured, A drainage tube is inserted as far as the bladder through the skin, as tisual through a separate small opening, and exceptionally allowed to remain for eight to ten days. 85. Opening of the Bladder ivith Resection of the Symphysis. — Where a large transverse incision does not afford sufficient room for operations in and upon the bladder, it is best to follow Helferich's procedure: after separating the attachments of the nauscles (above, the abdominal recti and pyramidales; below externally, the obturatores extern!) a triangular wedge with broad upper base and the point above the pubic arch is resected subperiosteally from the symphysis and the periosteum on the posterior surface properly detached. This manipulation does no further injury to the firmness of the pelvis. Dr. Niehans makes the symphyseal resection on one side only, but does it thor- oughly. P. Perineum. The perineal region appears rather complicated anatomically, especially as regards the fasciae. Operations on the perineum are intended to expose the lowest part of the rectum, the urethra, the prostate and seminal vesicles, the vagina, the uterus, and the base of the bladder. PERINEUM. 1 35 The operation which formerly occupied the foreground and fur- nished the most frequent indication was lithotomy. 86. Perineal lithotomy was looked upon as the normal pro- cedure until quite recently, the only question having been the selection of the most appropriate method among its different varieties — lateral incision, bilateral incision, median incision. That the incision from below has been practised so long is to be explained by the fact that the infection of the wound in the high operation could not be prevented, while in the perineal operation at least the escape of the urine and the wound secre- tions could be provided for, so that their infiltration into the tissues would not increase the danger of infection. At present the only definite indication for perineal lithotomy is in those rare cases in which small stones cannot be removed by lithotripsy, though they are too large to pass through the intact urethra. In such cases the urethral incision is made in the membra- nous portion and the perineal incision coincides with external urethrotomy. The latter is performed, moreover, in lacerations, strictures, fistulse, for digital exploration of the bladder, and finally for the removal of foreign bodies from the bladder and urethra. Other indications for the perineal incision are ab- scesses and neoplasms of the prostate and seminal vesicles. Excepting the middle lobe which often projects into the bladder, the prostate is best made accessible from the perineum, and Dittel and Zuckerkandl have given minute directions for the operation. Diseases of the uterus are treated through the vagina, diseases of the rectum preferably through a posterior incision (see Surgery of the posterior pelvic region). Still, the prostate with the seminal vesicles can also be very well reached through this posterior incision beside and beyond the rectum. 87. Opening of the Cavernous and Bulbous Portion of the Urethra. Median Incision. — A median incision is made down to the fibrous albuginea of the corpus cavernosum. Unless the 136 OPERATIVE SURGERY. latter requires opening or removal for disease, the urethra is reached beside the lateral circumference of the corpus caver - nosum, especially beside the bulb, one of the wound margins being drawn aside. 88. Opening of the Membranous and Prostatic Portion of the Urethra. Normal Incision for Giving Free Access (Figs. Fig. 48. 48 and 49). — This operation also gives access to the prostate, seminal vesicles, and the urethral extremity of the vasa defe- rentia. It requires a large external opening, hence the median incision is at once out of the question. A purely lateral inci- sion, such as was formerly made by preference, divides the ves- sels and nerve twigs passing from the internal pudendal artery and nerve toward the median line (posteriorly the external hemorrhoidal arteries and nerves, anteriorly the perineal and bulbosa artery, with the nerves running parallel to them). Al- PERINEUM. 137 tliough sacral resections have shown that the unilateral division of these nerves does not necessarily lead to permanent motor disturbances, still injury of these structures is to be avoided on principle, and the transverse curved incision is to be considered the normal procedure for giving free access. The incision begins on the right between the tuber ischii and Fig. 49. rectum, passes forward to the posterior end of the palpable bul- bus urethr^e, and symmetrically backward on the opposite side. After dividing the skin and the sujDerficial thin fascia, we reach the ischio-rectal excavation laterally in the adipose tissue between the pelvis and rectum. This is separated without cut- ting as far as the lower surface of the levator ani muscle. During this step the external hemorrhoidal nerve and artery are pushed or draw^n backward, the perineal nerve and artery 138 OPERATIVE SURGERY. (trans versus perinei) and the bulbosa forward. Close to the bulb the connecting fibres between the external sphincter ani and the bulbo-cavernosus muscle are divided transversely and the bulbus urethrse is drawn forward. The superficial trans- versus perinei muscle remains in front. At the anterior sur- face of the rectum an organic muscle-fibre layer connects the bundles of the levator ani muscle transversely. This is covered by a fascia in front which rises to Douglas' pouch. At the point where this fascia joins the deep layer of the pelvic fascia over the bulb it is severed and drawn backward, together with the above-named muscular layer and the lower end of the rectum. In this way the posterior circumference of the uro- genital diaphragm is exposed, namely, below the triangular urethral ligament, above the posterior broad margin of the deep transversus perinei muscle which covers the membranous por- tion of the urethra as far as the prostate. Within the deep transversus perinei muscle Cowper's glands are situated, and may there be rendered accessible. Working upward along the diaphragm without cutting, the fibres of the levator ani muscle, which run in the sagittal plane postero-inferiorly, are displaced to both sides, and thus we reach the smooth posterior surface of the prostate and higher up the seminal vesicles which can be made clearly visible. The latter are loosely united with the peritoneum and may be easilj" de- tached up to their upper end. Should the incision fail to give sufficient room, it can be lengthened backward on both sides, the sacro-tuberous ligament being severed at its attachment to the tuber ischii. 89. Internal Pudendal Artery at the Perineum, and Internal Pudendal Nerve at the Perineum. — Incision close to the easily palpable tuber ischii, passing along the medial border of the pubic arch forward through the skin. The fascia is divided, sparing the cutaneous branch of the pudendal nerve which passes to the scrotum. In the anterior portion the belly of the SACRAL REGION. 139 ischio-cavernosus muscle is exposed. Close to its attachment the superficial transversus periuei muscle is severed at the as- cending ramus of the ischium, and at the same time the deep layer of the fascia is divided vs^hich forms the inferior covering of the uro-genital diaphragm, and is reflected on the inner sur- face of the internal obturator muscle. The artery lies on the inner surface of the last-named muscle, passing forward above the attachment of the sacro-tuberous ligament; the internal pudendal nerve lies beside it and more superficially. Q,. Sacral Region. Since the conviction has gained ground that, in those cases in which intra-peritoneal exposure of the pelvic organs is im- possible or contra-indicated, access from behind is for various reasons preferable to that from the perineum, the surgery of the sacro-coccygeal region has acquired a greater interest. 90. The rectum in particular is often exposed from behind for the extirpation of neoplasms, but this way is also employed for reaching the upper part of the vagina, the uterus, the pros- tate, the base of the bladder, and the seminal vesicles. The cutaneous incision (normal incision) begins at the side of the gluteal fold, usually the left, in the groove between the depressed sacrum and the prominence of the glutseus max- imus, two fingers' breadth below the superior posterior iliac spine. It passes downward to the median line and along this to the tip of the coccyx at the posterior margin of the anus, eventually circling around the latter into the raphe of the per- ineum. Along the sacrum the attachment of the glut?eus maximus is severed and the edge of the bone laid bare. At the margin of the sacrum the ligaments and muscles are divided and we enter the depth by the side of the bone (Zuckerkandl, Wolfler). A better view is gained by the extirpation of the coccyx, accord- 140 OPERATIVE SUKGERY. ing to the method used by Verneuil for imperforate anus and employed by Kocher for the excision of the rectum. Where necessary a portion of the sacrum is likewise resected, either Ketro-rectal fascia with fat Levator ani muscle V \ External sphiocter ^ Fat Incision of glutseus maximus muscle Anus Divided coccyge°us*^muscle | ' Pjnfoimit, muscle Divided sacro-tuberous and sacro-spinous ligaments oacrum ( attacnment oi gluteus ^ " maximus muscle) Left seminal vesicle Vas deferens Divided sacro-tuberous and sacro-spinous ligaments External sp'iincter / Base of Levator ani muscle bladder Rectum drawn out toward the right Sacruni Pyrif ormis muscle Fig. 50. — Parasacral Posterior Pelvic Incision. the left margin only or a large piece as far as the fourth, third, or even the second sacral foramen according to Kraske's method. We may go, at least on one side, as far as the second sacral SACRAL REGION. 141 foramen without causing permanent injury, although the nerves for the bladder and rectum are derived from the fourth and fifth sacral nerves and the internal pudendal from the third sacral. If the bone is not resected, we sever at the left margin of the sacrum and on both sides of the coccyx the attachment of the tuberoso-sacral and spinoso-sacral ligaments; of the attach- ments of the muscles, from above downward, the pyriformis, the coccygeal, and ischio-coccygeal ; below the tip of the coccyx the levator ani and sphincter ani. If the coccyx is removed, it is exarticulated with the resection knife ; if a portion of the sacrum is resected, it is divided with a few powerful blows of the chisel and its lower end dissected out in its entire width in connection with the coccyx. This occasions often rather free hemorrhage, both from the divided bone and especially from the sacral arteries (sacralis media and lateralis), the former derived from the aorta, the latter from the hypogastric. As these vessels closely adjoin the sacrum they are at times hard to seize and to ligate, and a temporary tamponade must be resorted to. At the lowest part of the rectum the thick prominence (several centimetres high) of the external and internal sphincter ani with the median levator is to be divided if the anal portion is to be enucleated. Alongside of the rectum the levator ani muscle is divided to the raphe of the perineum ; during this step some branches of the external hemorrhoidal artery (from the internal pudendal) will spirt. For exposing the rectum higher up the main conditions are, first, the proper detachment of the connections with the anterior surface of the sacrum, of the sacro- coccygeal muscle and liga- ments ; second, the thorough division of the peritoneum in the region of Douglas' pouch, which in the male reaches down to the palpable upper margin of the prostate, in the female to the fornix vaginae. After the peritoneum is divided the rectum can be so far withdrawn that a portion 20 to 25 cm. distant 142 OPEEATIVE SURGERY. from the anus may be stitched into the anal ring without using force. In freeing the rectum higher up, branches of the median hemorrhoidal artery (from the hypogastric) and of the internal hemorrhoidal artery (from the inferior mesenteric) must be li- gated ; the thickest branches lie laterally. After the fascia is severed and the vessels coming from the side and behind are Anterior circumflexa humeri artery Musculo-cutaneous nerve Musculo-cutaneous nerve Brachial artery | Brachial artery Deep brachial artery and radial nerve Fig. 51. ligated, the rectum can be withdrawn from the wound with a large blunt hook, so that after dividing the frontal prerectal layer of the fascia the upper circumference of the prostate and the seminal vesicles with the inferior end of the vas deferens can be distinctly seen along with the base of the bladder. Near the upper end of the seminal vesicles in an outward direction the inferior extremity of the ureter can also be exposed. UPPER EXTREMITY. 143 R. Upper Extremity. a. Sliouhler Jieyion. 91. Subclavian Artery by Transverse Incision (Figs. 51 and 52). — Incision 1 cm. below the middle third of the clavicle, dividing the iSbres of the platysma with the sensory supra- Long head of biceps Circumflexa anterior humeri artery Cephalic vein Deltoid muscle Pectoris major m. , Brachialis internus m .M I ;sci I In-cutaneous n BiCH-V's , \ Biceps muscle Median nerve Brachial artery I Laeertus fibrosus bicipitis Brachial artery Median vein Brachio-radialis muscle Pectoralis major muse Subclavian Subclavian muscle Subclavian arter Cephalic vein Deltoid muscle Root of me- dian and ulnar nerves M '/ / ^.•■. Anterior thoracic nerves Fig. 53. clavicular nerves. The cephaHc vein at the anterior margin of the deltoid is to be preserved when the fascia is divided. The clavicular portion of the pectoralis major is severed to the mar- gin of the deltoid. Beneath the clavicle the tense fascia of the subclavian muscle is divided and drawn down together with the cephalic vein which passes to the subclavian. The axillary plexus lies deeper and outward. Between the most medial nerve trunk (ulnar with cutaneus medius) and the vein lies the artery on the serratus anticus muscle. 144 OPERATIVE SURGERY. 92. Under the subclavian muscle the superior thoracic artery (Figs. 51 and 52) branches from the main trunk and at the same point the latter is surrounded by the motor branches to the pectoralis major and minor, namely, the anterior thoracic nerves. Subclavian Artery by Longitudinal Incision (Fig. 36). — Incision upon the clavicle, beginning at the limit between the middle and outer third, extending in the palpable furrow be- Axillary artery Subscapular artery Thoracica longa artery Fig. 53. tween the deltoid muscle and the clavicular portion of the pec- toralis major muscle toward the axillary fold. After the skin is divided the cephalic vein appears in the fascia and is drawn to the medial side if the artery is to be ligated close under the clavicle. But this has the drawback that a point is exposed where the important anterior thoracic nerves pass from without and above over the artery in their course to the pectoral muscles. UPPER EXTREMITY. Uo Where the choice is free, therefore, the cephahc vein is drawn laterally upward. Under its terminal portion, i.e., be- fore it empties into the subclavian vein, lies the artery and laterally from it the nerve trunks of the axillary plexus. 98. Under the upper margin of the pectoralis minor muscle below which the artery passes we strike the point where the thoracico-acromial artery is given off (Fig. 36), whose branches lie in front of the main artery. 'Tncep<5 mu'scl Ulnai nerve Coraco-brachialis niuseie Median nerve Axillary vein Teres major muscle Latissimus dorsi muscle Anconaeus long-us muscle Subscapular artery Subscapular nerve C'ircuniflexa scapulae aii«ry Thoracico-dorsalis artery ( Subscapular muscle with ■) teres minor Fig. 54. Detachment of the pectoralis major for a short distance along the clavicle facilitates the operation. 94:. Long Thoracic Artery (Fig. 58). — Incision along the anterior axillary fold, the arm being abducted, beginning at the lateral surface of the thorax. After the fascia is divided the artery is found directly behind the margin of the pec- toralis major, passing down the thorax or the serratus an- 10 146 OPERATIVE SURGERY. ticus major in the axillary line. Behind it lies the long thoracic nerve. b. Axilla. 95. Axillary Artery (Figs. 53 and 54). — Direction from the middle of the clavicle to the middle of the anterior axillary fold. It lies on the lateral wall of the triangular prismatic space be- tween the thoracic wall interiorly (serratus anticus major) ^ pectoralis major and minor anteriorly, and scapula, (subscapular muscle) posteriorly. Incision through skin and fascia in the prolongation of the internal bicipital sulcus, extending upward at the inner margin of the muscular prominence of the coraco- brachialis which appears under the pectoralis major toward the arm. The belly of the coraco-brachialis is exposed. The axil- lary plexus, which is palpable even through the skin on the rounded eminence of the head of the humerus, is in sight. We pass between the two most lateral nerve trunks. The thinner external one of these is the musculo- cutaneous, the thick medial one is the median; sometimes only the latter is visible. Higher up the median consists of two parts, the lateral one of which unites with the musculo -cutaneous nerve. The artery lies in the fork between the two roots of the median. The ulnar nerve lies. in a median direction from the vessel ; the radial nerve posteri- orly ; the chief vein quite anteriorly ; a smaller collateral vein exteriorly from the artery. 96. Anterior Circumflex Artery (Figs. 51 and 52). — Incision at the anterior margin of the deltoid at the point where the finger can be pressed in upon the surgical neck of the humerus. On the fascia lies the cephalic vein. It is important for determining the furrow between the deltoid and pectoralis. major. After dividing the fascia the muscles are separated from each other without cutting, the former being drawn out- ward, the latter inward. The short head of the biceps with the coraco-brachialis, which, coming from above, passes under tha UPPER EXTREMITY. 147 pectoralis, is freed on its lateral side and drawn in a median direction. We enter between it and the long biceps tendon. The artery runs transversely, adjoining the bone close under the rounded head, above the attachment of the pectoralis. 97. Posterior Circumflex Artery and Axillary Nerve (Figs. 55 and 56). — Palpation at the posterior margin of the deltoid muscle toward the surgical neck of the humerus will distinctly feel the angle, open below, formed by that muscle with the posterior scapular muscles or the teres minor. After dividing the skin and the fascia which adheres rather firmly to the deltoid, the margin of the latter is freed and drawn upward, then upward and backward the lower margin of the teres minor is exposed above the teres major and latissimus muscles lying in the posterior axillary fold. In the angle formed by the margins of the teres minor and deltoid the tissues are separated without cutting toward the bone, the long head of the anconaeus which projects under the teres minor being left in the rear. First appears the thick axillary nerve which gives off a cutaneous branch downward along the margin of the deltoid. Below we strike the posterior circumflex artery which passes from the space between the teres major and minor, and whose branches pass up and down. 98. Subscapular Artery and Nerves (Figs. 53 and 54). — In- cision on the arm, beginning along and above the posterior axillary fold, the arm being strongly abducted. On the fascia, intercostal roots of the internal cutaneous nerve may appear. After the fascia is divided, the artery becomes visible at the upper margin of the latissimus dorsi muscle (which forms the posterior axillary fold with the teres minor), in the loose adi- pose tissue. The trunk is short. 09. The continuation of the trunk toward the thorax is the thoracico-dorsalis artery, accompanied by the thick subscapular nerves which come from above. 100. The other main branch is the circumflexa scapula? 148 OPERATIVE SURGERY. UPPER EXTREMITY. 149 150 OPERATIVE SURGERY. artery which passes backward between the latissimus (with teres major) and subscapular muscles on the medial side of the anconseus longus muscle. c. Arm. The brachial artery may be felt in the internal bicipital sulcus through the entire length of the arm, below the equally palpable median nerve which crosses the artery in the middle from without inward, passing over it. The artery can be com- pressed in its entire length against th^ biceps. 101. Brachial Artery at its Middle (Figs. 51 and 52). — In- cision upon the cord of the median nerve which can be distinctly felt in the internal bicipital sulcus when the arm is abducted. On the fascia is the thin internal cutaneous nerve. The fascia is divided to expose the belly of the biceps muscle which is drawn laterally. The median nerve is completely exposed and separately drawn in a median direction. Immediately beneath is the brachial artery in front of the intermuscular ligament at the bone, with the two concomitant veins. Near its median side is the middle cutaneous nerve. Below the middle of the arm the basilical vein enters the brachial and the middle cutaneous nerve passes through the fascia. These structures can' be exposed by the same incision as for the ligation of the brachial artery. 102. Deep Brachial Artery on the Outer Side of the Arm below the Middle (Figs. 55 and 56). — Incision at the outer margin of the prominence of the aconseus externus muscle which can be readily located by being grasped from behind, passing downward at the humerus from the attachment of the deltoid. The body of the anconseus muscle is exposed by an incision be- hind the strip of fascia which indicates the external intermus- cular ligament and the muscle is detached from the latter liga- ment as far as the bone. The artery comes forward obliquely from behind ; beside it close to the bone is the radial nerve. UPPER EXTREMITY. 151 On the Dorsal Surface of the Arm above the Middle. See Exposure of the radial nerve at the same point (Figs. 55 and 5(3). On the Inner Side of the Arm in the Upper Third (Figs. 51 and* 52).— Incision in the internal bicipital sulcus from the height of the posterior axillary fold downward through skin and fascia. The latter is divided on the prominence of the anconseus longus muscle behind the white streak of the internal intermuscular hgament. Along the anterior surface of the last-named muscle we proceed toward the bone behind the attachment of the anco- nseus internus to the humerus. The first to appear is the pro- funda artery which gives off a downward branch to the internal head of the triceps (collateralis media artery). Somewhat deeper lies the radial nerve which, descending from above over the tendon of the latissimus, passes between the ancongeus internus and longus muscles toward the dorsal surface of the humerus. The superior collateral ulnar artery comes within the same incision. It arises some distance below the profunda and runs in the internal bicipital sulcus behind the large vascular and nerve trunks. The terminal branch of the deep brachial (the collateral radial artery) may be felt on the base of the external condyle • of the humerus in the furrow between the brachialis internus and brachio-radialis and is to be there ligated behind the radial nerve. 103. Superior Collateral Ulnar Arter?j.— For its ligation in the upper third of the upper arm see Ligation of the deep brachial. At the lower end the artery can be felt on the dorsal surface of the internal condyle and should be looked for beside the ulnar nerve behind the internal intermuscular ligament. lOi. Inferior Collateral Ulnar Artery.— The artery lies on the base of the internal condyle above the projection marking 152 OPERATIVE SURGERY. the attachment of the pronator teres, and can there be felt. It is found after dividing the tense fascia which carries a main branch of the median cutaneous nerve and the junction of the basihcal vein with the median. 105. Median Nerve (Figs. 51 and 52). — See Ligation of 'the brachial artery. The nerve in the upper half lies on the exter- nal, in the lower half on the internal side of the artery and more superficially. 106. Ulnar Nerve (Figs. 53 and 54). — Incision in a line ascending vertically from the internal condyle at the anterior margin of the belly of the triceps. Division of the fascia behind the white streak marking the attachment of the intermuscular ligament exposes the body of the triceps and at the same time the rather superficial nerve, behind the above-named ligament. 107. Radial Nerve. In the Loiuer Third of the Arm (Fig. 5Y). — Incision at the anterior margin of the brachio-radialis muscle. The fascia of the latter is divided and we penetrate without cutting along the margin of the muscle to the bone. On the outer side of the brachialis internus muscle lies the nerve which toward the elbow joint is already divided into the superficial and the deep branch, the latter resting on the bone, and both are in front of the external intermuscular ligament. Beloiv the Middle of the Arm on the Lateral Surface (Figs. 55 and 56). — Incision in a line ascending vertically from the external condyle at the lateral margin of the belly of the triceps below the attachment of the deltoid to the humerus ; the triceps is exposed (external head) and we penetrate at its margin toward the outer surface of the humerus, laterally from the brachialis internus muscle. The nerve adjoins the bone; on its external radial side the deep brachial artery runs parallel to the main trunk; behind it is the inferior cutaneous radial nerve. Above the Middle on the Dorsal Surface (Figs. 55 and 56). — Incision in a line ascending vertically from the tip of the olec- UPPER EXTREMITY. 153 ranon on the clorsfJ surface of the arm between the posterior margin of the delt(^id and the easily detached prominence of the long head of the triceps. At the lateral margin, after division of the fascia, we jDenetrate toward the bone, the fingers separat- ing the two above-mentioned heads of the triceps. The nerve lies between them. In the Upper Third on the Medial Side (Figs. 51 and 52). — See Ligation of the deep brachial artery in the internal bicipital sulcus. 108. Musculo-cutaneous Nerve. Beloiu the Middle of the Arm (Figs. 51 and 52). — Incision at the outer margin of the belly of the biceps, the cephalic vein being preserved; the fas- cia is divided as far as the body of the biceiDS, and the finger is insinuated behind the inner surface of the latter. The nerve lies under the thin fascia of the brachialis internus. Care should be taken lest the outer margin of the brachialis internus be exposed instead of that of the biceps. Above the Middle of the Arm (Fig. 51). — Incision in the in- ternal bicipital sulcus. The body of the bicej^s is laid bare and the muscle drawn laterally. The nerve lies at the lateral margin of the coraco-brachialis muscle through which it has passed so as to reach the anterior surface of the brachialis in- ternus muscle. d. Elhoiu Region. 100. Brachial Artery in the Bend of the Elhoiv (Figs. 51, 52, and 57). — Incision midway between the two condyles, some- what nearer to the ulnar side, at the medial edge of the biceps tendon. On the fascia are the oblique median vein and the cutaneous branches of the median cutaneous nerve. Under the thin fascia the characteristic fibres of the aponeu- rotic bicipital fascia, passing obliquely downward toward the ulna, become visible and are divided in the direction of the cu- taneous incision. Immediately beneath, the artery lies im- 154 OPERATIVE SURGERY. bedded in the fat accompanied by two veins. The biceps tendon lies laterally. 110. Median Nerve (Fig. 57), 0.5 cm. in a median direction at the lateral margin of the pronator teres muscle. The brachialis internus muscle supports the bundle of vessels and nerves. In performing this ligation we must remember that Radial artery - Biceps tendon Median nerve Brachialis internus nius Brachial artery Pronator teres muscle Ulnar artery Fig. 57. the artery descends from the internal bicipital sulcus, hence not to penetrate into the depth on the lateral side of the biceps tendon. The brachial artery divides into the radial and ulnar a finger's breadth below the line of the joint. 111. Ulnar Nerve (Fig. 55). — Incision from behind upon the base of the internal condyle ; closely adjoining this subf ascially lies the thick nerve, descending between both attachments of the internal ulnar muscle to the condyle, and passing at the olecranon to the flexor profundus. 112. Radial Nerve (Figs. 58 and 59). — At the elbow joint the radial nerve, together with its deep branch, lies in the furrow between the brachio-radialis and brachialis internus muscles. Incision in the prolongation of the external bicipital sulcus at the anterior margin of the belly of the brachio-radialis in the bend of the elbow. The cephalic vein is drawn down. After the fascia is divided we strike beside the biceps tendon the musculo-cutaneous nerve which pierces the fascia so as to furnish the sensory supply to the radial anterior side of the UPPER EXTREMITY. 15") forearm. If we penetrate at the external margin of the brachi- alis internus muscle we reach on the bone the superficial and deep branch of the radial nerve, one behind the other, and beneath them the terminal branch of the collateral radial artery. e. Forearm — Volar Surface. 113. The Radial Artery (Figs. 58 and 59) forms the straight continuation of the brachial artery ; for two-thirds of its length it can be readily felt, is nowhere covered by muscles, and only in the upper third is the brachio-radialis drawn over it by the fascia. The direction of the artery is determined by a line from the middle of the bend of the elbow to the point where the pulse is felt, or below this to the prominence of the trapezium. This line at the same time marks the limit of the muscular branches of the median and radial nerves at the forearm. In the Lower Third.— The hand being hyperextended, the incision is made between the prominent tendon of the internal radial muscle and the margin of the radius or the tendon of the brachio-radialis. Skin and fascia are divided; the artery lies immediately under the fascia between two veins upon the pro- nator quadratus muscle. The superficial branch of the radial nerve is no longer visible, as it passes dorsad under the tendon of the brachio-radialis muscle at the lower third of the forearm. I7i the Middle. — Incision between the muscular prominences of the radiaHs internus and brachio-radialis muscles which rise on both sides. In the furrow lies the artery on the radial at- tachment of the flexor polHcis longus muscle. On its radial side is the superficial branch of the radial nerve. In the U2oper Half. —The artery lies more deeply on the radius because the muscular prominences of the brachio-radialis and the radialis internus are no longer present. Incision in the distinctly palpable furrow between these muscles. On the fascia appear the cephalic vein and a thick branch of the mus- 156 OPERATIVE SURGERY. culo-cutaneous nerve. The fascia is divided. The brachio- radialis muscle is to be well drawn aside in a radial direction, and the artery lies deep upon the radial attachment of the pro- nator teres. To the radial side of, the artery lies the superficial (sensory) twig of the radial nerve. 114. Ulnar Artery (Figs. 58 and 59). — It can be felt in the lower half because the greater portion is not covered by muscles ; above, after being given off at an angle from the brachial ar- tery, it lies between the deep muscles, namely, the flexor digi- torum sublimis and profundus. The line indicating the cuta- neous incisions for its ligation passes from the internal condyle of the humerus to the prominence of the pisiform bone. The line does not correspond to the position of the artery which lies more toward the median line, especially above. In the Lower Half. — Incision in the furrow between the in- ternal ulnar muscle and the flexors ; this furrow is well marked in the vertical prolongation from the medial margin of the pisi- form bone upward. Skin and fascia are divided; we penetrate toward the bundle of flexors, not under the internal ulnar muscle. The artery lies between two veins. The ulnar nerve is close to its ulnar side. I7i the Upper Half. — Incision in the above-mentioned line at the margin of the internal ulnar muscle which is limited by a palpable furrow. Occasionally the ulnar nerve can be felt through the skin. After the skin is divided, we strike the basilical vein with a branch of the cutaneus medius nerve on the fascia. In the latter the interstice between the internal ulnar and the palmaris longus muscles above, and the flexor sublimis below, is marked by a distinct white streak. When the fascia is severed along this streak the finger penetrates without cutting alongside the internal ulnar muscle to the flexor digitorum profundus, the flexor sublimis being pushed aside. If we are in the true interstice between the two last-named muscles we come first upon the thick ulnar nerve. We pass UPPER EXTREMITY. ]57 _ Bracliio-radialis muscle Musciilo-cutaneous nerve \ Inferior collateral I'adial artery >- Radial nerve - -■ — Brachialis interniis muscle ; — Middle of the bend of the elbow Supinator longus muscle Radial nerve Pronator teres muscle Internal ulnar muscle. Flexor sublimis muscle. Ulnar nerve. Ulnar artery Radialis internus muscle - Median nerve- Pronator teres muscle- Interosseal artery - Interosseal nerve' Flexor sublimis muscle' Radial artery" Radial ner\e Supinator longus (brachio-radialis) muscle RadiaUs internus muscle Ulnar nerve. Tendon of internal ulnar muscle Ulnar artery Radial artery Tendon of radialis internus muscle if-jMjJ Tendon of palmaris longus muscle The two radial i |f;iZZ Ramus palmaris ^ems ( ^^^, ^Ulnar artery Ulnar nerve -Trapezium Ospisiforme Flexor pollicis brevis Ulnar artery muscle Tendon of flexor sublimis Median nerve. Supei-flcial i:)almar arch Process of unciform bone Ulnar nerve '--'frr-V- Tendon of flexor digiti II. .■V~Deep palmar arch <^..^ \ Median nerve, '^<^^ 1 thumb branch ■ ,^,>^ Adductor pollicis muscle First lumbricalis muscle t f¥: k.-^ Ulnar nerve Digitalis ^'olaris artery" 1 11^ Fig. 5!). Figs. 58 and 59.— Arteries and Nerves of the Forearm aud Hand. 158 OPERATIVE SURGERY. laterally in front of the nerve because it supplies branches to the 'muscles beneath (internal ulnar and flexor' profundus). Toward the upper end the artery lies more medially from the nerve. 115. Interosseal Artery (Figs. 58 and 59). — This branch of the ulnar artery can be exposed through the same incision as that for the ulnar artery in the upper third, by passing in a median direction from the flexor profundus muscle until the median nerve with its branches is found. Below the latter the interosseal artery passes tov/ard the interosseous ligament be- tween flexor profundus and flexor pollicis longus. Upon it lies the interosseous branch of the median nerve. The interosseal artery can also be exposed by the incision for the interosseus nerve just named (see Fig. 58). 116. Median Nerve (Figs. 58 and 59). .Above the Wrist Joint. — Incision through the skin between the tendon of the internal radial muscle and the palmaris longus ; close above the wrist joint we expose the point of perforation of the 117. Cutaneus palmaris nerve (from the median) ; the upper part of the latter, together with the trunk of the nerve, lies under the fascia of the deeper muscular layer. In the Middle. — Incision in the middle of the forearm at the radial end of the internal radial muscle, in the interstice toward the brachio-radialis muscle. The internal radial muscle is drawn toward the ulna. In the furrow appears first the radial artery and at its ulnar side we strike the flexor digitorum sub- limis muscle, whose radial margin is laid bare and drawn vig- orously to the ulnar side. The thick nerve becomes visible on the digitorum profundus muscle, accompanied by an artery. In the Upper Third. — Incision at the radial margin of the internal radial muscle in the deep furrow toward the brachio- radialis. Toward the ulna, beside the radial artery there ex- posed, we strike the pronator teres muscle which is drawn up- ward or divided. UPPER EXTREMITY. 159 The nerve is now laid bare, above the point where it passes under the teildon of the flexor digitorum sublimis muscle ; be- low, the radial attachment of this muscle must be severed from its main body so that the latter can be drawn toward the ulna. The median nerve rests on the flexor profundus. The same incision exposes: 118. Tlie Interosseus Nerve (from the Median). It lies more deeply on the interosseous ligament, in the furrow between the flexor digitorum profundus and flexor poUicis longus muscles. The interosseus nerve supplies the last-named muscle and farther down the pronator quadratus. Beneath the interosseus nerve lies the interosseal artery (branch of the ulnar artery). Deep Incisions on the Volar Side of the Forearm. — Bearing in mind the course of the radial artery and nerve on the one side, and the interosseal artery and nerve on the other side, we can penetrate on the radial side of the median throughout the entire length to the interosseal ligament and the radius without danger of causing any serious incidental injury, since this is the border line between the two nerve distributions. On the interosseal ligament we not rarely flnd deep abscesses due to extension of inflammations of the tendinous sheaths of the hand, requiring free and deep incisions. /. Forearm — Dorsal Surface. 119. Deep Branch of the Radial Nerve (Figs. 60 and 61). — Incision on the dorsal surface at the margin of the -eminence of the brachio-radialis and the radiales externi, extending be- tween these muscles and the extensor digitorum communis in a line vertically downward on the radial side from the head of the radius which can always be distinctly felt. The fascia is divided and the oblique attachment of the extensor digitorum communis is drawn backward and that of the radialis externus longus muscle forward. The characteristic oblique fibres of the 160 OPERATIVE SURGERY. supinator brevis muscle are thus laid bare. When these are divided, the nerve is exposed a thumb's breadth below the joint, descending from the' volar to the radial and dorsal side. Some of its longer branches pass between the extensor communis and radiales externi on the dorsal surface of the radius to the ten- dons of the abductor and the flexors of the thumb. Incisions on the dorsal surface of the forearm, whose muscles are supplied by the radius, may be made over the whole limb along the ulna ; also along the radial margin of the external ulnar muscle which adjoins the ulna and receives its nerve sup- ply high up. On the radial side incisions are admissible in a line from the head of the radius to the styloid process of this bone, ^'.e., from the point where the radial nerve pierces the supinator brevis, downward between the external radial muscles »and the extensor digitorum communis. In the lower half, where the external radial muscles pass under the oblique thumb muscles, the incisions must be made upon the radius, between the thumb muscles and the tendon of the brachio-radialis mus- cle. In an ulnar direction from the thumb muscles, in the lower half of the forearm, incisions can be made between all the tendons of the dorsal surface, as no larger vessels and nerves need be feared there. g. Wrist Joint — Volar Side. 120. Ulnar Artery at the Pisiform Bone (Figs. 58 and 59). — Its pulsation can always be distinctly felt here. Furnishing the main supply of the superficial volar arch, the artery requires ligation in hemorrhages at this point which resist other measures. Incision 5 mm. in a radial direction from the distinctly pal- pable prominence of the pisiform bone, extending through the skin and the common volar ligament of the wrist. The artery lies in a cushion of fat on the ligamentum carpi volare pro- UPPER EXTREMITY, 161 prium. The thick uhiar nerve adjoins it toward the pisi- form bone. 121. Median Nerve (Figs. 58 and 59). — Incision in the palm where the thenar and hypothenar eminences join, extending through the skin and the fascia of the thick ligamentum carpi volare proprium. The nerve lies flat on the common mucous sheath of the flexors and divides into two terminal branches: the first going to the muscles of the thenar excepting the ad- ductor, and to three finger margins at the thumb and index finger; the second, to two lumbricales and four more finger margins. Ji. The Hand — Dorsal Side. On the dorsum of the hand a line from above the centre of the middle finger upward to the wrist divides the distribution of the radial and ulnar nerves. The arterial dorsal arch and its intermetacarpal twigs are relatively unimportant vessels. In incisions, therefore, the tendons require the most attention. The extensor tendons at the wrist joint have to a great extent separate mucous sheaths down to the middle of the metacarpus. 122. Radial Artery on the Dorsum of the Hand (Figs. 60 and (11). — Main supply of the deep volar arch. Incision at the most posterior palpable end of the intermetacarpal space between thumb and index finger, along the ulnar side of the tendon of the extensor pollicis longus. On the fascia, twigs of the dorsal branch of the radial nerve and the cephalic vein must be pre- served. Passing between the bases of the above-named meta- carpal bones we strike the artery on the transverse ligament uniting them. Peripherally from the artery is the first interos- seus muscle. A common digital branch for the index finger and thumb, given oif by the artery, is very apt to be mistaken for it. 123. Badial Artery on the Trapezium (Figs. 60 and 61). — Longitudinal incision from the lower end of the radius to 11 162 OPERATIVE SURGERY. the base of the first metacarpal bone, between the tendons of the extensor poUicis longus and brevis muscles. In the sub- cutaneous tissue we must preserve the cephalic vein running parallel to the tendons and the dorsal radial nerve which can be felt upward on the radial side of the radius. In an oblique direction from the course of these structures and the tendons the artery lies under the fascia upon the joint capsule and bone. Dorsal Branch of the Ulnar Nerve (Figs. 60 and 62). — This can be distinctly felt on the ulnar side of the unciform. It is exposed by a longitudinal incision extending from the lowest point of the ulna downward on the ulnar side, and lies upon or in the fascia, passing dorsad under the internal ulnar muscle. Dorsal Branch of the Radial Nerve (Figs. 60 and 61). — This is exposed by the same incision as that for the radial artery on the trapezium (which see). It can be felt through the skin on the radial side of the lower end of the radius, after it has taken a dorsal direction at the lower third of the forearm under the tendon of the brachio-radialis muscle. i. The Palm of the Hand. In the palm the vessels and nerves run in the direction of the interstices of the fingers, -the tendons in the direction of the fingers, all under the tense superficial palmar fascia. The latter with its processes (ligamenta vaginalia) accompa- nies the tendons to the fingers, but between them ends in curves, ■concave below, which are attached by septa to the ligamenta capitulorum metacarpi, so as to separate the tendons with the muscles from the vessels and nerves. Above the muscles of the thumb and the hypothenar emi- nence the superficial layer of the palmar fascia coalesces with the deep layer. Under the palmar fascia the bundle of flexor tendons with the lumbrical muscles lies in a mucous sheath which extends UPPER EXTREMITY. 1G3 '^.M mmi ^m%k Brachio-radialis muscle ( Deep branch Extensor j -■I of the radial digitorum V I nerve communis m. ) Deep branch of the radial nerve Supinator brevis muscle iii Wl Extensor pollieis longus muscle • Dorsal branch of the ulnar nerve 'Radial artery (trapezium) ^Radial artery (on the dorsum) Radial artery Radial nerve Tendon of extensor pollieis longus muscle Dorsal metacarpal artery Fig. 60. Fia. 61. Figs. 60 and 61.— Dorsal Radial Artery, Radial Nerve with Branches, Dorsal Ulnar Nerve. 164 OPERATIVE SURGERY. from the ends of the forearm bones to the base of the metacar- pus. The flexor poUicis longus has a separate sheath. Under the bundle of tendons is the thinner deep fascia, covering the interosseus muscles and the bones. The guiding -points around the wrist are the following: The OS pisiforme with the attachment of the internal ulnar nerve, the proximity of the palpable ulnar vessels and nerve on its Tendon of the interosseous muscle j Ulnar extensor tendon for the terminal phalanx Digital artery Digital nerve Digital artery Digital nerve Ulna Ulnar nerve (dorsal cutaneous branch; Fig. 62. radial side ; on the ulnar side of the wrist under the os pisiforme the projecting body of the unciform; a thumb's breadth down- ward and somewhat radially from the os pisiforme in the palm the process of the unciform, under which are the deep palmar arch and the deep branch of the ulnar nerve; immediately above the thenar the prominence of the trapezium across which passes the branch of the radial artery to the superficial volar arch. The wrist joint has for its fascia a transverse thickening of the common fascia (ligamentum carpi commune dorsale and volare) and a deep fascia on the joint capsule; besides, on the palm, the stout ligamentum carpi volare proprium which keeps the tendons in the groove of the carpal bones and from which springs a portion of the thumb muscles. 126. Superficial Volar Arch (Figs. 58 and 59). — Longitu- dinal incision from the junction of the thenar and hypothenar eminences, extending toward the fourth finger ; its middle should be in the transverse line of the fold between the hand and the abducted thumb. At the intersecting point of the two lines the UPPER EXTREMITY. 105 arch can be felt pulsating. After dividing the skin and the stout tendinous palmar fascia, the arch (imbedded in fatj be- comes at once visible under the smooth inferior surface of the latter. The arch forms the continuation of the ulnar artery and here begins to curve toward the side of the thumb. The thick common digital arteries spring from its distal portion. The arch rests upon the longitudinal digital branches of the ulnar (these become visible) and median nerves. If the artery cannot be found, the ulnar artery must be ligated at the os pisiforme. The ulnar nerve is to be exj)osed by the same incision ; the superficial branch passes downward over the palpable process of the unciform ; the deep branch passes into the depth between the abductor and flexor brevis at the ulnar side of the process and supplies the flexor brevis and opponens digiti minimi, two lumbricals, and all the interossei with the adductor pollicis. 127. Deep Volar Arch (Figs. 58 and 59). — This arch, con- trary to the superficial, springing mainly from the radial artery, gives off large vessels to the lateral margins of the hand, while its intermetacarpal branches are small. Incision in the fold of the thenar eminence, passing from its upper junction with the hypothenar eminence toward the index finger. The centre of the incision corresponds to the middle of the thenar eminence. After dividing the skin and palmar fascia (and eventual ligation of the superficial arch) we enter at the radial margin of the lumbrical muscle beside the flexor tendons of the index finger. Then appears: 128. The radial branch of the median nerve which is drawn toward the radius together with the superficial muscles of the thenar (flexor brevis and opponens). In the depth we see the transverse fibres of the broad adductor pollicis muscle. Directly beneath the muscle, which is divided, the transverse artery appears on the deep fascia, somewhat nearer to the wrist than the superficial arch. 129. The common digital arteries are to be exposed under 166 OPERATIVE SURGERY. the fascia between the interdigital fold and the superficial arch, by corresponding longitudinal incisions. Beside them, rising toward the surface, are the large digital branches of the ulnar and median nerves. j. Fingers. 130. The main portion of the subcutaneous soft parts on the fingers consists of the tendons which leave only the narrow lateral surfaces free. The flexor tendons lie upon the perios- teum. On the middle phalanx the tendon of the deep flexor passes through that of the superficial. The latter is semilunar in section (convex toward the bone), the former cylindrical. The two crura of the flexor sublimis pass around the tendon of the flexor profundus and are attached to the lateral surfaces of the middle phalanx. The flexor profundus muscle, after passing through the fissure of the flexor sublimis, likewise be- comes flatter and is attached to the base of the terminal phalanx. As far as the base of the terminal phalanx the tendons are sur- rounded by a tubular prolongation of the superflcial palmar fascia, the ligamenta vaginalia, and from the condyles of the metacarpal bones downward they are invested with closed mu cous sheaths which at the thumb and little flnger approach the mucous sheath of the palm -and often communicate with ^"t. From the bones and joint capsules vincula tendinum pass to the under surface of the tendons. The extensor tendon of the flngers is attached to the base of the flrst phalanx by isolated fibres and divides into three crura ; the central one is joined under the two lateral ones by the fibres of the lumbrical and interossei muscles (the flexor of the first and extensors of the terminal phalanges), and they are attached together at the base of the middle phalanx. The lateral crura descend laterally at the upper interphalangeal joint, pass again to the dorsum, and are attached at the base of the terminal phalanx ; all the extensor tendons are fiat, like fasciae. On the LOWER EXTREMITY. 167 thumb the extensor brevis muscle ends on the base of the first phalanx ; the extensor longus, situated somewhat to the dorso- ulnar side, ends with its three crura at the base of the terminal phalanx. As the ungual phalanx has tendons attached only at the base, the choice for incisions there is free ; they may be made median or lateral according to indications. The digital arteries and nerves (Fig, 62) pass in part at the middle phalanx from the volar to the dorsal side ; in the incisions on the middle phalanx regard is to be had mainly for the larger vessels and nerves beside the volar tendon, hence lateral inci- sions should be placed nearer the dorsum. On the first phalanx the two volar and two dorsal digital arteries and nerves are well developed, but here, too, the main vessels pass beside the volar tendons (the nerves on the volar side of the arteries and veins), so that incisions here may be purely lateral. Only at the base of the first phalanx should the deeper incisions deviate toward the palm after division of the skin, owing to the broad tendinous attachment of the lumbrical and interossei muscles. Where choice is free it is better to make incisions on the ulnar than the radial side, because of the short flexors of the first phalanx the lumbricals approach from the radial side. S. Lower Extremity. Gluteal Region. Branches of the Hypogastric Artery. 131. Superior Gluteal Artery (Fig. 63). — The point for its ligation can be marked through the skin, by feeling at the level of the upper end of the intergluteal furrow and at the upper margin of the belly of the glutaeus maximus the upper circum- ference of the great sciatic foramen. Incision in the direction from the posterior superior iliac 168 OPERATIVE SURGERY. spine to the tip of the great trochanter, corresponding to the upper two-thirds of this line. Division of the skin, fascia, and the thick glutseus maximus, parallel to its fibres. After sever- ing the fascia of the glutseus medius, this muscle is laid bare, without cutting, at its lower margin and drawn up. Under it the finger feels the upper circumference of the great sciatic fo- raraeu. Here, above the upper margin of the pyriformis mus- cle, the thick artery passes directly backward from the pelvis and at once gives off large branches (the main branch going laterally). Beside it the superior gluteal nerve (Fig. 63) leaves the pelvis, passing between and supplying the glutseus medius and minimus, and following the main branch of the artery lat- erally to the tensor fasciae latse muscle. 132. Inferior Gluteal (Sciatic) Artery (Fig. 63). — Incision in the direction from the inferior posterior iliac spine to the base of the great trochanter, parallel to the incision for the ligation of the superior gluteal artery; the medial two -thirds of the line given ,are used. Division of the skin with the fatty subcuta- neous tissue, the fascia, and the fibres of the thick glutseus maximus muscle. Under the latter the posterior margin of the pyriformis muscle becomes visible and is laid bare with the fingers ; under its medial end the artery emerges accompanied by the nerve of the same name which, like the artery, gives off thick branches to the glutaeus maximus. The point where the artery passes out of the pelvis is found by the spine of the is- chium and the spinoso-sacral ligament, extending in a median direction from its point. Above the spine we feel the lower mar- gin of the great sciatic foramen over which the artery emerges. 133. The posterior femoral cutaneous nerve passes in the direction of the continuation of the arterial trunk (Fig. 72). Deeper and more laterally, directly upon the bone, lies the easily palpable main trunk of the 134. Sciatic nerve which descends over the base of the spine of the ischium and the obturator internus muscle. LOWER EXTREMITY. 169 Lumbo-dorsal fascia Sacro-luinbalis muscle Serratus posticus infe rior uiuscle j Latissimus dorsi muscle Lumbo-costal fascia Glutaeus maxunus m Glutaeus medius m. Super'r gluteal artery Pyriformis muscle Tip of the great I trochanter ) Base of the great trochanter j M,\Wm m /if* Latissimus dorsi muscle Twelfth intercostal nerve Quadratus lumborum m. First lumbar nerve Transverse abdominal m. Ext'l abdom'l oblique m. IntT abdom'l oblique m. Posterior super"r spine of the iMum ( Posterior inferY spine of the ilium j Glutaeus maximus I muscle Int'l pudendal artery Infl pudendal nerve Pyriformis muscle Sciatic artery Sciatic nerve Posterior cutaneus I femoris nerve Obturator internus m. (with gemelli) Fig. 03.— Nephrotouiy. Gluteal and sciatic arteries. 170 OPERATIVE SURGERY 135. Internal Pudendal Artery (Fig. 68). — Incision as for the ligation of the inferior gluteal artery. The vessel lies medially of and under the inferior gluteal artery on the posterior surface of the spine of the ischium, accompanied by the internal pudendal nerve which rests upon it. It may be recognized by its re-entering the pelvis below the spine. Inguinal Region. 136. External Hiac Artery (Figs. 64 and 65). — Incision parallel to and immediately above the middle third of Poupart's ligament. Division of the skin and the well- developed super- ficial fascia. The superficial epigastric artery which ascends vertically in the latter must be severed. Division of the apo- neurosis of the external abdominal oblique. The internal oblique and the transversus are lifted with the handle of the scalpel from the ascending groove of Poupart's ligament, then the thick transverse fascia is cut. The artery lies under the middle of Poupart's ligament, imbedded in adipose tissue with glands ; inward from it is the vein, outward the fascia of the psoas muscle. Between the latter and the margin of the inter- nal iliac muscle, which lies about 2 cm. laterally from the artery in the depth, is the cjural nerve. Upon the artery are the thin crural branches of the genito-crural nerve which supply the medial anterior side of the skin of the thigh in the upper third. The branches of the external iliac artery, namely, 137. In- ferior epigastric and 138. Circumflexa ilii artery, can be ex- posed by the same incision as the external iliac, at their point of origin above Poupart's ligament, under the abdominal mus- cles and under the transverse fascia. 139. Inferior Epigastric Artery at the Anterior Abdominal Wall (Fig. 36). — Incision two or three fingers' breadth above Poupart's ligament, parallel to its medial third, through skin, LOWER EXTREMITY. 171 Internal iliac muscle Poupart's ligament Psoas muscle ( Fascia of external abdominal ■( oblique muscle External iliac artery Superficial epifiastric artery- External iliac vein Internal oblique and transverse muscle Inferior epif;aslric artery y-r-T) .* S'lpt-rfi'-ial epi- internal cir- / iff^/ \ gastric artery cumflex and - Ir ''^^ . ■ obturator art. ^ M*V^=^ Femoral veui -yj'luit —Internal circumflex artery Pectineus muscle Point midway between symiiliysis and ant. sup. iliac spine Incision for ex- ternal iliac artery Femoral artery- Femoral vein Adductor longus muscle Sartorius muscle Internal saphenus nerve Sartorius muscle Femoral artery- Femoral vein Internal saphenus nerve Vastus intemus muscle Tendon of adductor magnus muscle Superficial artery of the knee joint Tendon of adductor magnus muscle Vastus internus muscle Internal condyle of the femur Fig. c: FiG. G4. Figs. 01 and 0.5.— External Iliac Artery and Femoral Artery with its Branches. 172 OPERATIVE SURGERY. superficial fascia, the thick fascia of the external oblique and that of the internal oblique which can at least be partly sepa- rated from it. The margin of the rectus abdominis is laid bare. Beneath this, covered by a very thin layer of connective tissue (transverse fascia), we recognize the subserous fat, and upon it the artery ascending obliquely from without and below to the wall of the rectus. The transverse fascia, which below lies upon and above under the artery, here exhibits what is known as the plica semilunaris. 140. Circumjlexa Ilii Artery (Fig. TO). — Incision at the outer third of Poupart's ligament. Division of skin, superficial fascia, the muscular layers in which the branches of the ilio- inguinal nerve are exposed, and the thick transverse fascia. The peritoneum being slightly pushed up with the fingers, the artery is found parallel to Poupart's ligament on the internal iliac fascia; obliquely outward and downward it is crossed by the lateral cutaneous femoral nerve. 141. Aorta and Common Iliac Artery (Figs. /'' ■ Fig. 78. TibiaUs Posticus Nerve, lutenial Saphenus Major Vein. Nerve, Saphena 192 OPERATIVE SURGERY. horizontal level of the head of the fibula. We divide the fascia, hut preserve the minor saphena vein and beside it the commu- nicans tibialis nerve (suralis medius). These structures are drawn inward. They mark the contact of the two heads of the gastrocnemius between which we penetrate. The large vascular and nerve branches passing to the two heads of the gastrocne- meus are drawn aside. Under the lateral head we strike the margin of the attachment of the soleus which descends inward from above and without, and the thin tendon of the plantaris longus which passes inward and downward. At the upper margin of the soleus the trunk of the tibio-peroneal begins, after giving off the tibialis antica artery. Hence the margin of the soleus must be drawn, downward or nicked so as to get under that large branch. As in the case of the popliteal artery the tibialis posticus nerve and the vein are drawn outward in order to reach the artery. The popliteal artery descends on the popliteal muscle, at whose inferior margin it gives off the tibialis antica artery forward through the interosseal ligament, about 6 cm. below the line of the knee joint. The Leg — External Surface. 165, Peroneal Artery (Figs. 80 and 81). The direction of its course is in a straight continuation of the popliteal artery along the medial posterior surface of the fibula. The posterior surface of the fibula can be felt through the entire length of the leg. The incisions are made in a line passing from the posterior circumference of the head of the fibula to a point be- tween the internal malleolus and the Achilles tendon. The artery arises in the upper third of the leg from the tibio-peroneal trunk. Above the Middle. — Incision upon the posterior fibular sur- face behind the eminence of the peroneal muscles. The com- municating peroneal nerve comes in view. The fascia lata is LOWER EXTREMITY. 193 Fig. 81. Fig. 80. 13 194 OPERATIVE SURGERY, divided behind the peroneal muscles. The attachment of the soleus is separated from the fibula until the deep fascia presents which covers the flexor hallucis longus muscle on the dorsal surface of the fibula. After this fascia is severed, we penetrate into the depth between it and the muscle and at the medial margin of the latter find the artery before it enters the muscle or between the fascia and the posterior surface of the muscle. Below the Middle. — Incision at the posterior surface of the fibula as above. After the fascia is divided, the soleus muscle is drawn medially. The artery lies superficially under the deep fascia which covers the flexor hallucis. The tibialis posticus nerve lies in a median and posterior direction from it. 166. Internal Saphenus Nerve (Fig. 78). a. At the Knee. — Incision in the line of the joint at the posterior inferior circum- ference of the internal condyle of the tibia, behind the tendon of the sartorius. The nerve is in the furrow between the sarto- rius in front and the stout tendon of the gracilis behind. The saphena major vein lies on the fascia. h. On the leg the nerve is found throughout its entire length along the inner edge of the tibia beside the saphena major vein, in the line of the incisions made for the ligation of the tibialis postica artery. c. At the ankle joint the nerve is palpable beside the saphena major vein at the anterior circumference of the internal mal- leolus. 167. Suralis Externus Nerve {Communicans Peronei). At the upper end (Figs. 72 and 73) the nerve is exposed by the same incision as the trunk of the peroneal nerve, close to the biceps tendon, directly under the fascia. At the Loiver End (Figs. 76 and 77). — Incision midway be- tween the external malleolus and the Achilles tendon. Here the nerve is subfascial, having united with the communicans tibialis to form the external saphenus nerve. The saphena minor vein lies beside it. LOWER EXTREMITY. 195 168. Tibialis Posticus Nerve (Figs. Y8 and 79).— To be ex- posed in the entire length along the tibialis postica ai'tery ; being laterally from it above, posteriorly below, and inferiorly in the sole of the foot {i.e., nearer the skin). 169. Suralis Medius Nerve {Communicans Tibialis; Figs. 72 and 73). — See Ligation of the popliteal and tibio-peroneal arteries. In the upper two-thirds of the leg the nerve descends vertically on the fascia with the saphena minor vein, in the middle of the calf. The Foot. Plantar Arteries and Nerves. — In the median line of the sole of the foot the deeper structures are covered by the body of the flexor brevis muscle. Analogous to the palm of the hand, therefore, we enter alongside of this median bundle and the two lateral muscular eminences. The latter consist superficially of the abductors of the great and little toe. 170. The Plantar Arch at the Intermetatarsal Interspace (Fig. 82). — Incision in the depression laterally from the ball of the great toe, in the direction of a line from the second toe to the tuberosity of the os calcis, backward through the skin, the abundant adipose tissue, and the tense plantar apo- neurosis. The internal plantar nerve is exposed with its thick branches. It is to be drawn toward the inner margin of the foot. The tendon of the flexor digitorum brevis to the second toe, and at its medial margin and more deeply that of the flexor digitorum longus with the first lumbrical, are exposed and drawn laterally. Under these is the thick adductor hallucis muscle. Rather deeply under the latter muscle we strike the point where the artery passes through the first metatarsal inter- space. 171. Internal Plantar Arterij and Nerve (Figs. 82 and 83). — Incision in tlie direction from the tip of the tuberosity of the OS calcis to the first toe (Fig. 83), from the anterior circumfer- 196 . OPERATIVE SURGERY. ence of the eminence of the heel forward through the skin, the abundant fat, and the firm plantar aponeurosis with its longi- tudinal fibres. The body of the abductor hallucis is exposed. The flexor brevis digitorum lies laterally. The vessel and 172. The internal plantar nerve are situated under this muscle. The artery is very small, the nerve thick and covered with abundant fat. The tendon of the flexor hallucis longus lies under these structures. 173. External Plantar Artery and Nerve (Figs. 82 and 83). — Incision in the course of a line from the tip of the tuberosity of the OS calcis to the fourth toe, forward from the eminence of the heel through the skin, the abundant fat, and the thick plantar aponeurosis. The body of the flexor brevis digitorum is exposed, between which and the short head of the flexor longus the artery and 174. The external plantar nerve appear laterally, the former very thick, the latter narrow. The deeper tendons are not exposed. 175. Plantar Arteries at their Origin from the Tibialis Postica Artery (Figs. 78 and 82). — Incision beginning on the medial side of the foot, one flnger's breadth under the palpable sustentaculum tali, extending horizontally backward. Division of the skin and the ligamentum laciniatum, under which the body of the abductor hallucis is exposed. This is lifted from the inner surface of the os calcis. The two arteries with the plantar nerve rest on the flexor tendons. 176. Dorsalis Pedis Artery (Figs. 74 and 75). — Course, from a point midway between the two malleoli to the first metatarsal interspace. At its Entrance into the Metatarsal Interspace. — Incision between the bases of the first and second metatarsals. The skin and fascia are divided, sparing a branch of the superficial peroneal nerve which is drawn laterally, as is also the saphena LOWER EXTREMITY. 197 major vein. In a median direction appears the tendon of tlie extensor hallucis brevis, and still farther medially the thick tendon of the extensor hallucis longiis. Under the lateral mar- Plantar artery at its origin \ External plantar aiterj^ Abductor hallucis i i,2'j i Internal plantarnerve I B':F Internal plantar artery Flexis brevis digitorum *^-' Fig. 82.— Internal Plantar Artery and Nerve. Internal plantar artery ^/_ Flexor bievis lisit-ii im \\ Fat 1 External plantar aiteiy External piauLai ueive Fig. 83.— External Plantar Artery and Nerve. gin of the former the deep peroneal nerve emerges and under it the artery, a thick interdigital branch of which passes forward. Midway on the Dorsum of the Foot. — Incision in the above- named direction. On the fascia the superficial peroneal nerve is drawn outward. Under the fascia we expose the tendon of 198 OPERATIVE SURGERY. the extensor hallucis longus, and laterally the tendon and body of the extensor hallucis brevis muscle. The latter is drawn laterally downward, and the artery is found beneath; the deep peroneal nerve, which is rather thick, being on its external side. The artery rests on the articular ligaments. In the Line of the Ankle Joint. — The skin is divided mid- way between the two malleoli. The superficial peroneal nerve appears in the direction of the incision and is drawn outward. We open the fascia with the ligamentum cruciatum above the tendon of the extensor hallucis longus; this muscle, which still contains muscular fibres, is drawn in a median direction. Be- neath it is the artery, outward and forward of it the deep pero- neal nerve. PART III. EXCISIONS (RESECTIONS). T. General Observations. Definite types of operation can be laid down for the excision of the bones and joints. As regards the soft parts it is not worth while to separate excisions from incisions, unless the pathological side of the subject, especially tumors, is to be con- sidered at the same time. By excision is meant the removal of a portion of an organ or member from the continuity of an organ or part of the body. In the case of the joints it is cus- tomary to employ for the oj)eration the special term "resection." Eesections form the greater portion of this part of the book ; as to the excision of bones we shall restrict ourselves in the main to the total removal of the small bones. As regards the technique, excisions belong to the simplest operations. For as soon as the part in question is once laid bare, the task is to enucleate it as thoroughly as possible from its surroundings, the adjoining soft parts being immediately detached from the bone (when such is the one to be resected) with sharp or blunt instruments. The resection is correct in proportion to the thoroughness with which the bone is laid bare, i.e., in inverse proportion to the number of soft parts adhering to it. This simple rule is largely violated by beginners in the practice of resection. The point which will be again emphasized under amputations in connection with Ollier's subcapsular and subperiosteal method, is the most important requirement here for the incisions in the depth. In recent years surgeons have even gone beyond this 200 OPERATIVE SURGERY. subcapsulo-periosteal method of resection (Konig, Bergmann, Eiedel, Tiling) and have recommended instead of the detach- ment of the ligaments, particularly the lateral ones, the chisel- ling away of the bony processes (tubercles, trochanters, con- dyles, malleoli), a sort of osteoplastic resection. Oilier made use of this method even earlier in isolated cases; we employ it for the resection of the shoulder and partly of the elbow. The only difficult and important portion of the operation is the correct location of the first incision. This must answer the requirement of giving perfectly free access to the depth. This access is to be direct, and moreover in the division of the over- lying soft parts no unnecessary incidental injury should be caused. Therefore, not only should larger vessels and nerves be spared, but even muscles and tendons should be avoided, and in choosing interstices between muscles and tendons — a point upon which we lay particular stress — only those should be selected which correspond to the borders of nerve distribution. If the function of a muscle is to be preserved, its motor nerve must remain intact. This consideration is decisive for the method of resection. U. Lower Extremity. 177. Excision of the Phalanges of the Toes and the Meta- tarsal Bones (Fig. 84). — According to the statements made in connection with incisions on the toes and fingers, it is evident that only lateral incisions closer to the dorsum are admissible in order to spare nerves and tendons. On the toes and their joints it is more conservative as regards the performance of the operation, and more suitable with reference to the cicatricial petraction, to make two smaller lateral incisions ; for the meta- tarsal bones a dorsal incision along the extensor tendons and the digital branches of the peroneal nerves is sufficient. The incision must extend beyond the adjoining joints if it is to LOWER EXTREMITY. 201 afford ample room. The head of the bone is always first laid bare because its ligamental connections are more easily detached than those of the base. 178. Metatarso-Tarsal and Anterior Tarsal Resection (Figs, 81 and 85). — This is a very important operation in infec- tious diseases (especially tuberculosis) of the anterior tarsal Fig. 84. — Resection of the Phalanges. Resection of the Metatarsal Bones, Fig. 85. — Anterior Tarsal Re- section (Usual Arrange- ment of the Joint Capsules). joints because, as a rule, all their capsules communicate with one another. Closed capsules are found most frequently at the joint between the first metatarsal and the first cuneiform, at the ante- rior and posterior surface "of the cuboid, between the head of the talus and navicular bone, the talus and calcaneus. Tubercular ostitis frequently begins in the base of the metatarsal bones, and then occasionally a resection of the bases of the metatarsal bones and the articular surfaces of the adjoining cuneiform bones and 202 OPERATIVE SURGERY. the cuboid may suffice (metatarso- tarsal resection) . If the joints are involved, the simultaneous removal of the last-named bones together with the navicular will be more certain. In diffuse disease the articular surfaces of the talus and calcaneus are to be likewise removed. The resection is made from two dorsally placed lateral inci- sions. The medial incision extends from the posterior third of the first metatarsal to the inner circumference of the head of the talus which becomes visible when the foot is abducted. At the latter point the incision is carried through the skin only, lest the ankle-joint capsule be opened, which reaches to the neck of the talus. The incision, beginning in a median direction from the extensor tendon of the great toe, divides the attach- ments of the tibialis anticus to the first metatarsal and the first cuneiform bone and frees the dorsal surface of the cuneiform and navicular bones. Downward, the lower surface of the latter bone is freed in the same way ; the tendon of the tibialis posticus is left postero-inferiorly. The lateral incision, passing from the posterior third of the fifth metatarsal to the upper surface of the body of the calca- neus in front of the external malleolus, remains lateral from the tendons, by separating the attachment of the peroneus tertius from the fifth metatarsal and freeing the upper surface of the metatarsal bases and the cuboid bone. In order to ex- pose the lower surface of this bone the tendon of the peroneus brevis must be detached from the fifth metatarsal and that of the peroneus longus lifted from the groove at its outer and lower surface and drawn backward. Then follows the removal of the bases of the metatarsal bones and the articular surface of the talus and calcaneus. The shortened foot continues exceedingly useful both as re- gards support and locomotion. 1Y9. Intertarsal Resection (Fig. 86). — This operation is rela- tively frequent for clubfoot. The incision follows the cutaneous LOWER EXTREMITY. 203 folds transversely over the line of the joint on the anterior outer side ; the tendons of the anterior surface, exteriorly that of the peroneus tertius, being drawn in a median direction ; on the outer side the tendon of the peroneus longus is lifted from the groove of the calcaneus and cuboid bones and drawn back- ward. The extensor digitorum brevis muscle is separated at its upper margin from the bone and drawn forward and down- ward. The joint capsule is then incised in Chopart's line and as a rule the entire navicular bone, a portion of the cuboid, the Fig. 86. — Jledio-tarsal Eesection (Wedge- shaped Excision ia Clubfoot). Fig. 87.— Excision of tlie Tains (Outer Side). calcaneus, and the head and neck of the talus are cut through subcapsulo-periosteally (in children with the chisel) so that the foot can be straightened slightly beyond a right angle, the supination and adduction being corrected. Suture without drainage, immediate closed plaster dressing in good position. 180. Excision of the Talus (Fig. ST). — While it appears to be unnecessary to give definite directions for the excision of the small tarsal bones which is occasionally required, an exception must be made of the talus and calcaneus, whose removal is more frequently performed for tuberculosis, injuries, and club- foot. The latter two indications apply especially to the talus. As a rule a free lone'itudinal incision on the anterior outer 204 OPERATIVE SURGERY. side suffices, such as the one given by Vogt for the resection of the ankle joint. Beginning a hand's breath above the ankle joint at the anterior surface of the fibula, it passes on the outer side of the extensor tendons (peroneus fortius), leaving the branches of the superficial peroneal nerve in a median direction, over the lateral margin of the pulley of the talus which is readily felt in adduc- tion, as far as the tuberosity of the fifth metatarsal ; it pene- trates into the ankle joint and Chopart's articulation, exposing the pulley and head of the talus. On the neck of the talus the Fig. 88.— Excision of the Calcaneus. Fig. 89. — Frontal Section of the Ankle Joint, after Henle. attachment of the anterior and posterior joint capsules is freely separated toward both sides and in the sinus of the tarsus lat- erally the tense interosseous ligament is divided. Along the anterior margin of the tibia and fibula the joint capsule is de- tached, and laterally at the anterior and posterior end of the talus pulley the ligamentum talo-fibulare anticum and posticum is divided. Externally and along the posterior margin of the talus the capsular connection with the calcaneus is separated. In a forced adduction position the talus can now be lifted far enough to permit the insertion of an elevator beneath it so that the attachments of the ligaments and capsules on the inner side can be separated. LOWER EXTREMITY. •^05 181. Excision of the Calcaneus (Figs. S8 and 89). — Where the soft parts are flexible, sufficient room is furnished by a longitudinal incision on the medial side close to the Achilles tendon downward to the lowest posterior end of the tuber cal- canei, and thence transversely across to the outer side as far as the tuberosity of the fifth metatarsal. At the posterior root of the tuber the Achilles tendon is de- tached, the joint capsule at the postero-external circumference of the calcaneus is severed together with the calcaneo-fibular ligament ; the peroneal tendons in the tarsal sinus being drawn up, the interosseus ligament is divided, and the joint capsule to the cuboid bone infero-externally detached together with the Fig. 90. — Posterior Tarsal Rejection. firm calcaneo-cuboid ligament. The heel-cap is vigorously drawn over to the medial side, the tendon of the tibialis jDosticus is freed below at the sustentaculum tali and lifted up, and finally the attachment of the joint capsule to the talus, with the covering deltoid ligament (ligamentum calcaneo-tibiale) and in front the stout ligamentum tibio-calcaneo-naviculare, is sepa- rated. The bone must be seized with strong forceps. 182. Tola -Calcaneus and Posterior Tarsal Resection (Fig, 90). — The resection of the articulation between the talus and calcaneus has been performed by Annandale, by means of two lateral curved incisions, and it can be done by the method de- scribed for the excision of the calcaneus or the modified method for the posterior tarsal resection. The posterior tarsal resection, which is associated with re- 206 OPERATIVE SURGERY. moval of the talus and calcaneus and possibly the adjoining articular surfaces, furnishes unexpectedly good results with the foot in normal position, the leg bones descending to fill the de- fect (Kocher, Kummer). The procedure, according to the method to be described, is based on the possibility of preserving the tendons and muscles moving the foot (peronei, tibialis anticus and posticus). Incision beginning a hand's breadth above the ankle joint on the outer side beside the Achilles tendon, extending down- ward behind the external malleolus and the peroneal tendons as far as the tuberosity of the fifth metatarsal. From this incision the tendon sheaths of the peronei are opened, these tendons lifted forward, and in a manner analogous to that described for the excision of the talus and calcaneus these two bones are ex- articulated ; then the articular surfaces of the leg bones and of the cuboid and navicular are ablated. It is desirable to preserve a small projection of the external malleolus for the purpose of hooking the peroneal tendons behind it. If the tuber calcanei can be preserved, it may be utilized for osteoplastic purposes in an analogous manner to that of Piro- goff in amputation of the foot. It will be sufficient to illustrate this case by the lines of the saw in the adjoining figure. 183. Resection of the Foot (Figs. 91 and 92). — The resection in the talo-crural joint does not always give satisfactory results, owing to the complicated structure of the joint, the frequent involvement of the directly adjoining bones, and of the neigh- boring talo-tarsal articulation with its bones, especially the calcaneus. Hence the efforts directed to the continual improve- ment of the technique. Incisions have been made on all sides of the joint, in every direction. Anterior longitudinal incisions are made by Vogt (lateral), Konig and Riedel (bilateral with chiselling away of the mal- leoli), Meinhardt Schmidt (conjoined with posterior); anterior transverse incisions by Hiiter, formerly by Sabatier, Heyfelder, LOWER EXTREMITY. 207 Hancock ; posterior transverse incision by Liebrecht, conjoined with posterior longitudinal incision by Wackley, Textor ; inferior "stirrup-heel" incision by Busch, Hahn, Ssabanejew (with de- tachment of the tuber calcanei) ; lateral incisions, in part associ- ated with transverse incisions, by Moreau, Langenbeck, Oilier, Chauvel, Girard. We recommend the external lateral transverse incision (Reverdin, Kocher). The incision (see Fig. 91) begins at the height of the ankle joint, extending from the outer margin of the extensor tendons, or the still fleshy peroneus tertius, in a Supei'flcial peroneal uerve v Peroueus tertius muscle. \ Extensor communis muscle, Fissure of the joint Exfl sapbeiius nerve Tendons of the pero- neal muscles i'lo.. './I. — Resection of the booi. curve over the tip of the external malleolus as far as the Achilles tendon, leaving the latter intact. Skin and fascia are divided ; in front the superficial peroneal nerve is preserved and drawn aside together with the extensor tendons ; posteriorly we must preserve the external g'aphenus nerve, lying behind the peroneal tendons, which is formed by the union of the communicans peroneus and tibialis and supplies the outer side of the foot, also alongside of the Achilles tendon cutaneous branches passing to the heel, and the saphena minor vein. Where these structures cannot be preserved they may be divided without causing ma- terial injury. In front the incision now extends between the extensors and the fibula into the joint, and, the extensors being forcibly ele- 208 OPERATIVE SURGERY. vated, separates the capsular attachments along the anterior margin of the fibula and tibia to the internal malleolus and from the pulley of the talus at the neck of this bone as far medially as possible. The dorsal artery of the foot, lying on the joint capsule with the deep peroneal nerve, remains intact. - Patella Spine of the tibia Talus pulley Peroneal tendon Peroneus tertius muscle ■Tibial joint surface External malleolus Capsule Fig. 92.— Resection of the Foot. Close around the external malleolus the capsule and liga- ments are detached throughout, the latter especially also from the inner surface of the malleolus where they knit the joint with great firmness. At the tip and the posterior margin of the external malleolus the separation of the ligaments is associ- ated with the opening of the sheath of the peronei, posteriorly upward above the line of the joint, so that the tendons can be LOWER EXTREMITY. 209 drawn away with a strong hook. Should the latter be difficult, the tendons are severed and subsequently sutured in order to prevent the occurrence of pes calcaneus. Then the lower wall of the tendon sheath and, with it, the joint capsule are opened as far as the tibia, and at the posterior margin of the latter to the internal malleolus. Unless this is done thoroughly the succeed- ing step is made difficult. The next step is as follows. The foot which has been freed on the entire external, anterior, and posterior circumference from its capsular connection with the fibula and tibia, is forcibly turned medially over the internal malleolus, i.e., it is luxated totally inward in such a way that the sole points upward at the inner surface of the leg and the inner margin of the foot touches the inner margin of the tibia, as shown in Fig. 92. In this manner we gain an absolutely unobstructed view into the joint ; nothing remains to be done but to sever the ligaments at the projecting tip of the internal malleolus (carefully, lest we injure the tendons descending behind the malleolus) to per mit inspection of all the recesses of the articulation. It will then be easy to clear the joint and resect the talus. If the latter is to be preserved, we must guard against unnecessary opening of the talo-calcaneal joint, sparing the capsular attach- ments at the posterior and lateral circumference of the talus. The method described preserves the ligamental apparatus on the medial side and the support of the external malleolus on the outer side, and therefore guards as well as possible against lateral deviations of the foot. 184. Total Tarsal Resection (Figs. 93 and 94).— Wladi- miroff and Mikulicz have added to our measures for the preser- vation of the foot, even in very extensive disease, a procedure used by them in affection of the posterior tarsal bones and joints. In such a case we believe the method to be superfluous, provided the soft parts of the sole and heel can be preserved. But aside from this the method is especiall}^ valuable in disease 14 210 • OPEEATIVE SURGERY. of all the tarsal joints or bones. It enables us even in such a case to preserve a foot useful without prothesis by attaching, after excision of the entire tarsus, the sawed bases of the meta- tarsal bones to the sawed surface of the leg bones, the foot being in vertical position (in the prolonged axis of the leg). The patient walks on the anterior surface of the heads of the metatarsals, the toes being forcibly dorsoflected. If the navicular and cuboid bones can be sawed off, or the latter divided with the cuneiform bones, a broader and firmer sawed surface is obtained. In the same way as Pirogoff turns the posterior segment of the foot 90° and attaches it as a prolongation to the leg, so does this method with the anterior segment. Since Mikulicz's method starts with a presupposed defect of the skin of the heel — i.e., with quite a special case in which the direction of the incision is a natural result — we prefer to de- scribe the method for the typical case of disease of the entire tarsus with a useful integument. Incision quite analogous to that for posterior tarsal resec- tion, in the form of a lateral posterior curved incision, beginning as in Fig. 93 a hand's breadth above the ankle joint, extending downward behind the external malleolus and the peroneal ten- dons to the middle of the fifth metatarsus. In the above- described manner the bones and joints between the leg and metatarsus are exposed, the Achilles tendon being detached with the periosteum of the calcaneus, and the peroneal tendons lifted from their sheath and drawn forward. The vessels and nerves are preserved, the tendinous attachments of all the long foot muscles (peroneus tertius, brevis, and longus) are separated from the upper, outer, and lower surface of the metatarsal bones, and the attachments of the tibialis anticus and posticus from the upper, medial, and lower surface of the same bones. 185. Resection of the Lower Third of the Leg (Fig. 95). — In the case of extensive disease in the lower third of the leg bones, an attempt should be made, if possible, to expose the dorsal LOWER EXTREMITY. 211 surface of the tuber calcanei by a very long latero -posterior in- cision and to attach it to the correspondingly freshened sawed surface of the tibial diaphysis. 186. Resection of the Tibia. — In a case in which an exten- FiG. 95.— Resection of the Leg (Lower Third). Fig. 94. — Case of Total Tarsal Resection; Personal Ob- servation (after a Photograph). sive portion (the middle third) of the tibial diaphysis had to be resected for necrosis, the diaphysis of the fibula on the other side was removed by us and inserted into the excavated remnant of the tibia. 187. Resection of the Fibula. — The diaphysis and even the 212 OPERATIVE SURGERY. whole fibula can be removed by an incision behind the peroneal muscles in their entire length, without damaging the usefulness of the leg for support or locomotion or imjDairing the movements of the foot in any direction. At the upper end we must pre- serve the peroneal nerve which curves around the neck, in the lower half the peroneal artery which passes behind the fibula. 188. Artlirotomy and Resection of the Knee (Figs. 96, 97, 98).— Numer- ous methods for free opening of the knee joint have been devised, all of which we have tested. None of them however, gives absolutely sufficient ac- cess in so simple a manner as the trans- verse incision with lower convexity; to be sure, it must be carried laterally far enough backward to embrace at least two-thirds of the circumference of the knee. It is not quite clear to which surgeon belongs the merit of its intro- duction, as Park appears to have made the proposition and Textor is named as the father of the method. At all events Erichsen seems to have contributed to its general acceptance. It is certain, however, that after the skin has been divided by a transverse incision, the subsequent steps of the operation have been per- formed in widely varying ways. It is the latter which deter- mine the final result. Different procedures are required for arthrotomy and arthrec- tomy of the knee joint and for resection ; for, contrary to all other joints, in resection we aim at ankylosis (in good position), while in arthrotomy the possibility of recovery with mobility is to be kept in view. . — Resection of the Knee. LOWER EXTREMITY. 213 Resection of the Knee.— In a case of knee-joint disease doomed ah initio to resection, the skin and especially the tense Capsular incision under the condyles Capsular incis'n beside patella & ligament Quadriceps tendon Vastus ex- | Fascia lata ternus m. Ligamentum pateilse Vastus internus muscle Fascia lata Fig 97.— Arthrectomy of the Knee. Patella turned over Medial layer of fat Ligamentum patellae Lateral layer of fat Fig. 98.— Arthrectomy of the Knee. fascia lata are divided transversely and dissected up above the patella. The tendinous expanse of the vasti together with the 214 OPERATIVE SURGERY. stout quadriceps tendon is divided by an incision curving around the upper circumference of the patella, but reaching only to the outer surface of the capsule. The latter is then traced upward, outward, and backward along its outer surface to its attach- ment and reduplication at the femur ; with the visceral serosa it is dissected from the bone as far as the cartilaginous margins of the femur on the whole outer surface, also backward below the condyles, the attachment of the lateral ligaments being- separated. In like manner the tendinous fascia is dissected downward until the attachment of the capsule to the tibia is completely exposed from without. During this step the liga- mentum patellae and the lower attachment of the lateral liga- ments are severed. Then the capsule is here, too, separated all around from the margin of the tibia to the cartilaginous sur- faces and the menisci divided at the same time. In this way the entire anterior and lateral surface of the capsule with the covering patella and the ligamentum patellae are withdrawn in connection like a tumor, without the necessity of cutting into morbid tissue. Most surgeons make it a rule to continue the transverse in- cision at once into the joint, the ligamentum patellae being severed. It is obvious that this is no advantage in infectious and particularly tuberculous effusions into the joint; and as in this procedure the patella v/ith the quadriceps retracts upward, the excision of the pouch under the quadriceps is rendered more difficult as compared with our method. We always remove not only the patella, but we also divide the crucial ligaments and excise the menisci and ligaments. OUier's subcapsulo -periosteal method is not justified here for any surgeon who aims at ankylosis of the knee. The patella and its ligament as well as accessory ligaments contribute com- paratively little to the firmness of the joint, and everything depends upon securing a very firm union of the bones so as to obtain a perfectly useful extremity. If this is not effected, the LOWER EXTREMITY. 215 results, as a rule, will remain defective despite patella and liga- ments. This is apparent even from the fact that when anky- losis results in young patients after pure arthrectomy with preservation of the entire extensor apparatus, strongly flexed positions are secured, fully equal to those after resection in which the entire joint with the patella has been extirpated. For this reason we do not use Volkmann's transverse incision through the patella, particularly because we agree with Bockel that the patella itself is but too often involved in the disease. Therefore, contrary to Oilier, we here positively avoid the subperiosteal operation and make the simplest jDossible wound, covering the exposed and sawed bones merely with skin, fascia, and muscle; for, as we have stated, we have learned to rely absolutely on the bony ankylosis. Not that we have failed to observe that the contraction of the quadriceps is preserved ; but in ankylosis of the knee the vasti no longer produce any result, and the rectus femoris inverts its effect and acts merely on the thigh as a flexor in the hip joint. Eoom having been made by the excision of the entire anterior and lateral walls of the joint, it is easy to extirpate the posterior wall during strong flexion. To this end the crucial ligaments must be separated, best at their attachment in the intercondyloid fossa or close to the bone at the adjoining condyloid surfaces of the femur. Then we can reach the dorsal surface of the condyles of the femur and tibia and effect the exact removal of the macroscopically diseased tissue, possibly also excise in toto some mucous bursse, especially the popliteal. A clean wound surface remains which is thoroughly disinfected before the bones are sawed off, or dusted with iodoform in tuberculosis so as to pre- vent the further development of infectious materials left behind. In view of the expected firm ankylosis of exactly coapted bones, a very essential point is the manner in which the bones are sawed. In order to prevent the forward displacement of the femur on the tibia, all sorts of angular cuts have been made 216 OPERATIVE SURGERY. on the one hand, and attempts at fixation between the sawed surfaces on the other hand. Nails have been used for fixation or sutures have been appHed. But as these often tore out and failed to answer the purpose, Albert of Vienna and others have made angular cuts. We as well as Metzger and Fenwick have succeeded best by sawing the femur convex and the tibia corre- spondingly concave. The latter author attaches great value to the method, as shown in a paper published in 1871, and subse- quently he reported twenty -eight cases with very good func- tional results. Of course the surgeon must be master in the handling of the saw, but then the two surfaces can be so fitted together that any further artificial fixation becomes quite un- necessary ; provided, however, that the leg is fastened to a splint in complete extension. The curved sawing of the femur has another advantage in that its epiphyseal line, which determines the future growth, is most certainly preserved. After the bones are coapted, a simple deep cutaneous suture is inserted, drainage tubes having been passed through special openings. In numer- ous cases during the last tew years we have obtained by this operation perfect adhesion by first intention as in simple wounds of the soft parts, so that in one or two weeks a permanent sili- cate-of-soda dressing could be applied as for simple subcutaneous fracture, and the patient could get up six weeks after the oper- ation. Arthrotomy of the Knee. — As resection of the knee differs from the type described for resections in general, special men- tion must be made of the method in which ankylosis is not desired. In cases of arthrotomy and arthrectomy in which there is any prospect of a movable joint we have come to the conclusion, after various experiments, that every breach in the continuity of the extensor apparatus of the knee joint is harm- ful. No matter how exact is the suture of the ligamentum patellae, of the patella, or of the quadriceps tendon, or how good is the course of the wound, we can never expect or attain as LOWER EXTREMITY. 217 rapid and vigorous contractions of the quadriceps as when that muscle with its tendinous apparatus has been kept quite intact as far as the sjjine of the tibia. And this latter mode can be executed even in very extensive disease without greatly com- plicating the operation and especially without diminishing the certainty that all morbid parts of the joint will be removed. We proceed in the following manner: Anterior curved incision, beginning latero-posteriorly over the line of the joint, extending through skin and fascia, which are detached as flaps from the anterior surface of the patella and its ligament, as in resection. But instead of severing the quadriceps tendon transversely above the patella, we expose obliquely upward the margin of the vastus internus and ex- ternus. Then we divide the capsule at the margin of the patella alongside of the latter and the ligamentum patellae, separate its attachment to the femur externally and posteriorly (Fig. 97), together with the attachment of the internal and external ligaments to the femur to a point behind and above the condyles, and turn the capsule downward. Now the patella can be easily luxated first laterally, then medially, and the joint opened wide enough to permit inspection of its greater portion. If all the folds are to be inspected, we must separate the attachments of the crucial ligaments between the condyles of the femur as during resection. Then all the recesses of the joint are open to view. The last-named ligaments remain in connection with the tibia below, and above with the periosteum of the dorsal surface of the femur, and therefore adhere in good position. According to requirements we can now extirpate the entire synovial membrane or excise circumscribed patches. Finally the patella is turned over and freed from adhering fun- gous granulations, or diseased bone is thoroughly removed, and the posterior surface of the quadriceps tendon cleared of any remnants of the diseased bursa. If the popliteal and semi- membranosa bursse are degenerated, they can be cleaned in 218 OPERATIVE SURGERY. the same manner. The cartilages are cut off whenever or wherever they are at all discolored or softened by penetrating granulations. Special care should be taken lest diseased patches in the bone be overlooked, for they must be thoroughly scraped out. Where the capsule has been preserved it is carefully sutured, then the flaps of skin and fascia are brought in contact by some deep sutures, and after the insertion of drainage tubes the con- tinuous cutaneous suture is applied. In order to insure perma- nent recovery in tuberculosis, iodoform is dusted in; or else, after temporary iodoform tamponade, we may follow the method recommended by us and recently somewhat modified by Berg- mann, Sprengel, Helferich, and others; namely, cutting a few primary temporary deep sutures, and inserting an exact unin- terrupted secondary suture after the lapse of twenty-four or even forty-eight hours. By that time all after-hemorrhages have ceased. The temporary sutures have the advantage of preventing the retraction of the skin and fascia. Irregular resections and excisions of the knee joint, for in- stance, of one condyle of the tibia or femur, are permissible only when we are sure of an ankylotic union of the remaining condyle with the opposite bone. 189. Resection of the Patella. — In primary disease of the patella this is an important operation for the prevention of diffuse affection of the joint. Longitudinal incision, separation of the covering quadriceps fascia and periosteum, and enuclea- tion from the anterior wall of the capsule are the several steps of this simple operation. Its results are very satisfactory, for perfect mobility of the joint may be preserved (see reports by Dr. Kummer). 190. Osteotomy and Cuneiform Resection of the Tibia (Fig. 99). — Transverse incision {i.e., in the cleavage line of the skin) two fingers' breadth below the line of the joint, extending from the spine of the tibia to the eminence of the calf muscles; the LOWER extke:.iity. 219 periosteum is detached and the chisel applied in the direction of the cutaneous incision. The attachments of the ligamentum patellae must not be injured, for between it and the tibia is a bursa mucosa which may communicate with the joint. In pronounced genu valgum it is preferable to excise a wedge from the tibia whose base should be directed medially ; otherwise, during straightening, there may be too much drag- ging upon the head of the fibula with consequent paralysis of the peroneal nerve which surrounds it. 191. Sujoracondylic Osteotomy of the Femur (Fig. 99). — The incision which follows the cleavage line of the skin is oblique both externally and internally, passing forward interiorly from above posteriorly, through the skin and fascia lata, which is very thick, especially on the outer side. The vastus (internus or externus) is freed at its posterior margin and drawn upward ; the periosteum is divided from the condyle upward and sepa- rated in front and behind ; the bone is cut with the chisel for three-fourths of its thickness and the rest broken. The superior internal or external artery of the knee joint must be borne in mind, on the inside especially the deep branch of the arteria articularis genu suprema. Next to Macewen, who developed this method into the normal procedure for genu valgum, we were the first to perform osteotomy of the femur for this affection. 192. Osteotomy and Siihtrochanteric Cuneiform Resection of the Femur (Figs. 100 and 101). — Transverse incision through the skin, the fascia of the glutseus maximus, and the tendinous attachment of the vastus externus muscles to the bone at the outer side, at the level of the base of the great trochanter, so that the trochanter minor remains above the line of division. The terminal branch of the external circumflex artery runs parallel to the incision (see Ligations). The bone is cut with the chisel obliquely from above postero-externally to below antero-internally in order to prevent dislocation of the lower 220 OPERATIVE SURGERY. fragment medially or forward from above, during forced ab- duction. The operation is performed for the correction of adduction, flexion, and shortening following coxitis that has healed in bad position, also for old and congenital luxations of the hip joint. ^IG. 99.— Osteotomy of the Fe- mur. Cuneiform Osteotomy of the Tibia. Fig. 100. Fig. 101. Figs. 100 and 101.— Subtrochanteric Osteotomy. After-treatment in forced abduction with elevated pelvis and plaster dressing with double stocking. 193. Resection of the Diaphysis of the Femur. — Incisions can be made, without fear of incidental injury, on the outer side through the whole length of the bone, from the base of the great trochanter (where the terminal branch of the external circumflex artery passes under the vastus) to the external LOWER EXTREMITY. 221 condyle of the femur (where the external superior artery of the knee joint runs transversely around the bone, at the posterior margin of the vastus externus, between it and the biceps muscle). Resection of the pelvis Arthrectomy and re- / section of the hip ) Fig. 103. 194. Resection of the Hip (Figs. 102, 103, and 104).— Angu- lar incision, beginning at the base of the outer surface of the great trochanter, passing obliquely upward to the anterior point of the trochanter, thence bending at an angle in the direction of the fibres of the glutseus maximus, and extending obliquely upward and medially through the skin and the often abundant 222 OPEEATIVE SURGERY. adipose tissue. Usually at the base of the great trochanter larger branches of the external circumflex artery are cut and ligated. On the outer surface of the great trochanter the fascia of the glutseus maximus muscle is severed, thus exposing the Crlutseus maximus muscle Glutseus medius muscle Pyriformis muscle Great trochanter Obturator internus muscle Quadratus f emoris muscle Fig. 103.— Resection of the Hip. periosteum and the attachment of the gluteus medius muscle which covers the whole of the tip of the trochanter. Upward and backward the incision divides the fibres of the glutseus maximus, and usually in the upper portion some larger vessels are cut and must be ligated. The layer of fat thus laid bare is separated, and at the lower LOWER EXTREMITY. 223 margin of the glutseus medius we reach the interstice between this muscle and the glutseus minimus above and the pyriformis below. Entering here and drawing the pyriformis down, we immediately strike the posterior surface of the capsule of the GlutfBus maximus muscle Glut£Eus medius and minimus I muscles \ Tendons of the pflutei muscle Great trochanter Posterior wall of the capsule with the attachments of the pyriformis and the ob- turator muscles Fig. 104.— Resection of the Hip. dorsal wall of the acetabulum. Anteriorly we follow the upper margin of the slender pyriformis tendon to the attachment of the glutseus medius to the great trochanter, and separate this forward in its whole extent close to the bone, i.e., dissect it away from the upper point and the outer surface of the tro- chanter. 224 OPEHATIVE SURGERY. At the anterior margin of the great trochanter we separate the tendon of the glutseus minimus with the glutseus medius and draw these muscles forward with hooks. From the inner sur- face of the great trochanter and the trochanteric fossa we sepa- rate the tendons of the pyriformis, the obturator and gemelli, and finally the obturator externus, and lift these tendons with the periosteum from the inner and posterior surface of the tro- chanter, drawing them backward en masse. In this way the muscles supplied by the superior gluteal nerve, viz., the glutaeus medius and minimus, are crowded for- ward and upward toward the tensor fasciae muscle, which is supplied by the same nerve and is of special importance for the subsequent abduction of the thigh ; while the rest of the mus- cles, glutaBus maximus, pyriformis, and obturators, which are mainly supplied by the inferior gluteal nerve, remain below. To be sure, the pyriformis muscle receives now and then a twig from the superior gluteal nerve, but in that case the branch is given off so high up that its injury is out of the question. Thus the whole posterior surface of the head and neck of the femur is laid bare, with as much of the trochanter as is required, and we merely have to ligate some branches of the circumflex arteries which run transversely oVer the capsule of the neck and possibly the external circumflex at the base of the great tro- chanter, where it passes through the vastus externus and around the femur. If fungous granulations on the synovial membrane necessitate its excision, it will not be difficult to dissect it out for quite a distance from behind, before it is opened ; to separate it from its attachment to the acetabulum and the neck of the femur, and to remove the j)osterior wall in toto. The thigh being strongly adducted, rotated inward, and flexed, the liga- mentum teres is detached and the head luxated backward, and in this position the acetabulum is open to inspection. Fun- gosities are removed with forceps and scissors until the joint is. thoroughly cleared. UPPER EXTREMITY. 225 Among the numerous methods for the resection of the hip joint we know of none which is ecjually conservative regarding muscles, nerves, and bone, and affords as thorough an inspec- tion of the joint. It is a further development of Langenbeck's method, on whose oblique incision it is based, but which does not suffice, especially for the extirpa- tion of the capsule alone with preser- vation of the bone. Hence we abstain from making comparisons with other modes of operation. If arthrotomy alone is intended, the muscular attachments to the trochanter are not first separated, but the capsule is opened at once along the upper mar- gin of the acetabulum as far as the neck of the femur, and with the cap- sule the periosteum and muscular at- tachments are separated from the neck and the trochanter. 195. Resection of One- Half of the Pel- vis (Fig. 102). — Performed by Kocher and Roux with very satisfactory func- tional result, so that my patient, in whom the head of the femur was resected at the same time, can walk without a cane, though he limps badly. We give a characteristic illustration from a photograph taken three and a half years after the operation. Fig. 105. V. Upper Extremity. 196. Excision of the Phalanges, Metacarpal Bones, Inter- phalangeal and Metacarpo-phalangeal Joints (Figs. 100 and 107). — For the phalanges and joints only lateral incisions, for the metacarpals dorsal incisions, come in question. Incisions 15 326 OPERATIVE SURGERY. on the fingers are placed nearer the dorsum, and this all the more in proportion as they are lengthened peripherally. Eegarding the fingers it is necessary to make bilateral inci- sions in order to prevent cicatricial retraction and lateral curva- tures after the removal of bones. Extensor tendons and nerves on the dorsum of the hand (radial and ulnar nerves) are to be Fig. 106. Fig. lur. Figs. 106 and 107. — Resection of the Phalanges and Metacarpals. Resection of the Articulations of the Fingers. Frontal Section of the Wrist Joint after Henle. spared ; the incisions are to be made on the bones as felt subcu- taneously and carried beyond the adjoining articulations. Where there is no contra-indication, the resection should be subperiosteo-capsular, and the head of the bone is to be exposed first because it can be made more easily movable. On the metacarpal bone of the thumb the tendon of the ex- tensor brevis with the periosteum is to be pushed to one side, and the thenar muscles to the other side ; at the upper end of UPPER EXTREMITY. 227 the bone the attachment of the tendon of the abductor longus must be separated. On the remaining metacarpals the external and internal interosseal muscles are to be detached with the periosteum. Only the metacarpo-carpal joint of the thumb is isolated ; the others are connected with the wrist joint. 197. Resection of the Hand (Figs. 108 and 109). — For free opening of the wrist joint we have generally employed the method known as Langenbeck's, which is probably used most largely. Farabceuf states that the dorso-radial incision had been introduced in 1869 by Bockel. We have practised the same incision before Langenbeck's time, not only on the living patient, but have demonstrated it on the cadaver in our courses of instruction. At all events it was Langenbeck who secured recognition for the method, which has great advantages over earlier procedures. Dorso-radial Incision. — The hand being in strong ulnar flexion, we make a straight incision through the skin from the middle of the second metacarpal to a point at an equal distance above the middle of the wrist joint, in the axis of the forearm. The incision lies between the tendons of the extensor digitorum communis, with the extensor indicis proprius on the one side and the extensor jDollicis longus on the other side. The skin is divided slowly, preserving peripherally the branches of the super- ficial radial nerve which pass to the middle finger; then we sever the common dorsal ligament of the wrist with the fascia and penetrate at the forearm to the radius, at the wrist joint through its capsule and downward to the base of the third met- acarpal. On the latter we detach the tendon of the radialis ex- tensor brevis, and at the base of the second metacarpal that of the radialis extensor longus with the periosteum ; we expose the dorsal surface of the second metacarpal with the interosseal muscles between the latter and the third metacarpal, and later- ally close to the bone we begin to lift the tendons out of their grooves and to separate the capsule of the wrist joint. 328 OPERATIVE SURGERY. The method of Bockel and Langenbeck, however, has this drawback, that in order to gain room the external radial mus- cles must be detached. No matter how carefully we make the method a subperiosteal one — as Trelat puts it (Faraboeuf), peel- ing between tree trunk and bark— it entails grave injury to the chief dorsal flexors of the hand, and this may be the reason why a volar subluxation of the hand with greatly restricted dorsal flexion so often results. It is, therefore, justifiable, in Extensor digitorum communis muscle Extensor digiti V. muscle Ulna Ligamentous disc Semilunar bone Dorsal ligament of the wrist Unciform bone Fig. 108. — Arthrotomy and Resection of the Hand. view of these common disturbances, to be more sparing of the radial muscles and place the incision on the ulnar side of the flexor tendons, though still on the dorsum, i.e., to use the dorso- ulnar incision (Figs. 108 and 109), as it is called. This incision, proposed by Lister, lies far more to the ulnar side, between flexor and extensor carpi ulnaris. It should be 7 to 8 cm. in length ; it begins, the hand being in slight radial flexion, at the middle of the interspace between the fourth and fifth meta- carpal, passes toward the middle of the wrist joint and thence upward in the middle line of the dorsal surface of the forearm. At its lower end the incision preserves the dorsal branch of the ulnar nerve, which is easier than to save the radial in the dorso- radial incision, because the ulnar nerve turns toward the middle UPPER EXTREMITY. 229 line farther down. The incision divides the fascia and the com- mon dorsal ligament of the wrist, opens the capsule at the base of the fourth metacarpal upon the unciform bone and ulna, but preserves the tendons of the extensor digiti minimi proprius and extensor communis between which it passes. The capsule is styloid process of the ulna Lieamentous disc ^^^^j^g ''*^ IJnper row of carpal bones '^jf^j^^H^^ -^s magnum \J^'^ <^^' rX Tnciform bone Extensor digiti V , Fig. 109.— Artlirotomy and Resection of the Hand. separated toward both sides and with it the tendon of the exter- nal ulnar muscle at the fifth metacarpal. The detachment of the external ulnar tendon is less harmful than that of the two external radials. The ulnar muscle par- ticipates only to a minor degree in dorsal flexion as compared with the external radials which are attached to the radio-carpal or main joint. It is true, the external ulnar contributes mate- rially to ulnar flexion ; but this movement predominates only too much after resection as a result of gravity, for at a later stage 230 OPERATIVE SURGERY. the hand appears inclined to the ulnar and volar side or even con- tractured in these directions. For this reason the separation of that tendon would act rather favorably than otherwise. More- over, the extensor tendons are less liable to prolapse from the wound of the dorso-ulnar incision than from the dorso-radial. The extensor tendon of the little finger is most apt to be in- jured, but as this finger is provided with a double extensor and has far less important functions than the index finger, this is of no importance. Above on the ulnar side the tendons of the extensor minimi digiti and the external ulnar are lifted from the groove in the ulna and the capsule is detached round about the ulna. When the joint is diseased between the ligamentous disc and the ulna and between the ulna and radius, the disc must be excised. The separation of the capsular attachments round about the ulna is easy. After the capsule is separated from the fifth metacarpal we naturally enter the joint between the pisiform and cuneiform ; the tendon of the internal ulnar muscle is left intact at the former bone. The hamulus of the unciform, too, can more easily be freed than in the dorso-radial incision. The bundle of the common volar tendons is readily lifted en masse from its groove, and the attachment of the capsule to the fifth, fourth, and third metacarpals, can be separated on the palm, while the attachment of the internal radial tendon is left intact at the second metacarpal. The tense capsular attachment to the volar margin of the radius is likewise separated. On the dorsum the capsule is separated from the dorsal mar- gin of the lower end of the radius to a point under the external radials and the extensors of the thumb, the tendons are lifted out of their grooves, and the attachment of the supinator longus is also separated. But the tendons of the external radials are' left attached to the dorsal surface of the third and second meta- carpals; the hand is forcibly luxated completely in the radio- volar direction so that the thumb touches the radial side of the UPPER EXTREMITY. 231 forearm. The enucleation of the carpal bones and the removal of the thinnest possible layer from the bones of the forearm and metacarpus now present no difficulty; only about the trape- zium and trapezoid access is not so free for the removal of these and the three ulnar metacarpal bases. In cases where the disease affects mainly the radial side of the wrist and meta- carpals or is confined exclusively to the radial side of the joints, the dorso-radial method is preferable to that described. Be- tween the trapezium and trapezoid, or between the bases of the first and second metacarjoals, special attention should be devoted to the radial artery, which here turns into the deep volar arch. We consider as essential in our method that the tendons of the external radials be . kept intact, and that it is possible, by complete luxation of the joint, to obtain a free view into all recesses and over all the bones. In the after-treatment of resection and arthrotomy of the hand it is of importance that dorsal flexion at the wrist joint be secured by a splint such as we have had in use for many years, and which effects firm fixation of the wrist joint while permit- ting movements of the fingers. As for the finer function of the fingers their vigorous flexion alone comes in question, dorsal flexion at the wrist joint is the only correct position, for by the stretching of the flexor tendons it keeps the fingers at once in passive flexion and hence permits a greater degree of such flexion with very slight exertion. 198. Resection of the Ulna. — The ulna lies subcutaneous through the entire length of the forearm, in the space between the external and internal ulnar muscle. It can, therefore, be partially or totally excised without difficulty or incidental injury. 199. Resection of the Radius. — The radius is far less readily accessible than the ulna. On the posterior side of the radius the condyle can always be felt under the skin and therefore can be resected from a portion of the incision whose direction and 232 OPEKATIVE SURGERY. position are more fully described under our method for the resection of the elbow. On the diaphj^sis the middle third is palpable on the posterior surface between the extensores radiales (longus and brevis) and the extensors of the fingers. Incision can here be made without having to fear the vessels, nor need nerve twigs be considered, since the adjoining muscles obtain their radial branches higher up. The upper third of the radius is covered by the supinator brevis through which the motor branch of the radial nerve passes dorsad. The lower third is covered externally by the tendons of the brachio-radialis and the radiales externi which run longitudinally, by the pronator quadratus, by the extensors crossing the dorso-radial side obliquely, and by the abductor of the thumb. An incision along the entire length of the radius down to the bone is possible only in the line for the ligation of the radial artery, during which the superficial (sensory) branch of the radial nerve is displaced toward the radial side, and the vessels are pushed to the ulnar side. For the nerve lies toward the radius above; below, at the lower fourth of the forearm, it turns to the dorsal side. TJie Free Openmg of the Elbow Joint. 200. Besection of the Elhoiv (Figs. 110 and 111). — As in all arthrotomies and resections of the joints which require a free view into the joint for the correct removal of all diseased tis- sues, we adhere to the principle that a somewhat complicated cutaneous incision matters little if thereby we can preserve not only all the muscles with their attachments, but especially spare the nerve fibres which supply the muscles. This was our main reason for introducing the posterior curved incision for the arthrotomy of the shoulder to be described hereafter, and in the same sense we have modified the old method for the resection of the elbow. UPPER EXTREMITY. 233 At first we practised the simple method of von Langenbeck with posterior longitudinal incision ; l)ut we found that access was not as free as was desirable, particularly in cases of fungous inflammations localized in the region of the head of the radius upinator longus muscle External uoudjle Head of tlie radius jrnal ulnar uiuscl Triceps muscle I Ulna Anconseua quartus muscle Fia. 110.— Resection of the Elbow. Supinator longus muscle I External condyle 1 I Head of the radius Point of attachment of the anconeeus IV. niuscletothe ulna Triceps muscle // I Divided fascia Attachment of the ancongeus IV. muscle to the uhia Fig. 111.— Resection of the Elbow. or extending in this direction. Such access is furnished by Ollier's bayonet incision— an excellent method. But even the latter has the drawback of placing the anconseus quartus muscle out of function. It is true, the obhque middle portion of Ollier's incision passes through the interstice between the external head 234 OPERATIVE SURGERY. of the triceps and the anconseus quartus ; but since the branch of the radial nerve which supphes the latter muscle descends from above as the terminal twig of the above-mentioned branch supplying the head of the triceps, the muscle must atrophy after OUier's operation. But in the case of the elbow it is our partic- ular duty to do our best to secure actively movable joints, and for that reason the anconseus quartus should be preserved, as it is a true articular muscle for the tension and fixation of the capsule. This we effect in the following manner. The elbow is bent to about 150° and an angular incision is made as in Fig. 110. This begins, like Ollier's incision, at the edge of the outer surface of the lower margin of the humerus, 3 to 5 cm. above the line of the joint; it runs essentially parallel to the axis of the humerus, i.e., in a vertical direction to the head of the radius, thence corresponding to the lateral margin . of the anconaeus quartus to the edge of the ulna 4 to 6 cm. below the tip of the olecranon, and. bends up about 1 or 2 cm. on the medial side of the ulna. Above, the incision reaches to the lateral edge of the humerus between the brachio-radialis, radiales externi, and extensor digitorum communis muscles, all of which remain in front, and the anconseus brevis which re- mains behind ; then on the postero-external circumference of the head of the radius it severs the capsule and penetrates down- ward between the lateral margin of the anconseus quartus and the external ulnar muscle to the lateral surface of the ulna. The last offshoots of the anconseus quartus downward at the edge of the ulna are cut, for frequently they reach very far down the forearm. Accordingly the incision completely separates the muscles supplied by the forearm branches of the radial nerve from those innervated by the deep branch of the radial nerve at the fore- arm, and thereby avoids any subsequent atrophy. After the bone is laid bare and the capsule opened, the next step depends upon the fact whether the removal of the olecranon is required UPPER EXTREMITY. 235 or not. If the latter is diseased, the chisel is applied in the line of the incision without unnecessary detachment of the muscles and tendons, and the olecranon is cut obliquely at its base (more deeply on the dorsal side). Then the flap consisting of triceps, anconseus quartus, and olecranon can ha turned over toward the ulna, and the joint is open to inspection. According to the extent of its involvement, the olecranon can be enucleated in the most conservative manner. If the olecranon is to be preserved, we proceed as follows. The external head of the triceps is separated from the humerus with the periosteum and the attachment of the capsule, the anconseus quartus from the outer surface of the ulna, the at- tachment of the triceps from the tip of the olecranon, and a portion of the internal ulnar muscle from the inner surface of the ulna. This triceps-anconseus flap with the capsule is turned inward over the olecranon like a cap, the arm being extended. As shown in Fig. Ill, the joint can now be freely inspected from behind externally and be made to gape as soon as the external lateral ligament and the capsule are detached from the external condyle of the humerus and the neck of the radius. In this way the entire extensor apparatus is preserved in toto, as regards both muscles and nerves. According to the indica- tions for the arthrotomy, we now detach as gently as possible the internal lateral ligament from the inner margin of the ulna and the medial surface of the trochlea, also the muscles, in connection with the periosteum, from behind forward so far as absolutely necessary, from the internal and external condyle, when the resection of the bone can be performed if required. In cases of fungous disease of the capsule, we open the joint, on principle, as late as possible, by carrying the incisions only as far as the joint capsule, and dissect its outer surface free. In this way the v/hole morbid mass of tissue can be more accu- rately extirpated en masse. In resection of the olecranon we 236 OPERATIVE SURGERY. have for many years practised the curved sawing in order to secure an olecranon to the new joint. This aids largely in pre- venting forward subluxations of the forearm. We have above laid stress on the fact that in comparison with the simple posterior longitudinal incisions, of which Langen- beck's is the most common, the curved incisions, of which Oilier 's method is the best representative, possess great advan- tages in giving more room and exposing the joint more thor- oughly, especially about the head of the radius. Hardly any- body will be inclined to employ transverse incisions, whether straight or curved, combined or not with one or two longitudinal incisions. The principal direction of the incision will always have to be longitudinal -if the muscles and their nerves are to be preserved. The only method which we have to mention according to Faraboeuf 's description, since it resembles our own, is that of Auguste Nelaton, who combines an external longitu- dinal incision upon the head of the humerus with one running at a right angle backward from the head of the radius to the ulna. But even Nelaton employs it mainly for the sufficient exposure of the head of the radius and, like Oilier, pays no attention to the preservation of the anconseus quartus. Hueter likewise and, according to Faraboeuf, Marangos have recommended cutaneous incisions related to ours, but they differ in the principal object and intention of the incision. 201. Resection of the Diaphysis of the Humerus. — The ex- cision of the humerus offers less simple conditions than that of the femur. The mode of removal of the upper and lower ends maybe gathered from the description of the corresponding joint resection. Upon the diaphysis the relation of the radial nerve must be principally borne in mind. The nerve curves from within around the posterior surface of the humerus toward the outer side. The external bicipital sulcus is the only line in which we can cut down upon the diaphysis over its entire length, from the UPPER EXTREMITY. 237 lower end of the surgical neck (in the region of which the cir- cumflex artery and nerve must be spared) to the condyles below. We divide the fascia of the deltoid so that the anterior margin of the muscle can be drawn backward with the arm in the abducted position; then we open the fascia of the biceps and penetrate close to the margin of the muscle and under it along the coraco-brachialis and the outer margin of the brachi- alis internus down to the bone. The radial nerve with the off- shoots of the deep brachial artery (collateralis radialis) remains on the outer side; in the lower third the musculo-cutaneous nerve, which descends between the biceps and brachialis internus to the lateral anterior side, is drawn medially. 202. Resection of the Articulation of the Humerus. a. From in front, in disease of the head of the humerus (Figs. 112 and 113). The head of the humerus projects considerably beyond the socket in front, for in a horizontal direction the diameter of the socket is but half that of the head covered with cartilage. The head, therefore, is more readily accessible from this side in the same proportion as the socket is exposed with greater difficulty from in front. The simplest method is the an- terior longitudinal incision practised by Baudens, Malgaigne, Eobert, and Dubreuil ; but perfected particularly by Langenbeck and his pupils. The improvement of the operation by Hueter, Oilier, and Chauvel, who substituted for the vertical incision an oblique one from the acromion downward through the deltoid so as to spare the latter, appears to be the most rational pro- cedure, since this muscle is of the greatest importance for sub- sequent movements. The incision begins above the coracoid process on the clavicle and passes down along the anterior mar- gin of the deltoid. The margin of this muscle, to which the clavicular portion of the pectoralis major muscle is closely ad- joining, is mapped out by the cephalic vein. This is cut above or dissected out toward the pectoralis. If necessary the deltoid is detached for some distance close to the clavicle, bv a transverse 238 OPERATIVE SURGERY. incision. The acromial branches of the thoracico-acromialis and transverse scapular arteries are to be ligated. The anterior margin of the deltoid is drawn outward. This brings into view the muscles springing from the coracoid process : pectoralis minor, short head of the biceps, and coraco- brachialis. At the lateral margin of the latter we cut down on Fig. 112.— Anterior Resection of the Humerus. the bone and, the arm being slightly rotated inward, open the sheath of the biceps tendon above the sulcus of the biceps which can be distinctly felt. The opening is made downward and up- ward through the upper wall of the capsule until the tendon is exposed at its attachment to the upper margin of the socket and can be readily drawn inward. This exposure of the biceps ten- don has for its object not only its preservation, but it is intended especially to render the head of the humerus accessible in a line UPPER EXTREMITY. 539 along which the muscular attachments meet from in front and behind. Then follows the separation, by vertical incisions close to tho bone and parallel to the bicipital sulcus, of the tendons attached to the capsule, namely, that of the subscapularis from the tuberculum minus, those of the supraspinatus and infra- Pectoralis major muscle ectoralis minor muscle laviele Coracoid process bhoi t head of the biceps and coraco- Jomt cavity [brachialis Biceps tendon ( Divided margins of the I capsule Cephalic vein "Humerus Deltoid muscle Fig. 113. — Anterior Resection of the Humerus. spinatus and teres minor from the tuberculum majus. At the same time the humerus is rotated so that the joint surface is ex- posed more and more, first anteriorly, then posteriorly. Any transverse incision through the capsule between the head and the socket is to be absolutely avoided. If the humerus requires exposure farther downward, regard must be had for the anterior and posterior circumflex arteries at the surgical neck and for the axillarv nerve ; the former may need ligation. 240 OPERATIVE SURGERY. h. From hehiyid (Figs. 114, 115, and 116) when the socket is largely affected or in diffuse disease of the joint. As shown in Fig. 114, the cutaneous incision passes from the acromio-clavicular joint over the highest part of the shoulder along the spine of the scapula to near its middle, thence down- ward in a curve toward the posterior axillary fold, ending two fingers' breadth above the latter. The upper part of the incision penetrates into the acromio-clavicular articulation (the covering ligaments of which are severed) and in its further course runs along the upper margin of the spine. The descending portion of the incision divides the thick fascia along the posterior mar- gin of the deltoid muscle, which is thus exposed in its lower portion, when the finger draws the muscle vigorously forward. The fibres of the deltoid which are attached farther backward along the spine must be cut, and thus a small posterior triangle of the muscle is placed out of function. The attachment of the trapezius is separated above at the spine, the supraspinatus muscle is detached with the elevator, as is the infraspinatus below, until the finger can seize the lateral margin of the spine at the point where it rises from the scapula. The supraspinatus and infraspinatus muscles being drawn aside, the spine is cut through at this point with a blow of the chisel. During this step care should be taken lest injury be done to the suprascapular nerve, which descends under the muscles named from the supraspinatous into the infraspinatous fossa ; the nerve, however, is protected by the inferior transverse scapu- lar ligament. Before cutting the bone it is desirable to make two gimlet-holes for the subsequent suture of the divided surfaces. Or else, the periosteum can be divided backward and forward, a small piece of bone excised, and the periosteum sutured over it. After the bone is cut, the acromial portion can be completely turned forward or luxated in the acromio-clavicular articulation, by the exercise of some force and the insertion of a sharp hook. UPPER EXTREMITY. 241 Teres minor muscle Deltoid muscle ' Posterior margin of ^ the deltoid ^ - muscle Infraspinatus muscle rticular surface of the clavicle Crista scapulee Divided surfaces ot the deltoid muscle Divided surfaces of the deltoid muscle j Divided surface of the -| ciista sLdpiila; .irticular surface of acromion ^Articular surface of clavicle >^'V;1 Supraspinatus m Infraspinatus m. /-S i\ Teres minor m. ^Divided surface of crista scap.; Articular surface of acromion •^ Biceps tendon [vide ''Articular surface of cla- / Post, surface of socket ' ( Capsule witli post, ten- /v5^\.^- ' dinous attachments /^ \L^^ Jt Supraspinatus m. ^^ -^ .^ Teres minor muscle Infraspinatus muscle Figs. 114, 115, and 116.-Posterior Resection of the Articulation of the Humerus. (The divided sur- faces of the deltoid muscle appear much too long in the illustrations, as merely a small posterior tnangle is cut off.) 16 242 OPERATIVE SUEGERY. During this step the deltoid becomes spontaneously detached from the muscles of the scapula, with whose smooth under surface it is connected only by some loose connective tissue (Fig. 115). After the acromio-deltoid flap is turned over, the upper, outer, and posterior surfaces of the head of the humerus are freely accessible, covered by the tendons of the outward rotators, supra- spinatus, infraspinatus, and teres minor. The posterior surface of these muscles is likewise exposed. Much now depends on the fact that the incision on the head of the humerus be placed correctly so as to avoid unnecessary injury. At the point where the muscles named with their tendons are attached to the tuber- culum majus and the spina tuberculi majoris, i.e., at the an- terior margin of these attachments and the posterior margin of the palpable bicipital fossa, a longitudinal incision is made upon the bone, passing upward along the upper margin of the supraspinatus; thus the capsule is divided on the upper surface of the joint and the biceps tendon is exposed as far as its at- tachment to the upper margin of the socket. Along the posterior margin of the biceps the attachments of the external rotators to the tuberculum majus are separated and drawn backward. In this way the biceps tendon is freed below from its bony fossa so that it can be drawn forward and the sheath of the biceps laid bare for inspection. In order to facilitate this step the elbow is brought forward and the arm rotated outward. Now the attach- ment of the subscapularis to the tuberculum and the spina tuberculi minoris becomes visible and is separated from the bone forward and inward. It is quite easy to spare the circumflex nerve and vessels which emerge from below the teres minor muscle; in fact, their injury does not come into question when the operation is correctly performed (Fig. 116). As soon as the head is entirely freed — still more so, of course, when it is removed by resection — we obtain an excellent view into the socket, one that is far better than is possible by the anterior mode of operation. It need hardly be pointed out that UPPER EXTREMITY. 243 this is at present of special importance, in comparison with the former f>ractice, when it was almost thought to be a matter of course that in resection of the humerus decapitation of the head alone was performed. Unless the affected tissues are removed from every part of the joint in tubercular disease, operative treatment has been deprived of most of its value. Resection of the shoulder joint from the above-described posterior curved incision not only allows absolutely free inspec- tion of the joint, but it fulfils the indication of keeping the del- toid with the other shoulder muscles in function, for it injures neither the muscle nor the afferent nerve. But it possesses a material advantage over resection from in front, inasmuch as it makes it possible, in the case of absent or limited disease of the head, to restrict ourselves to the detachment of the muscles passing from the posterior surface of the scapula to the capsule, while leaving the latter intact at the anterior circumference of the head, together with the covering subscapular muscle and the coraco-humeral ligament. This is the best way of guarding against the frequent subluxation of the head of the humerus toward the coracoid process. The method, therefore, deserves special consideration in arthrectomies. 203. Resection of the Clavicle, of the Sterno-clavicular and the Acromio-clavicular Articulations. — As the clavicle lies under the skin for its entire length, its resection is a simple matter whenever it can be made subf)eriosteal. After dividing the skin, platysma (with the supra-clavicular nerves), and the fascia, the periosteum is readily pushed back. Sawing through the clavicle in the middle facilitates the separation of the two halves. At the upper margin the attachments of the clavic- ular portion of the sterno-mastoid muscle and the trapezius, at the lower margin the clavicular portion of the pectoralis major and the deltoid, are to be separated; at the posterior surface the subclavian muscle, and medially the costo-clavicular ligament. 244 OPERATIVE SURGERY. For the resection of the acromio-clavicular articulation merely the stout mass of ligaments on the surface of the joint is to be divided to make the clavicle movable. The sterno- clavicular articulation per se likewise presents no difficulty from an anterior incision ; for the meniscus facilitates the separation of the ends of the joint. But where the excision cannot be made subcapsulo-periosteal, we must bear in mind, during the separation of the interclavicular ligament, the trans- verse vein in the sternal notch ; during the separation of the sterno -mastoid muscle, the continuation of the same vein behind this muscle to the external jugular vein; during further divi- sion of the subclavian muscle and the costo- clavicular ligament, the pleura and the subclavian vein. 204. Resection of the Scapula (Fig. 117). — Total resection was first performed by Langenbeck (Gies) in 1855. In disease and especially in tumors of the scapula, which are not rare, it is important that this bone be excised thoroughly but without un- necessary incidental injuries. The periosteum should be pre- served wherever feasible, together with the covering muscles, in view of possible regeneration. On the other hand, where preservation of the periosteum is out of the question, as in tumors, it appears to be particularly desirable to remove thor- oughly all the muscles which are placed out of function, in order to prevent relapses. In total excision of the scapula, these include the muscles moving the scapula alone or acting from the latter upon the arm. Curved incision from the point at which the acromion must be severed, over the spine of the scapula to its posterior margin, and downward to the angle of the scapula. It is a great advan- tage for the function of the arm if a good part of the acromial portion can be preserved, because to it are attached important muscles — the trapezius from above and the deltoid from below. If the acromion is to be removed completely, the incision at its beginning at once passes into the acromio-clavicular articulation UPPER EXTREMITY 245 and divides it fully. If a portion is preserved, the acromion is severed with a chisel at the respective point. The triangular flap formed by the above-described incision is turned forward over the latero-posterior fibres of the deltoid and backward over the ascending portion of the trapezius to the margin of the latissimus dorsi muscle. The finger is in- FiG. 117. —Resection of the Scapula. serted under the exposed posterior margin of the deltoid and the muscle separated as close as the disease permits, along the crista and the acromion as far as the acromio-clavicular articulation or to the point where the acromion is cut with the chisel. In this way, similarly to our resection operation for the shoulder joint, the posterior surface of the capsule with the covering tendons of the outward rotators is laid bare. If the articular portion of the scapula can be preserved, one muscle 246 OPERATIVE SURGERY. after another is cut upon the insinuated finger or elevator, and the articular portion of the scapula is sawed off. But if the articular portion is to be removed likewise, the tendons are sep- arated from the head of the humerus as in resection of that bone ; from the tuberculum majus, the supraspinatus and infra- spinatus and teres minor ; from the tuberculum minus, the sub- scapular ; and below from the spina tuberculi minus, the common attachment of the latissimus dorsi and teres major. At the lower margin of the teres minor the axillary nerve and posterior circumflex artery are to be preserved or the latter ligated ; farther backward the circumflexa scapulae artery must be ligated. Next the trapezius is divided, the finger being insinuated under its fibres from the cut surface of the acromion, and the muscle is separated along the crista scapulae, also behind along the inferior edge of the crista. At the anterior end the acromial branches of the thoracico-acromialis artery must be ligated. The scapula, now more freely movable, is drawn down; the muscles attached at the upper margin are separated antero- posteriorly; the omo-hyoid combined with ligation of the ter- minal branch of the transversa scapulae artery, the levator scapulae at the posterior upper angle with ligation of the branches of the dorsalis scapulae artery (transversa colli). Then the broad, rounded attachment of the serratus anticus major muscle at the posterior margin of the scapula is separated when the scapula is turned over, and finally the attachments of the thin rhomboids are cut at the same point, with eventual ligation of the dorsalis scapulas artery, which passes along the scapular margin on the serratus posticus superior muscle. PART IV. AMPUTATIONS AND EXARTICULATIONS. Introduction. The complete removal of a limb or a portion of it is called amputation. If the removal is made at the joint it is generally called exarticulation. Quite a number of indications for the choice of the method of amputation have become nugatory since the introduction of the antisejDtic wound treatment and the im- provement in the technique in connection with the latter. In former times two considerations pre-eminently determined the surgeon to follow a definite method in the removal of a portion of a limb : 1. The desire to favor rapid and undisturbed recovery. 2, The formation of the most useful possible and painless stump. In order to secure rapid healing, the wound was sought to be made small, smooth, and so placed that the margins were well nourished and coapted themselves spontaneously; finally the best possible escape of the secretions from the wound surface was aimed at. Nowadays, thanks to asepsis, we can make the largest wound heal by first intention, can even tolerate considerable tension of the wound margins, and can sufficiently provide for the escape of the wound secretions, which at any rate form an element for a few days only, by separate small openings. Moreover, the usefulness of the stump formerly depended far more upon the method than it does to-day, since it was by the method that the surgeon had to secure the mobility of the 248 OPERATIVE SURGERY. skin on the stump, the correct placing of the tendons and mus- cles to the ends of the bones, and the removal of the nerve stumps from the region of the cicatrix. At present even these considerations are largely done away with when the course of the wound is aseptic. Amputation is permissible anywhere, provided sufficient tegumentary covering for the stump can be obtained and the cicatrix (superficial and deep) can be protected from injurious pressure from without. Development of the Methods of Amputation. In order to show the connection of the various methods of amputation, we give in Figs. 118 to 122 a synopsis of the devel- opment of the complicated incisions from the simple circular methods. The simplest and oldest methods have recently again become the most frequent. These are the circular incisions. By circu- lar incisions we understand, in opposition to other authors, not only transverse incisions, but also those running obliquely to the axis of the limb, provided the line of the incision continues in one direction, or the incision lies in a single plane. In the fol- lowing diagrams we give the fundamental type of the circular method from which all other methods can be derived, first by the addition of longitudinal incisions, and then by the rounding of the resulting angles. The addition of a single longitudinal incision with rounding of the angles results in the so-called oval incision (an oval with a pointed side is strictly not an oval). The addition of two longitudinal incisions with rounding of the angles results in true flap incisions. The incision '•'■en raquette'''' and the quadrangular flaps are transitions from the circular to the latter methods. Wherever possible the circular method is to be preferred. For the employment of the oval and flap methods we shall always give the special indications. In the introduction, therefore, we can confine ourselves to the descrip- AMPUTATIONS AND EXARTICULATIONS. Development of the Methods of Ampi-tation. b. Oblique circular incision (oblique method) 249 Fig. 118.— I. Fundanieutal Type : Circular Metlioil. b. Oblique incision rii raqnette Fig 119 —II. Transition to the Oval Method (Incision en ragwef ^e=:Pedunculated Circular Jlethodj. a. Transverse oval incision b. Oblique oval incision Fig. 121.— IV. Transition to the Flap Blethod (Angular Flap 3Iethod= Doubly Pedunculated Circular Method). b. Unequal flaps Fig. 1~'~'.— V. Flap Method C^ounded Flaps). 250 OPERATIVE SURGERY. tion of the circular methods and only briefly point out the indi- cations. The transverse circular method secures to the skin the best vascular supply and nutrition. It is contra-indicated in favor of the oblique circular method : first, when more healthy skin is present on one side of the limb than the other, otherwise the amputation would have to be carried unnecessarily high ; sec- ondly, when the portion of the limb to be operated on is much thicker above than at the point of incision, as this renders the retraction of the skin difficult ; thirdly, when the cicatrix cannot be placed at the end of the stump because it is exposed to pressure from below. Figs. 129 and 130 sufficiently illustrate the vary- ing position of the suture : in the transverse circular method, below on the stump ; in the oblique circular method, above the stump laterally. It is evident without much argument that for the reasons above given the transverse circular method finds a far more general application because it can be adapted to most cases, is easily executed, and furnishes a movable tegumentary covering for the end of the stump which is free from cicatrices. The incision en raquette and the oval method give more room with equal preservation of integument, or equal room with greater preservation of integument (including the soft parts) and therefore are to , be preferred in some difficult exar- ticulations (at the thumb, hip, and shoulder). The flap method is preferable where the skin or the other soft parts on one side of the limb call for special consideration. This is the case, for instance, at the heel and the muscles at the shoulder and hip. The drawback of the flap method, which applies in a minor degree even to its fundamental type, the oblique circular method, is the defective nutrition of the skin. The performance of the transverse circular method is suffi- ciently illustrated in Figs. 123, 124, and 126. The oblique circular method (see Figs. 126, 127, and 128) differs from the transverse in one essential point, namely, that AMPUTATIONS AND EXARTICULATIONS. 251 Fig. 12;^.— Transverse Circular Method: showing the Fig. I:i4.— Transverse Circular Method; showing retraction of the skin and the application of the how the deep muscles together with the perios- knife. teum are pushed back with the raspatory. Fig. 125. — Transverse Circular Method after Sawing Fig. 120.— Oblique Method; pinching up of the skin the Bone; showing the hollow cone (in sagittal for marking the lower end. section) from the skin to the bone. Fig. 127.— Oblique Method; pinching up of the skin Fig, 128.— Oblique ^Method: showing tlie ai^plication for marking the upper end. of the knife for the gradual deep division of the soft parts. ' / h.< .1/5 %^ Fig. 129.— Position of the Suture in the Transverse Fig. 130.— Position of the Suture in the Obhque Circular Method. Method. 252 OPERATIVE SURGERY, the skin is lifted from the underlying tissue and must be dis- sected back with the knife, while in the transverse circular method it is merely drawn back. Another difference lies in this, that the relation of the cutane- ous incision to the point of division of the bone must be deter- mined in varying ways. The plane in which the limb is ablated forms a wound surface for the covering of which integument must be spared. In the transverse circular method the knife must be applied one-half the greater diameter of the limb (measured at the point of division of the bone) below the line along which the bone is sawed; in the oblique circular method, the whole diam- eter of the limb. In the latter case the upper end of the oblique incision is at the level where the bone is divided (Fig. 127). These measurements should be taken very liberally, since one to two centimetres must be available for the broad coaptation of the wound margins. The elastic retraction of the wound margins need not be considered for wounds to be healed by first inten- tion, as it is readily overcome by the suture and becomes useful for a good adaptation of the integument to the wound surface. In the open wound treatment the measurements should be doubled. The cutaneous incision severs the skin, subcutaneous adipose tissue, and superficial fascia. Both hands of an assistant re- tract the skin vigorously during the transverse circular incision, the knife cutting the tightening fibres always close to the edge of the skin. In the oblique circular method the upper and lower ends are best marked by small incisions made by pinching up a fold of skin as in Figs. 126 and 12Y. The two small angles of this "rhomboid incision" also facilitate the subsequent suture. The left hand then grasps the longer skin margin and draws it up with great force so as to detach it from its base to the level of the upper end of the incision (Fig. 128). Wherever possible the fascia is included. The edge of the knife must never be AMPUTATIONS AND EXARTICULATIONS. 253 directed toward the llap, but always against the underlying tissue. At the margin of the retracted skin the muscles are divided in a plane transverse to the axis of the limb (Fig. 128) ; where the muscle is thick, the superficial layers are first severed and allowed to retract upward, and the deeper layers are divided in a higher plane because the superficial muscles usually retract more strongly. The same plan is followed in the puncture method. This is admissible in the formation of two short equal flaps ; the divided skin being drawn back, the muscles detached from the bone, the knife inserted in one of the angles between the flaps, carried along the bone, and pushed through in the other angle between the flaps, so as to divide the muscles obliquely along the margin of the skin by one smooth cut. The same is done on the other side, the muscles being lifted off. This operation requires a long, sharp, two-edged knife. Then follows the incision through the periosteum in the plane in which the muscles have retracted (Fig. 124). This is pushed without cutting along the bone as far as necessary for covering the sawed surface of the bone completely with perios- teum, and the bone is severed at the margin of the detached periosteum. Where the periosteum adheres closely, as on the rough lines of epiphyses and tendinous attachments, it is sepa- rated with the knife. Where no muscles are to be divided, as on certain joints, all the soft parts at the margin of the retracted skin are severed down through the periosteum, and the bone is enucleated sub- periosteally, in the case of joints subcajDsularly, to the point of division (Oilier 's subcajjsulo-periosteal method). In all cases in which the end of the bone is to act as a direct support, as especially on the epiphyses, it must be rounded off, either by curved sawing or by osteoplastic covering with a rounded bony process, as in Pirogoff's and Gritti's operation. 254 OPERATIVE SURGERY. After the removal of the limb the vessels are ligated, best with tine silk ; the stumps of nerves and tendons are searched for, drawn out, and cut off at the level of the wound surface. Where the suture fails to bring the raw surfaces in exact coap- tation throughout, a glass drainage tube with large lateral open- ings is inserted through a special small incision (for its direction see the figure showing the cleavage lines of the skin). Then follow a few deep button sutures and an uninterrupted exact cutaneous suture. X. Lower Extremity. Amputations at the Foot. For the foot the chief rule is to make the incisions for amputation so that no cicatrix extends to the sole. Therefore oblique incisions and their modifications are here the normal methods. The longer flap must always lie on the plantar side. The second rule is to look upon the foot always as a whole, excepting isolated amputations of the toes, i.e., to ablate it in a transverse line (Major). 205. Removal of the Toes, with or without Metatarsal Bones (Fig. 131). — Amputations and exarticulations of the toes are fully analogous to those of the fingers. For the phalanges and interphalangeal joints the oblique method is indicated; for the metatarsals and the metatarso-phalangeal joints, the oval method. The dorsal portion of the incisions extends to the bone and enucleates it subperiosteally. On the first and last toe the dorsal portion of the incision is made, not on the middle of the phalanges and the metatarsus, but more toward the median line of the foot so as to bring the cicatrices out of reach of lateral pressure. 206. Exarticulation of all the Toes (phalango-metatarsal ex- articulation ; Fig. 132). — All the toes are circumscribed by an incision at the base where they separate from the common in- LOWER EXTREMITY. 255 tegument of tlio foot, so that tlie incisions coincide with tlie interdigital folds. On the sole the incision runs exactly in the groove of the ball of the toes. Laterally on tlie great and little toes two dorso-lateral longitudinal incisions are added. The toes being flexed' strongly toward the sole, the dorsal tendons are severed as high as possible at the margin of the Tig. 131.— Exaiticulation of the Great Toe, Exarticulation of the Second Toe with the Ble- tatansal, Amputation of the Third Toe, Amputation of the Fifth Metatarsal. Fig. 133. — Exarticulation of the Toes. Fig. 133.— Metatarsal Ampu- tation. wound, a small knife cuts the lateral ligaments and the dorsal and plantar joint capsule, and lastly the plantar tendons as high as possible. 207. Metatarsal Amputation (Pig. 133). — This operation has the advantage over the metatarso-tarsal exarticulation that the attachments of the chief muscles of the foot are all preserved, not only tibialis posticus and peroneus, but also tibialis anticus, peroneus brevis and tertius. The foot, there- 256 OPERATIVE SURGERY. fore, remains movable in all directions. It is likewise quite useful for support, as the important support of the fifth meta- tarsal at its posterior end is preserved, the only one lost being that of the head of the first metatarsal. Oblique incision v^ith the formation of a plantar flap, which is at once separated in such a way as to pass with long strokes of the knife through the muscles obliquely to the point where Tuber.of fifth metatarsal ) Tubercle of Istmetatars'l Tubercle of the first metatarsal Fig. 134 (Plantar surface;. ' Fig. 135 (Dorsal surface). Figs. 134 and 135.— Tar so- metatarsal Exarticulation (Lisfranc). the bones are severed, in order to spare the branches of the inter- nal and external plantar artery. All the plantar bones, one after the other, are circumscribed with a small scalpel and sawed off. 208. Metatarso-tarsal Exarticulation (Lisfranc; Figs, lo-i and 135). — Passing between the metatarsus in front, the cunei- form bones and the cuboid behind. The jDlantar flap extends to the middle of the balls of the toes. The joint is characterized laterally by the tuberosity of the fifth metatarsal, behind which lies the line of the joint (Fig. 135). On the medial side a small LOWER EXTREMITY. 257 eminence, the base of the first metatarsal, is distinctly palpa])le. Oblique incision with two dorso-lateral cuts so as to lay bare the line of the joint. The line of the joint is convex downward and outward, has a depression above, due to the recession of the second cuneiform bone which stands back from the oblique convex line 2 to 3 cm. from the third cuneiform, and 1 cm. from the first. The two joints are opened first (the first, third, fourth, and fifth), the second last. The strongest ligament is between the first cunei- form and the base of the second metatarsal (compare Fig. 135), and until that is severed the joint cannot be made to gape. As in all operations on the foot, the vessels are preserved in the plantar flap. Where the tegumentary covering is insufficient, the removal of the first cuneiform does not lessen the function of the foot any more than Lisfranc's exarticulation alone. 209. Anterior Intertar sal Exarticulation {J agQY] Fig. 137). — Between the cuneiform bones in front and the scaphoid be- hind, the cuboid being sawn through. Operation like Lis- franc's, somewhat less integument being preserved. The method has the advantage over Chopart's of preserving the strong liga- ment from the calcaneus to the cuboid and scaphoid bones. 210. Posterior Intertarsal Exarticulation (Chopart; Fig. 136). — Between calcaneus and astragalus behind, the cuboid and scaphoid in front. The operation has often resulted in a bad stump, owing to equinus position of the foot and chafing at the anterior lower circumference of the calcaneus. The best pre- ventive measures for this are, to attach the dorsal flexor tendons firmly to the stump, prophylactic tenotomy of the Achilles tendon, and care for healing by first intention. The line of the joint is characterized on the medial side by the marked projection of the tuberosity of the scaphoid bone behind which it lies, and laterally by an eminence on the body of the calcaneus in front of which it lies. The oblique incision 17 258 OPERATIVE SURGERY. strikes the line of the joint above, and below passes to the pos- terior end of the balls of the toes. Two small dorso-lateral in- cisions facilitate the exarticulation. We penetrate into the joint between the head of the astraga- lus and the scaphoid which is convex below ; on the outer side and more deeply the knife should again be directed toward the toes. Tubercle of the calcaneus Jhopart's line \ Tuber, of the I scaphoid bone Fig. 13G (Dorsal surface). ' Fig, 137. Fig. 136. — Medio-tarsal Exarticulation (Chopart). Fig. 137.— Medio-tarsal Amputation (Jager). Horizontal section of the Foot after Heitzmann. for the lateral portion of the joint between calcaneus and cuboid is concave forward. If the edge is directed backward we reach the joint between astragalus and calcaneus. The main connection between the bones is the Y-shaped ligament from the body of the calcaneus to the scaphoid and cuboid bones. 211. The terni "tarsal amputation" can be applied to the operation in which, after exarticulation, the joint surfaces of the astragalus and calcaneus are sawed off because the tegumentary LOWER EXTREMITY. 259 covering does not suffice for a Chopart operation. As the cap- sule of the ankle joint is not opened (the operation extends to within 1 cm. of the margin of the cartilage of the astragalus joint) the resulting foot is still movable. 212 a. Siibastragaloid Exarticulation (Malgaigne, Textor; Figs. 139 and 143). — Oval incision, beginning horizontally under <=S27( Post, intertarsal exarticulation CChopart) Anterior intertarsal exarticulation (Jager) Tarso-metatarsal exarticulation (Lisfranc) Metatarsal amputation Fig. 138. Fig. 139.— Subastragaloid Exarticulation (Malgaigne, Textor). the tip of the external malleolus, extending toward the dorsum to Chopart's line (which is distinctly marked, as above, by the tuberosity of the scaphoid), along which it descends vertically to the sole on the medial side, back to its point of beginning on the outer side. Chopart 's joint is opened from above between the head of the astragalus and the scaphoid. Then, without penetrating deeper into this joint, the narrow knife is turned immediately up- ward and backward under the head of the astragalus so as to 260 OPERATIVE SURGERY, sever the strong ligamentum interosseum astragalo-calcaneum in the sinus tarsi, and the calcaneus is enucleated, first on the upper, outer, and lower surface, then inward, and lastly behind. Fig. 140.— Exarticuiation of the Foot (Syme, Uiodifled). On the medial side the most difficult point is the sustentaculum tali, which extends high up. When the tegumentary covering is insufficient the head of the astragalus is sawed off. 2126. Osteoplastic Suhastragaloid Amputation. — Performed by Hancock by the attachment of the severed tuber calcanei to the sawed lower surface of the astragalus. The indication for the operation is of ex- ceptional joccurrence. 213. Exarticuiation of the Foot (Syme ; Figs. 140 and 141). — The total removal of the foot at the ankle joint has been per- formed by Syme, a flap having been formed from the integument of the heel. This method has the drawback that in place of the enucleated tuber calcanei a cavity is Fig. 141. — Frontal Section . through the Ankle Joint, left whlch IS UOt filled Up. Worthy of recommendation is the oval incision with the formation of a flap from the medial side, be- ginning transversely over the tip of the external malleolus (Fig. LOWER EXTREMITY. 261 140). After dividing the skin, the strong lateral ligaments (lig. fibulo-calcaneiim and astragalo-fibularia) and the peroneal ten- dons are severed and the extensor tendons at the margin of Fig. 142.— Osteoplastic Exarticulation of the Foot (Pirogoff). the retracted skin ; the ankle joint capsule is opened and enu- cleated close to the bone along the calcaneus, downward from the flaps. The malleoli are circumscribed with the knife and sawed off. 214. Osteoplastic Amputation of the i^oof (Pirogoff ; Figs. 142 and 143). — The leg bones are sawed off immediately above Subastragaloid exarticula- tion (Malgaigne) Fig. 143.— Osteoplastic Exarticulation of the Foot (PirogoflP). the cartilaginous surface and to the sawed surface is attached that of the tuber calcanei to lengthen the leg. The preservation 262 OPERATIVE SURGERY. of the tuber calcanei has the great advantage that the skin of the heel remains well nourished and the so-called heel cap re- mains filled. It is far preferable to Syme's exarticulation. The simj)lest and most reliable method is the following: Tenotomy of the Achilles tendon. Incision beginning at the level of one malleolus, extending in the axis of the leg — the foot being kept at a right angle — over the heel ("stirrup" inci- sion), and ending at the level of the opposite malleolus. The incision throughout is carried vigorously down to the bone and severs the tendons within and without completely. Second incision extending directly forward at a true right angle from the ends of the first incision, so that the anterior end lies a good thumb's breadth in front of the ankle joint. This incision severs only the skin and fascia, at the margin of which the extensor tendons are divided. The astragalo- crural joint is opened from in front, the lateral ligaments are divided under the malleoli until the astragalus is laid bare to its posterior end. Then the tuber calcanei is sawed off vertically behind the astragalus, in the plane of the stirrup in- cision, and turned up with the skin of the heel. The malleoli and articular portions of the leg bones are circumscribed with the knife and sawed off transversely. The suture exactly coapts the sawed surfaces. The gait subsequently is excellent. In order to avoid the turning of the calcaneus, which in our opinion, however, is quite serviceable, many surgeons have sawed the calcaneus obliquely (Schede,Volkmann) or horizontally (Dupasquier, Lefort) or at a curve and angle (Bruns, Bockel). For the horizontal division the oval incision is to be recom- mended (similar to Fig. 139), beginning horizontally under the tip of the external malleolus. By this horizontal incision room is gained for sawing. All these modifications have the drawback, as compared with the above-described method, that a portion of the cicatrix is placed too near the inferior surface of the foot. LOWER EXTREMITY. 203 215. Amputation of the Ley (Figs. 144, 145, and 140). — We indicate the suitable incisions merely by illustrations; for the performance we refer to the descrijjtion of amputations in gen- eral. The oblique incision is the method most frequently employed ; at the upper and lower end it is best to form the flap in front so as to cover the epif)hyses, which are sawed in a curve. About the diaphysis, however, the ob- lique incision is made so that the flap lies antero-externally, lest the anterior edge of the tibia (which should always be rounded off) be pressed too firmly against it. It is well to separate the periosteum of the inner surface of the tibia with the tegu- mentary flap so as to protect the bone. The interosseous ligament adheres Fig. 144.— Intra-malleolar Amputation. Fig. 145. — High, Medial, and Intra- malleolar Amputation of the Leg. firmly to the bone and is dissected up with the periosteum by means of the knife. The division of the muscles between the bones must be made smoothly in a transverse plane so that the vessels are divided with one cut. Throughout the length of the leg the vessels to be ligated are: tibialis antica artery (and vein) on the interosseous liga- 264 OPERATIVE SURGERY. ment, tibialis postica artery on the deeper calf muscles, in the lower two- thirds the peroneal artery on the dorsal surface of the fibula or of the flexor hallucis longus muscle. Extensor digit, longus muscle Tibialis anticus nerve Tibialis antica artery Peroneus longus muscle Tibialis posticus muscle Peroneal artery Soleus muscle Gastrocnemius muscle. Tibialis anticus muscle Flexor dig. communis m. Tibialis postica artery Tibialis posticus nerve ^Soleus muscle • Fig. 146.— Transverse Section ot the Leg, after a Photograph. 216. Exarticulation of the Knee (Figs. 147 and 150). — Fur- nishes an excellent stump when the course is aseptic. Whether the preservation of the articular cavity (Socin) is a permanent advantage is still uncertain. Fig. 147.— Exarticulation of the Knee. Oblique incision with anterior flap, beginning posteriorly in the line of the joint and ending in front four fingers' breadth below the spine of the tibia. If the leg is kept half flexed (at an angle of 135° with the thigh), the direction of the incision lies in the prolongation of the axis of the thigh (Fig. 147). LOWER EXTREMITY. 265 The skin with the fascia is dissected back, the capsule with the ligamentum patellae is divided in front, the meniscuses and lateral ligaments in front and laterally, then along the inter- condyloid eminence of the tibia the crucial ligaments are sepa- rated, the posterior wall of the capsule is severed along the tibia, and the operation is completed by a transverse incision through the posterior soft parts. Where the removal of the patella appears necessary on ac- count of pro thesis, the flap is turned over, the patella circum- scribed with the knife, and enucleated subperiosteally. Fig. 148.— Intracondylic Amputation (Garden). The main vessels are the popliteal artery and vein. Among the larger branches the articularis genu artery and occasionally muscular branches to the gastrocnemius require ligation. 217. Amputation of the Femur (Figs. 14S-152). — Formerly and even now one of the more frequent amputations. An oblique incision is to be recommended for any level, and so is the circular method, with the exception of the lower end, owing to the bad position of the cicatrix. 218. Intracondylic Amputcdion (Fig. 1-18; Garden and Bu- chanan). — In amputation at the lower end of the femur in chil- dren Buchanan simply divides the condyles in the epiphyseal line. Garden saws off the condyles in a curve at their greatest 266 OPERATIVE SURGERY. circumference and by this means obtains an excellent stump which easily bears the weight of the body. Oblique incision beginning at the level of the condyles and extending in front to the spine of the tibia. 219. Supracondy lie Amputation {Fig. 151) is performed by an oblique incision with flap (Langenbeck) on the anterior inner side because the adductors draw the thigh forward and inward; were the incision made directly anterior, the bone would be crowded too far toward the inner angle of the wound. Fig. 149.— Osteoplastic Supracondylic Amputation (Gritti) A modification of this frequent amputation is Gritti's supra- condylic amputation (Fig. 149).' Oblique incision, the upper end lying posteriorly directly over the eminence of the condyles, the lower end in front, two fingers' breadth under the patella. The ligamentum patellae is divided at the upper end. After sawing through the femur and the cartilaginous surface of the patella, the latter is attached to the femur or nailed to it. 220. The amputation through the middle (Fig. 151), owing to the massive muscles, is best performed in such a way as to form two short vertical flaps (Lisfranc and Esmarch), and after their retraction to divide the muscles transversely by a smooth cut. Very smooth wounds can also be obtained by inserting LOWER EXTREMITY. 2G7 the knife on both sides of the bone after the division of the skin. When the muscles are well developed, the periosteum should be pushed up several centimetres in order to obtain sufficient integument and to be able to cover the sawed surface with periosteum. 221. The high amputation (Fig. 151) is performed by an oval incision in a manner resembling exarticulation of the femur. The longitudinal portion of the incision is on the outer side, extends down to the bone, and permits its enucleation sub- periosteally to the point of division. Outer surface Biceps muscle Popliteal artery- Popliteal vein- Tibialis posticus nerve- Peroneal nervt' Fig. 150.— Transverse Section through the Lower End of the Femur and Knee Joint (after Braune). 1 — Inner surface Sartorius muscle Great saphena vein During amputation of the femur in the lower tjiird (Fig. 152) the vessels to be ligated are the femoral artery and vein, the articularis genu suprema artery antero- internally, and pos- sibly the superior arteries of the knee joint. In the upper two- thirds, besides the femoral artery and vein, the profunda femoris artery and in the upper third large branches of the external circumflex artery require ligation. 222. Exarticulation of the Hip (Figs. 153 and 154:) . — Though formerly a capital operation, the removal of the thigh at the hip joint can now, thanks to the improved technique, be per- formed without hesitation even on relatively feeble patients. Eose (Liining) extirpates the thigh like a tumor, either ligating the vessels immediately after their division or doubly ligating them before they are severed. In the case of tumors reaching high up into the region of the hip joint this procedure 268 OPERATIVE SURGERY. Crural muscle pectus femoris muscle Vastus extemus musclp i f vastus internus muscle , Saphenus nerve Sartorius muscle Femoral artery Inner surface GracDis muscle Adductor magnus m. Semi-membranosus'muscle Fig. 152.— Transverse Section through the Thigh (after a Pho- tograph). ( Incision for / resection \ Incision for am- ( putation Fig. 151.— High, Median, and Supra- condylic Amputation of the Femiu". Fig. 153.— Exarticulation of the Hip. LOWER EXTREMITY. 269 »^W' is the most suitable. For these rea- sons the technique requires no special description, as it varies in each case. Wherever the soft parts about the hip joint can be preserved this should unquestionably be done. For in the subsequent use of an artifical limb the I function of the muScles in the stump ) after exarticulation of the hip is of ^ the greatest value. Especially after operating subperiosteally a stump is obtained which gives vigorous mobility in all directions, similar to the high amputation of the femur. The elastic bandage is applied in the inguinal fold for the prophylactic arrest of hemorrhage, a figure-of-eight turn being invariably made around the pelvis to prevent dov/nward displace- ment. At the height calculated in the usual manner (see General remarks on amputations) the circular incision is carried through the skin and at its mai'gin the corresponding incision through the muscles to the bone, which is sawed through after the separation of the periosteum. Careful ligation of the vessels follows, after which the elastic bandage is removed. More suitable than the simple cir- cular method is an oval incision, the Fig. 154.— Frontal section of the Hip . i • 1 ^^'^ Knee Joints, after Henle. prolongation being on the outside (Fig. 151) of the bone, or eventually a short anterior and pos- terior flap. i.'"VS i^l*i^-x'>.. ^^!^a l:^ m 270 OPERATIVE SURGExiY. The exarticulation of the upper end of the femur is per- formed in various ways. After the amputation Beck divides on the outer surface of the femur the soft parts and enucleates the bone, separating with the knife the attachments of the periosteum at the Hnea aspera, of the tendons (of the three gluteal muscles, the pyri- formis, external and internal obturator with gemelli, quadratus femoris at and under the great trochanter, ilio-psoas at the lesser trochanter), and of the capsule about the anterior and posterior inter-trochanteric line. The ligamentum teres is torn by rotating the bone several times. We (Kocher, Eoux) precede the amputation by a resection of the hip, with a shortened posterior incision about the great trochanter (which see), ligating all the bleeding vessels, and then only apply the elastic ligature and make the amputation. Our method has the advantage that the inevitable hemorrhage from the smaller vessels (obturator, circumflex, and sciatic arteries) occurs at the beginning instead of the end of the operation. Otherwise the same vessels are to be ligated as in the high amputation of the femur. Y. Upper Extremity. 223. Amputation and Exarticulation of the Fingers (Figs. 155, 156, and 15Y). — For the fingers the main rule is to preserve even the smallest stump, provided it can remain connected with the tendons and be covered with healthy integument. All methods, therefore, are good. Where the choice is open, flaps from the volar side are to be preferred, so as to avoid cicatrices in the palm. The corresponding oblique incision is the most suitable, in fact necessary for the ungual phalanx. The posi- tion of the joints is readily located by bending the fingers, since the line of the joint is always peripheral from the dorsal emi- UPl'ER EXTREMITY. 271 nences (Fig. 155). Here the knife is applied and carried obliquely downward toward the palm. The phalanx being strongly flexed, the attachment of the extensors to the base is divided, then the dorsal capsule, the two lateral ligaments, and the flexor tendons. During amputations the volar flap must be turned back, so as to circumscribe the bone with the knife. For the exarticulation of the fingers in the i)halango- Interoi-sei and lumbricals Extensor digitoi-um longus Fig. 155.— Position of the Joints of the Fingers In Fig. 156.— Exarticulation of Fingers: Fifth, Flexion, and Attachments of the Tendons. Second, Fourth with Metacarpal. First with Metacarpal (Dorsal Surface). Tnetacarpal and in the metacarpo-carpal joint the oval incision is used, whose longitudinal portion extends backward over the head of the metacarpus or over the base of this bone. The tendons are divided at the margin of the retracted skin, then the periosteum is opened and detached, at the articular ends simultaneously with the capsular attachment. In the case of the thumb, index, and little finger, the dorsal portion of the incision is placed toward the median line of the liand instead of toward the middle of the bone or joint. 272 OPERATIVE SURGERY. In removing the metacarpals of the thumb and little finger it is a matter of special importance to keep the short thenar and hypothenar muscles quite intact, as in this way very useful movable stumps are obtained, especially with subperiosteal enu- cleation of the bone. For the exarticulation of the whole finger, with or without the metacarpal, the point for the transverse incision is exactly defined by the transverse fold between the palm and finger ; no incisions must be made farther back in the palm. 224. Exarticulation of the Hand (Fig. 15Y). — For this as well as for the amputation of the forearm the most variable styloid process of the radius Fig. 157.— Exarticuiatioii of the Third Finger, Exarticulation of the Hand, Amputation of the Forearm. methods are admissible by which a longer stump can be obtained. Contrary to Major's rule with reference to the foot, no ampu- tation should be made in the transverse line so long as a movable finger or portion of the hand can be preserved. Oblique incision, the upper end in the line of the wrist joint, the lower end in the palm. Under strong volar flexion the ex- tensor tendons and the dorsal capsule are divided; also the lateral ligaments and tendons under the styloid processes pro- jecting farther downward (external ulnar, extensors and ab- ductor of the thumb), and the upper row of carpal bones which is convex above is enucleated. In the line of the joint the bundle of flexor tendons is divided and anteriorly the volar UPPER EXTREMITY. 273 flap freed in its entire thickness. The volar flap has the advan- tages of excellent nutrition, delicate tactile sensation, and occa- sionally the preservation of movable muscular stumps. The vessels requiring ligation are the ulnar artery or its two branches passing to the volar arch in the palm and the branch of the radial artery to the superficial arch ; on the dorsal side the trunk of the radial artery passing to the deep arch. 225. Amputation of the Forearm (Figs. 157 and 158). — This presents no peculiarities deviating from the general rules. An oblique incision with volar flap is to be recommended for the Pronator teres muscle Radialis interaus muscle\^^ ^ — /^>C Radial nerve Palmaris longus muscle^,,^^ /^^^^^^^^^\^ Supinator longus muscle Flexor digitorum sublimis I /^R^^^^S^^l^eSO?^^-^'^^'''^^^ radial muscles Internal ulnar muscle-^ fl^^^^^^/t^^^^^^wl c ■ ^ ■. ■ ^T-7^S^^^^j W.-iP" ^^^ I — Supinator brevis muscle Ulnar nerve — X^^^^^^'^S^^^^CS^^/' — -Extensor digit, communis m. Ulnar artery "'A^ ^External ulnar nerve Flexor digit, profundus ^^■iC^^^^^^^^^^C.A.nconsdus quartus muscle Fig. 158.— Transverse Section of the Forearm in the Upper Third, after a Photograph. same reasons as at the wrist joint. It prevents cicatrices on the volar side. Ligation of the radial and ulnar arteries and the interosseal lying under and medially from the latter. 226. Exarticiilation of the Elhotv (Figs. 159 and 160).— It is an error repeated incessantly by instructors in operating, that the joint-line of the elbow is to be determined from the tip of the olecranon. It should be determined from the condyle of the radius, which can always be felt on the dorso-radial side. Oblique incision from the line thus determined in the bend of the elbow, extending a hand's breadth under the tip of the olecranon on the dorsal side. When the forearm is flexed at an angle of 135° the direction of the incision is parallel to the prolonged axis of the arm. The dorsal flap with the peri- osteum, and the attachment of the triceps and anconseus 18 274 OPEEATIVE SURGERY. qiiartus are freed beyond the tip of the olecranon and the dorsal surface of the humerus. In front the soft parts with the joint Fig. 159.— Exarticulation of the Elbow; Longituauial Incision after Braune. capsule are divided transversely, the flap being lifted and the knife carried into the humero- radial articulation. With the External lateral ligamen Condyle of the radius for de- i termlning the line of the joint I Annular ligamen iDternal lateral ligament division of the tense internal ligament the operation is finished. Ligation of the brachial artery in the bend of the elbow. UPPER EXTREMITY. 275 227. Amputation of the Arm (Fig. 161). — In order to obtain a broad covering of the arm stump we must bear in mind that the arm is much flattened from without inward when the volar surface is directed forward. Flaps should be formed from the broad side. Accordingly in an oblique incision the upper Fig. Itil.— Amputation of the Humerus. end of it falls in the internal bicipital sulcus. The biceps mus- cle retracts strongly. The upper limit for securing a useful stump by amputation is determined by the surgical neck to which the joint capsule is continued on the medial side ; on the other side, by the attach- ments of the deltoid, pectoralis major, and latissimus, which must maintain the equilibrium as the chief abductors and ad- ductors. Eegarding the rules for the high amputation compare the exarticulation of the humerus. Ligation is required for the brachial and the deep brachial arteries, together with 276 OPERATIVE SURGERY. smaller branches (collateral ulnar arteries). When the bone is sawed through at the turning-point of the radial nerve, its resection is particularly necessary. 228. Exarticulation of the Humerus (Fig. 162). — In remov- ing the arm at the shoulder joint it is as necessary as in exar- ticulation of the hip that wherever possible a musculo-periosteal V (!_ Fig. 163.— Exarticulation of the Humerus. stump be preserved. This will be important in the use of an artificial limb. The incision is made in accordance with this requirement. It is admissible, in a manner analogous to that of the hip, to make a high amputation at the level of the axillary folds, by means of a circular incision ; and, after sawing the bone, to add a longitudinal incision on the anterior surface as in resection of the humerus, and to enucleate the upper end of the humerus. UPPER EXTREMITY. 277 However, this is not absolutely necessary, as the hemorrhage can be controlled as certainly through a simple oval incision. ' The longitudinal incision begins under the clavicle on the outer side of the coracoid process and passes downward at the anterior margin of the deltoid to the level of the axillary fold, then turns laterally around the belly of the deltoid, extends transversely across the dorsal surface and upward under the anterior axillary fold, and terminates in the first part of the incision. Immediately after tracing the first longitudinal incision the cephalic vein and branches of the thoracico-acromial artery are ligated. In front we penetrate into the depth to the bone at the margin of the deltoid (the uppermost anterior fibres are severed), between it and the pectoralis major, divide the capsule in the bicipital sulcus and upward to the socket, and separate it with the tendinous attachments of the subscapularis, also the periosteum with the attachment of the pectoralis major on the inner side, the attachments of the supraspinatus, infraspinatus, and teres minor on the outer side of the bone, so that the head of the humerus can be readily forced out forward and upward. In cutting upon the surgical neck, the ligation of the circumflex arteries, or at least of the anterior artery, may come in ques- tion. When the cutaneous incision is then completed, it will be easy to ligate the main vessels before dividing the deep soft < parts transversely, and to separate the latissimus dorsi and teres minor muscles from the spine of the lesser tuberosity. Dur- ing this step we must carefully avoid injury of the axillary nerve, which turns behind the bone over the teres major in order to supply the deltoid. For the latter is the chief muscle of the remaining stump. 229. Exarticulation of the Ann ivitli the Slioidder Girdle (Fig. 163). — As a rule the oj)eration is performed for tumors which have involved the shoulder joint with the scapula, fre- quently also the axillary glands, vessels, and muscles. The 278 OPERATIVE SURGERY. preservation of any stump, therefore, is out of the question. Of course, cases occur in which only a portion of the scapula (acromion and articular portion) need be removed with the arm. Prophylactic arrest of hemorrhage is out of the question. The first care, therefore, in making the incisions is the ligation Fig. 163.— Exarticulation of the Shoulder Girdle. of the large vessels. Otherwise the direction of the incision is to be largely modified according to the involvement of the skin. The rule is an oval incision, the longer portion of which passes over the clavicle, beginning in the supraclavicular fossa. The periosteum of the clavicle is divided, the clavicle sawn through and bent apart with sharp hooks, and the subclavian muscle is carefully separated. The fascia is opened and the subclavian artery and vein and the brachial plexus are laid UPPER EXTREMITY. 279 bare. The nerves are divided singly, the vessels doubly ligated and cut. If the hemorrhage is to be reduced to the minimum, other vessels must be ligated, as follows: Branches of the subclavian which emerge laterally over the scaleni, namely, the three branches of the thyro-cervical trunk which pass from the scalenus upward (ascending cervical artery), upward and out- ward (superficial cervical artery), and laterally behind the clav- icle (transverse scapular artery) ; finally the thick transversa colli artery which passes backward over or through the brachial plexus so as to supply the scapular muscles (levator, supra- spinatus) and then descends along the scapula (as the dorsalis scapulae) between the rhomboid muscles and the serratus posti- cus superior. By this means we guard against serious hemor- rhage. Then the anterior incision is carried into the depth between the clavicular portion of the pectoralis major and the deltoid on the medial side of the large vessels, dividing first the pectoralis minor at the coracoid process, then the attachments of the pectoralis major and latissimus dorsi as close as possible to the humerus, during which step the skin is severed antero- posteriorly through the axilla. Then the arm together with the scapula and clavicle can be lifted off. The posterior incision passes backward over the acromion and downward on the dorsal surface to the jDosterior axillary fold. Along the upper margin of the clavicle, acromion, and spine of the scapula the upper portion of the trapezius is divided ; along the lower margin of the spine, the lower jDortion of this muscle. The scapula is now attached only by its upper margin to the omo-hyoid and levator scapulae, by its posterior margin to the serratus anticus major and rhomboids. Berger has done very meritorious work in developing the method of the exarticulation of the shoulder girdle.